A few years ago, I did a stint in General Practice. One of the commoner things people would come and see me for was a sore throat, and as a good antimicrobial steward I tended to send them away with self-care advice.

One bit of advice I routinely gave to adult patients was to gargle with salt water: dissolve half a teaspoon of salt in half a cup of boiled water mixed with half a cup of cold water, gargle with it for a minute and spit it out. I think it may even have been written on the little self-care leaflets I used to dish out.

This has a surprising amount of evidence behind it for a home remedy, though largely in the context of postoperative throat pain. It is now the published NHS advice for sore throats—it may have been at the time too, I’ve no idea.

What sticks in my mind about this advice is the number of people who mentioned at unrelated later appointments what excellent advice it had been. I even remember a singer telling me the advice had rescued a performance she thought she may have to cancel. In my experience, patients aren’t especially forthcoming with positive feedback on self-care strategies, but I really seemed to get a lot about this advice. Despite that, and despite a vague awareness of the evidence base, I didn’t really believe it. I mean, it sounds like utter nonsense, like the sort of folk remedies you hear for all kinds of things that aren’t evidence-based (and can even be downright unhelpful).

And yet… over the last week or so, for the first time in as long as I can remember, I’ve been suffering from a really sore throat. I tried gargling salt water. And, blow me down with a feather, it really works. Certainly, I’ve found it far more effective than any throat sweets or sprays I’ve come across.

I think there’s probably a deep message in here somewhere about common sense being remarkably uncommon, or about doctors being the worst patients, or about a disconnect between academic evidence and belief systems. But really, I’m just trying to say if you have a sore throat, try gargling with saltwater. It worked for me.

I came across the advert at the top of the post via the Boston Public Library online. I wonder if there are any medications advertised today as for both “man and beast”? If you’re wondering, you didn’t have to get your “beast” to gargle it:
it could also be applied topically (hence ‘liniment’, which is a word we don’t use nearly enough these days).

I don’t often stick work stuff on here… but here are a couple of videos of me and Michelle Henderson (one of my colleagues) talking about World TB Day, which is today!

Tomorrow is #WorldTBDay. Watch @sjhoward and Michelle Henderson talk about unique challenges of TB in the North East and symptoms to look for. pic.twitter.com/dEN8ejN5DA

— PHE North East (@PHE_NorthEast) March 23, 2018

#WorldTBDay the quicker TB is diagnosed the sooner it can be treated – watch the below to find out why early diagnosis is so important ⬇️ pic.twitter.com/SkzZGi2Tdd

— PHE North East (@PHE_NorthEast) March 23, 2018

When people accuse politicians of lying, I generally roll my eyes. Almost a decade ago, I laid into my local MP for sending me an inaccurate letter. Guido Fawkes picked it up and called the poor guy a moronic liar. The episode was a whiny hurling of personal insults that achieved nothing of value. I still slightly regret it.

And these days, too often people choose to quote politicians out of context, wilfully misunderstand their position, or turn slips of the tongue into conspiracy theories. I have no interest in any of that.

And yet. And yet. And yet, I have noticed a lot of inconsistency in Government statements on the Junior Doctors’ Contract dispute. I’m not accusing anyone of lying. I’m not even accusing anyone of being deliberately misleading. I’m just highlighting statements which, as far as I can see, don’t match one another.

Look through the list yourself. Check out the sources. Draw your own conclusions.

There will be no imposition.

Source: Government statement in response to petition, 21 March 2016

There has been no change whatsoever in the Government’s position since my statement to the House in February … We are imposing a new contract, and we are doing it with the greatest of regret.

Source: Jeremy Hunt, speaking in Commons debate, 18 April 2016

Is it really the Government’s position that “no imposition” and “we are imposing a contract” mean the same thing?

No trainee working within contracted hours will have their pay cut.

Source: Jeremy Hunt, speaking in Commons debate, 11 February 2016

No one will see a fall in their income if they are working the legal hours.

Source: Ben Gummer (Parliamentary Under Secretary of State for Health), speaking in Commons debate, 21 March 2016

Is it the Government’s position that “contracted hours” and “legal hours” mean the same thing? Or did Gummer choose to to undersell the Government’s own guarantee on 21 March?

It will actually cost us more. If you’re going to ask more doctors to work at weekends, you’re going to have to pay more.

Source: Jeremy Hunt, on The Andrew Marr Show, 7 February 2016

[We have agreed] the cost neutrality of the contract

Source: Jeremy Hunt, in letter to Professor Dame Sue Bailey, 5 May 2016

Does the government consider “cost neutrality” and “it will actually cost us more” to have the same meaning?

What we do need to change are the excessive overtime rates that are paid at weekends. They give hospitals a disincentive to roster as many doctors as they need at weekends.

Source: Jeremy Hunt, speaking in Commons debate, 13 October 2015

What we’re actually doing is giving more rewards to people who work the nights and the more frequent weekends.

Source: Jeremy Hunt, on The Andrew Marr Show, 7 February 2016

Was the Secretary of State mis-speaking when he said that the contract reduced excessive overtime rates at weekends, or when he said that the new contract increased them?

Certain features of the new contract will adversely impact on those who work part-time, and a greater proportion of women than men work part-time; women, but not men, take maternity leave and some aspects of the new contract have certain adverse impacts regarding maternity; certain features of the new contract will potentially adversely impact on those who have responsibilities as carers.

Source: Government Equity Analysis of new contract, published 31 March 2016

Shorter hours, fewer consecutive nights and fewer consecutive weekends make this a pro-women contract that will help people who are juggling important home and work responsibilities.

Source: Jeremy Hunt, speaking in Commons debate, 18 April 2016

Is it the Government’s position that it got its own Equality Assessment wrong when it concluded that it discriminated against women?

No doctor will ever be rostered consecutive weekends.

Source: Jeremy Hunt, speaking in Commons debate, 18 April 2016

Good practice guidance will be published in the near future to support employers, including guidance on rotas and scheduling, and will make clear that, where possible, routine rostering of consecutive weekends should be avoided.

Source: NHS Employers, 31 March 2016

Does the Government consider that “ever” and “where possible” mean the same thing?

We will make the NHS more convenient for you. We want England to be the first nation in the world to provide a truly 7 day NHS.

Source: Page 38 of the Conservative Party Manifesto, 2015

There is concern that the government may want to see all NHS services operating 7 days. Let me be clear: our plans are not about elective care.

Source: Jeremy Hunt, speaking in Commons debate, 25 April 2016

Were the Conservatives up front about not including elective care in their plan to make the NHS more convenient with a truly 7 day service?

Source: First line of the first page of the Conservative Party Manifesto, 2015

The first line on the first page of this Government’s manifesto said that if elected we would deliver a seven-day NHS.

Source: Jeremy Hunt, speaking in Commons debate, 25 April 2016

Will Hunt correct the Parliamentary record for misquoting his own Party’s manifesto?

It is now not possible to change or delay the introduction of this contract.

Source: Jeremy Hunt, in letter to Dr Johann Malawana, 19 April 2016

We will pause introduction of the new contract for five days from Monday should the Junior Doctors’ Committee agree to return to talks.

Source: Jeremy Hunt, in letter to Professor Dame Sue Bailey, 5 May 2016

Is Hunt claiming to have achieved the impossible? Or was was his earlier statement erroneous?

Images used under by or by-sa licence as appropriate. Sources (in order of appearance): Ted Eytan, Roger Blackwell, University of Salford Press Office, Garry Knight, Ted Eytan (again), Garry Knight (again), NHS Confederation, Roger Blackwell (again). Thank you all!

There are roughly half a million beds in residential or nursing care homes in the UK.¹ Private providers operate almost all of these beds (90%) though the sector isn’t particularly lucrative: the average operator draws a profit of less than £5 per resident per day. Most beds are funded either in full (40%) or in part (10%) by local authorities. The NHS pays for a few (5%).

Central Government funding to local authorities was cut by 25% per person over the period of the last Government, though these cuts were not uniformly distributed across the country. This came on top of smaller reductions in funding over the previous five years. As a result, local authorities had much less to spend on social care. The number of day care places plummetted by 50% over a decade. About 20% fewer people received local authority funded care in their own home. And, partly as a result of this, the number of older people in residential or nursing care homes rose by more than 20%.

Over the next five years, we will see a perfect storm in social care for elderly people. The number of people aged over 75 is predicted to grow from 5.3 million today to 6.1 million in 2020 (a virtually unprecedented rate of increase, almost double what happened over the last five years). Yet Central Government funding to local authorities is to be cut further. Funding is being reduced while demand is predicted to increase more than ever before.

The burden will fall on the NHS, as it is in NHS beds that people often wait for care home places. The absurdity of this is that the average per-night cost of staying in an NHS hospital is three times greater than the average care home cost.

Yet there is another insidious factor imposed by Government which will push this situation from ‘substantial problem’ to ‘perfect storm’.

Most workers in residential and nursing care homes are paid minimum wage. By 2020, this will rise fromt £6.50 to £9.

Few could argue with giving hard-pressed workers a living wage. But given that average care home profits are less than 21p per patient per hour, care homes cannot maintain their current charges while increasing staff wages by £2.50 per hour. Yet they cannot raise their fees because Government cuts mean that local authorities can’t pay.

So what happens when care costs increase and funding decreases? First, care is cut: HC-One, Britain’s third-largest care home provider, is already training carers to take on highly skilled tasks which were previously done by more experienced and expensive nursing staff. But, since the cost of those carers is also increasing rapidly, this is only a stop gap solution. As Southern Cross, previously the UK’s largest care home provider, showed in 2011: care home providers can and will collapse.

As care home companies collapse, the supply of care home beds collapses with them. More elderly people get ‘stuck’ in NHS beds, at much greater cost to the taxpayer, and much greater risk to their own health.

And, to add extra thunderbolts to the storm, the number of NHS beds is decreasing rapidly: by nearly a quarter over the last ten years, with no sign of slowing. In this context, an increase in elderly people needlessly occupying NHS beds due to a lack of social care will cause the NHS to grind to a halt.

The underlying problem here is that the Government fails to understand that protecting NHS funding does not protect NHS services. Health and social care are two arms of the same beast: cutting one leaves the other with more to do. Yet the long-term solution isn’t obvious: there are limits to the burden of tax people are willing to carry to fund health and social care services.

The forecast is for bigger storms ahead.

Today, Philosophical Transactions of the Royal Society B has published a paper I co-wrote with the Chief Medical Officer and some public health colleagues on antimicrobial resistance policy. The abstract says:

Antibiotics underpin all of modern medicine, from routine major surgery through to caesarean sections and modern cancer therapies. These drugs have revolutionized how we practice medicine, but we are in a constant evolutionary battle to evade microbial resistance and this has become a major global public health problem. We have overused and misused these essential medicines both in the human and animal health sectors and this threatens the effectiveness of antimicrobials for future generations. We can only address the threat of anti-microbial resistance (AMR) through international collaboration across human and animal health sectors integrating social, economic and behavioural factors.Our global organizations are rising to the challenge with the recent World Health Assembly resolution on AMR and development of the Global Action plan but we must act now to avoid a return to a pre-antibiotic era.

The paragraph which has received most attention – perhaps surprisingly in a paper which predicts that more people will be dying of AMR than cancer and diabetes combined within decades – is one on food prices:

Public support for action to tackle AMR is crucial, as many measures to mitigate the effects of resistance will incur substantial financial and societal costs, which will ultimately be borne by the public, both through taxation and,probably, through higher purchase costs of products whose manufacturing methods are altered. For example, a pricing paradox exists in farming whereby antibiotics, an increasingly scarce natural resource, cost less than implementation of more rigorous hygiene practices. Reversal of this paradox may lead to higher food prices. While these costs are undoubtedly lesser than the long-term cost of unmitigated antibiotic resistance, they are also more immediate and, superficially at least, discretionary.

Anyway, it’s all quite interesting stuff (though I guess I’m a bit biased). Read it here.

Today marks the 202nd birthday of John Snow, the anaesthetist whose work on cholera changed the course of modern medical history, kicked off the modern era of public health, and—in 2003—saw him voted the greatest doctor of all time in a UK poll.

Snow is best known for his work on the 1854 cholera outbreak in Soho, London. He used what we would now call epidemiological techniques to map the outbreak and figure out that cases were centred around the Broad Street water pump. It turned out that the pump was dug mere inches from a cesspit which was leaking into the water supply, causing illness in those who drank from it.

The relevance of Snow’s work to modern public health cannot be overstated. Having spent much of his bicentennial year writing speeches with the Chief Medical Officer, I’ve found myriad parallels to draw between modern public health and the 1854 outbreak, and today seems as good a day as any to share some of them.

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In the recent past, public health has been criticised for being too remote and too disconnected from the communities it serves, leading to a considerable gap between what public health teams provide and what people actually need. There are a number of ways of tackling this, but perhaps one of the most important developments in the last few decades has been the cultivation of truly integrated multidisciplinary public health teams. These bring together people with a wide variety of backgrounds and skills to work on some incredibly knotty problems.

And so it was with the 1854 cholera outbreak.

Snow couldn’t have worked on the outbreak alone, as he had no community connections. Without his partnership with Reverend Henry Whitehead, the curate of St Luke’s Church in Soho, Snow would never have been able to find details of the cholera cases he needed to draw up his impressive maps and tackle the outbreak. Only by working with someone with different skills and a different background was Snow really able to connect with his community.

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Following the Health and Social Care Act of 2012, much of the responsibility for public health services passed to Local Authorities. You don’t have to spend too much time around public health teams to hear occasional grumbles about this—while people recognise the potential for influencing the wider determinants of health by working in Local Authorities, there are often frustrations about having to convince non-specialists of the utility and evidence base of certain courses of public health action.

And so it was with the 1854 cholera outbreak.

People often believe that Snow himself removed the handle from the infamous Broad Street pump to prevent the spread of the cholera outbreak. He didn’t; probably because that would have been considered vandalism, and possibly because—as an anaesthetist—plumbing skills weren’t his forte.¹ Instead, he talked his Local Authority into removing the pump handle. He initially found it difficult to get the message across, and his beautiful maps actually stem from his attempts to persuade the Local Authority to take action rather than from his investigation itself. Ultimately, the Local Authority either bought his argument or tired of him banging his drum, and removed the handle, saving the day.

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In modern public health, people often complain that national government interferes in the ability of local teams to act, either through interfering with the supply of funds, or through giving seemingly endless direction on things that should be considered or done at the local level.

And so it was with the 1854 cholera outbreak.

It’s an oft-forgotten footnote to the outbreak story that, having heard of what had happened in Soho, the national government ordered that the Broad Street pump handle be re-attached. There were too reasons for this: electorally, the closure of the Broad Street pump was a bad thing, for it was one of the most popular pumps in London, renowned for the clarity and taste of its water; scientifically, it was thought that the idea of faeco-oral transmission of disease was simply too disgusting to be true.

Yet when the pump handle was reattached, the outbreak didn’t restart. This was probably because the cesspit next to the pump well had been emptied—but it should also remind us that no matter how crazy they may seem, not all ideas from national government are completely mad.

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Effectiveness in modern public health can often involve challenging and overturning the status quo, sometimes in the face of considerable opposition from those with entrenched views.

And so it was with the 1854 cholera outbreak.

At the time of the outbreak, disease was thought to be transmitted by miasma—bad air. Today, it’s easy to underestimate the degree to which this faintly ridiculous theory was accepted: a glance through contemporary medical journals will reveal paper after paper on the design of hospitals and homes to promote the best flow of miasma. Indeed, one of the reasons so many Victorian hospitals had their morgues in the basement was so that miasma from the dead wouldn’t waft across other patients.

Snow—an anaesthetist, let us not forget—overturned the apple-cart of contemporary medicine by suggesting that disease could be water-borne. Virtually nobody believed him, and after 1854, he spent much of the following four years prior to his death trying to compile data to demonstrate his findings. His was a revolution that didn’t come easily. The Lancet, in an editorial on Snow’s theory in 1855, said

In riding his hobby very hard, he has fallen down through a gully-hole and has never since been able to get out again … Has he any facts to show in proof? No!

Yet, of course, germ theory proved Snow right—and The Lancet finally got round to publishing a correction on Snow’s 200th birthday.

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When working in public health in the North of England, it can often feel like breakthroughs made here are not fully appreciated, respected and integrated into practice until they’ve been endorsed by others—and particularly those in London.

And so it was with the 1854 cholera outbreak.

Snow was born in York trained at Newcastle Medical School. The first cholera outbreak he helped to tackle was in Newcastle in 1831, and though he was just 18 at the time, many believe that this is when he first developed the idea that cholera may be transmitted through water. Yet it wasn’t until his London-based work 23 years later that anyone took a blind bit of notice!

Wendy and I had a wander round the Scottish National Gallery last weekend, as we often do when we visit Edinburgh. I know really nothing about art; Wendy knows a bit more. But we both enjoy a few minutes which take our minds of anything that bears any resemblance to stuff we do at work.

As I wandered, I was reminded of two research papers, one of which I’ve intended to feature on here for years, and the other which came out only last month.

The first was written by a neurosurgery registrar I once worked with. I’m sure he’s a high-flying surgeon these days. It’s from JRSM (where else), and is called Brain ‘imaging’ in the Renaissance. He wrote about the resemblance of Renaissance paintings to brain anatomy. I like this paper because of the slightly off-kilter thought process it would take to notice these things, and also because—in reference to Gerard David’s painting of the Transfiguration of Christ—it contains one of my favourite paragraphs from any paper:

Gerard David’s painting of the ‘Transfiguration of Christ’ resembles a coronal section of the brain. We find again the concept of the ventricles as the abode of the soul. God is represented in the third ventricle, with Elijah and Moses in the temporal horns of the lateral ventricles. Jesus, conduit between the Word of God and the human race, resembles the brain stem/spinal cord, conveying the message from the brain to limbs and organs.

Even with the annotated images in the paper, I can’t even begin to buy the argument that there’s any intentional resemblance (or, indeed, much of a resemblance at all). But that doesn’t matter: the fantastical combination of high-level anatomy, religion and art in those sentences tickles my grey cells no end. It’s like worlds are colliding right in front of my eyes.

The second paper is similar, but has a slightly different—though equally bizarre—though process behind it. Consider, if you will, Pinturicchio’s Madonna and Child with St John the Baptist:

Clearly, there’s only one reaction anyone could have when examining this masterful artwork from centuries ago: what the hell is going on with Madonna’s little finger?! And it’s not just Madonna as painted by Pinturicchio that has something funny with the fifth finger—Botticelli’s Portrait of a Young Man depicts something very similar:

Having noticed the weird finger in a load of art from the same period, Lazerri et al undertook a systematic reappraisal of the fifth finger in Renaissance paintings, in which they try to explain the funny finger from a medical or anatomical perspective. They don’t really come to much of a conclusion. They say that lots of subjects of Renaissance paintings seem to have camptodactyly of the little finger, while others might just be holding their little finger in a weird position.

But the conclusion doesn’t really matter. I’m just in awe that someone can notice something so offbeat, and then pursue it right through to researching, writing and publishing a paper in a medical journal. That takes a serious degree of self-confidence in your own random thoughts. Brilliant!