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Press releases Saturday 23 September 2006
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(3) BETTER TRAINING NEEDED TO REDUCE EMERGENCY CAESAREANS
(4) DOCTORS MUST DEBATE HOSPITAL CLOSURES
(Race and mental health: there
is more to race than racism)
http://bmj.com/cgi/content/full/333/7569/648
Psychiatry services in England and Wales have been accused of being institutionally racist, but are these accusations justified?
In 2005, the “Count me in” census for England and Wales showed higher rates of admission for mental illness and more adverse pathways to care for some black and minority ethnic groups and led to accusations of institutional racism within psychiatry. Several reports and inquiries have also alleged that psychiatry is institutionally racist.
But Professors Swaran Singh and Tom Burns argue in this week’s BMJ that these accusations are erroneous, misleading, and ultimately counterproductive
Higher rates of mental illness in migrant groups have been proposed as evidence of racism within psychiatry, they write. Yet rates of psychiatric disorder are high for all migrants, irrespective of ethnicity. This suggests an explanation that is not ethnic specific and is environmental rather than genetic.
High rates of detention and adverse pathways to care for ethnic minority patients have also been attributed to racism. Yet a recent UK study suggested that the greater stigma of mental illness in the African-Caribbean community might act as a barrier to early help seeking until a crisis develops.
It also suggested that, over time, the relationship between ethnic minority patients and mental health services deteriorates, thereby creating a spiral of downwards engagement.
Hence, a legitimate question is whether some groups of patients are more likely to refuse help from psychiatric services. And if so, why?
These findings highlight that there are perfectly reasonable alternative explanations for why the rates and manner of admission vary between different ethnic groups, say the authors. Construing racism as the main explanation for the excess of detentions among ethnic minorities adds little to the debate and prevents the search for the real causes of these differences.
In psychiatry, accusations of racism simply feed into ethnic minority communities’ alienation and mistrust of services. They create a self fulfilling prophecy whereby ethnic minority patients are primed to expect services to be poor and racist, decline all offers of voluntary admission, are detained, and disengage with services over time.
There is a serious risk to potential patient care if charges of institutional racism deter staff from taking clinically appropriate decisions and actions, they warn. Hence, any potential solutions must go beyond the health sector and involve statutory as well as voluntary and community agencies. The problem does not reside exclusively in psychiatry and hence the solutions cannot emerge from psychiatric services alone.
Contact:
Swaran Singh, Professor of Social
and Community Psychiatry, Health Sciences Research Institute, Warwick Medical
School, University of Warwick, Coventry, UK
Email: s.p.singh@warwick.ac.uk
(Letter - Stabbing: data
support public perception)
http://bmj.com/cgi/content/full/333/7569/652
Serious knife injuries are increasing, say trauma experts at the Royal London Hospital in a letter to this week’s BMJ.
Several recent deaths have fuelled the perception that forensic knife injuries have become an epidemic, resulting in a knife amnesty and government discussion of new punitive measures, write Charles Knowles and colleagues.
An increase in such injuries is supported by data from regional police forces and the Home Office, with 1200 reported attacks in London last year and 30% of homicides caused by knife injury. Crimes defined as “more serious wounding or other act endangering life” almost doubled nationally from 1995 to 2005.
The authors audited knife injuries at their east London hospital, one of Europe’s busiest emergency departments, to establish the size of this problem in a representative urban area.
They analysed data on forensic knife injuries (excluding deliberate self harm) from a database of all trauma calls from July 2004 to June 2006. Overall there were 309 forensic knife injuries; 259 patients were admitted, 184 were operated on, and eight died. The chest was the most common area injured, most patients were men, and mean age was 28.
To give a measure of changing incidence over a longer time, they also performed an audit of all cases coded as “stabbing” during the 10 year period from July 1997 to June 2006.
Over both periods, the data show an increase in the overall incidence of stabbings. The increased need for surgical intervention may also reflect increasing severity of injury, they say.
These data therefore seem to support the general perception that knife injuries are increasing, they conclude.
Contact:
Charles Knowles, Senior Lecturer
in Surgery, Trauma Service, Royal London Hospital, Whitechapel, London, UK
Email: c.h.knowles@qmul.ac.uk
(3) BETTER TRAINING NEEDED TO REDUCE EMERGENCY CAESAREANS
(Editorial: Caesarean delivery
in the second stage of labour)
http://bmj.com/cgi/content/full/333/7569/613
Many emergency caesareans could be prevented by the attendance of a more skilled obstetrician, say senior doctors in this week’s BMJ.
They call for better training in instrumental vaginal delivery (use of forceps or ventouse) for obstetric trainees to help reduce rates.
A recent UK study found that decisions made by senior (consultant) obstetric staff are important in determining whether a second stage caesarean section is the best method of delivery for women with delay in advanced labour. It found that a consultant obstetrician who performed a vaginal assessment was more likely to reverse a decision made by an obstetric trainee for a caesarean and proceed to a safely conducted instrumental delivery.
The authors warn that, without increases in junior doctors’ experience and recruitment into the specialty, the problems with second stage caesareans will rise.
According to the Royal College of Obstetricians and Gynaecologists audit figures, about 35% of caesareans for singleton pregnancies are performed because of failure to progress in labour, of which a quarter occur at full cervical dilatation. In 55% of these cases no attempt was made to achieve a vaginal birth with either forceps or ventouse. In those births where instrumental delivery was attempted, the audit noted a “failed” rate of 35% for ventouse and 2% for forceps.
Breech and twin deliveries can also lead to second stage caesareans. In the absence of an experienced and skilful obstetrician to perform assisted vaginal breech delivery, women are advised to undergo an emergency caesarean.
For twin deliveries, currently about 10% of second twins are delivered by caesarean section after the first has been delivered vaginally: 10 years ago, the rate was 5%. As many as two thirds of these caesareans are preventable, say the authors.
Despite problems relating to the inexperience of obstetric trainees, the United Kingdom is making great strides in terms of structured training, assessment of competencies, and consultant delivered intrapartum care, they write. Nevertheless, it is essential to recognise the need for obstetricians to maintain and develop their skills if women are to be offered safe alternatives to caesarean section when complications arise in labour.
Contact:
Chris Spencer, Consultant Obstetrician,
St John’s Hospital, Chelmsford, Essex, UK
Email: cpspencer@doctors.org.uk
(4) DOCTORS MUST DEBATE HOSPITAL CLOSURES
(Personal View: Doctors must
debate the issue of hospital closures)
http://bmj.com/cgi/content/full/333/7569/661
Doctors must debate the issue of hospital closures, says an article in this week’s BMJ.
This issue, which has suddenly become headline news, has never been the subject of a full national debate in the profession, writes general practitioner, Richard Lehman.
Over the past 15 years there has been much talk of centralising services, and many local campaigns over individual threatened local hospitals, but little systematic collection of evidence to inform decision making, he says. Instead the process has been driven largely by financial pressures, by the European Working Time Directive and its effects on junior doctors’ staffing, and recommendations from the royal colleges.
Inevitably these pressures have driven hospitals to amalgamate services, at some cost to local accessibility. Equally inevitably such moves are deeply unpopular with patients, who may have to travel considerable distances for acute care that used to be on their doorstep.
The services most likely to be cut or merged throughout Britain are paediatrics, obstetrics, and emergency services – the very ones that patients particularly want to be near.
This presents a dilemma for trusts seeking to maintain a lower level of service, for example by substituting a midwife led birth unit for a consultant led obstetric service. Such units only accept “low risk” births, but emergencies inevitably occur, requiring transit to the nearest consultant led facility. If considerations of cost are allowed to predominate that may be a very long distance, he warns.
This issue is one of several that need to be debated urgently before a further wave of such changes sweeps the country, he writes. It cannot be timed or located to suit electoral convenience.
We need clearer guidance on issues such as safe transit times for paediatric and obstetric emergencies, and we need more creative thinking on shared site working and flexible training rotas.
It is time for GPs to reassert their role as patients’ advocates, defending the principle of local care for local people, he says. If doctors do not take an active role in questioning the present direction of policy then the public will rightly see us as more interested in our own career structures and hours of working than in providing a safe and accessible service.
Contact:
Richard Lehman, General Practitioner,
Banbury, Oxfordshire, UK
Email: Richard.lehman@gp-K84059.nhs.uk
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