Weeding out the bugs in cannabis legalisation policies

As the new President-Elect was making his victory speech on 9 November last year, some liberals were rejoicing, rather than despairing, about what had just taken place at the ballot box. What they saw, sprouting among the rubble of the swing-state firewall that was meant to deliver the election for Hillary Clinton, were some very literal green shoots of progress, as four states – Massachusetts, Nevada, Maine and California – voted to legalise cannabis for recreational use. Continue reading

Progressive children’s legislation in reverse gear?

By Jane Tunstill, Emeritus Professor at Royal Holloway, University of London. 

It is no coincidence that the longest-running play on the London stage, The Mousetrap, which is still being shown after 64 years, is based on a key tragic event in the history of childcare policy in this country. Agatha Christie recognised that the death of Denis O’Neill in 1945, at the hands of his foster parents, was a topic to engage the attention of her readers, and audiences have certainly proved her right. The tragedy, and subsequent enquiry, directly triggered the 1948 Children Act, which introduced a national framework of children’s departments responsible for the systematic oversight of the welfare of children. Continue reading

From STEM to STEAM: Lessons from biomedical and health research

Professor Jonathan Grant

This blog post is an edited version of a speech given by Professor Jonathan Grant to The Culture Capital Exchange at St George’s House in Windsor Castle for a debate on the issue of excluding arts and humanities from the UK government’s ‘STEM’ research agenda. The full speech, and those of other invited speakers can be found on the Culture Capital Exchange website.
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Shifting policy attention to the social care workforce

Dr Shereen Hussein is Principal Research Fellow at the Social Care Workforce Research Unit in the Policy Institute at King’s. 

The year 2014 has seen growing attention given to the social care workforce, with a number of high profile reviews being published, including the Kingsmill Review ‘Taking Care’, the Unison report into home care ‘Time to care’, the Demos review of residential care and, launched today, the Burstow Commission review on the future of the home care workforce, ‘Key to care’.

The question of how to maintain a high quality social care workforce has received academic scrutiny for many years, with research highlighting the lack of career progression, low pay and status, and the inability of the sector to attract young and diverse groups of workers as some of the key issues. There are many reasons why we are in this state of ‘crisis’ but at the core is the assumption that care work is something that can be performed by ‘anyone’—it does not require a vast amount of skills and we can always find a willing worker to do it. While these assumptions go unspoken, they underline how the sector operates and derive from the perception of care work as ‘women’s’ work that comes ‘naturally’; if the family can do it why do we need a skilled professional to do it?

Key to Care (Burstow Commission report)Well, as you might have guessed, the majority of these assumptions are indeed wrong. Care workers are increasingly required to perform many tasks that go far beyond personal care; they are caring for adults and older people with complex needs, severe dementia and communication challenges. They are expected to provide care that is tailored to the needs of the people they care for and to be sensitive to their specific circumstances. The Care Act 2014 emphasises the key principle of users’ wellbeing as central to social care, thus care workers are expected to perform their tasks with a clear understanding of how to promote dignity, protect the people they support from abuse and neglect, and respect their wishes and autonomy. Additionally, the commitment to personalisation and minimising the use of residential (care home) services means that care workers increasingly provide care in people’s own homes and their communities, usually on their own without supervision or social support. Thus, in their day-to-day activities, care workers employ a high level of knowledge and skills ranging from those related to the understanding of specific illnesses and conditions to communication and softer skills.

It is difficult then to fathom the current lack of appreciation of this workforce. From evidence of many being illegally paid under the National Minimum Wage (Hussein 2011HMRC 2013) to increasingly fragmented working conditions, with zero hour contracts becoming commonplace. It is no surprise then that care worker vacancy and turnover rates are considerably higher than the UK labour force average (Hussein et al., in press).

In fact, one might wonder why over a million people continue to be care workers given these conditions. To understand this we need to look not only at who works in this sector, but more importantly what motivates people to do this work in the first place. Our extensive research in this area indicates the most common reason for people to work in care is their wish to help and assist others. This is expressed by several groups of workers, whether British women in their mid-forties, migrant workers in their thirties, or the few younger people aged under 25 years old. The majority relate their work to their own personal experience and the informal care they provide, or have provided, to members of their families. With this attitude many care workers go above and beyond their duties, usually continuing to finish their care tasks even when the 15-minutes allocated per visit have elapsed. But this comes at a cost: stress, lack of support and job insecurity are common themes discussed by care workers. And of course, there are some who join the sector simply because they have not gained enough qualifications to secure other jobs or because they need an employment foothold in their new migratory destination.

However, the key question remains: how can we recruit and retain a high quality workforce that is capable of meeting the exponential demand associated with an ageing population and the increasing diversity and complexity of care provision? It is simply not possible to rely on people’s goodwill and hope for the best. Especially when the current care provision structure is likely to reduce the key non-monetary reward for this workforce: getting the emotional reward from service users themselves. By operating a care commissioning system that is run by the minute and reducing the opportunity to have co-workers and supervisory support, care workers are in many cases left stressed taking their worries back home.

The sector needs to actively attract and retain high quality workers; this may be achieved first by providing basic job security and support. All the reviews into this sector call for enforcement of the basic pay level, the National Minimum Wage, and a reduction of potential exploitation through zero hour contracts and an end to inappropriate15-minute care slots. But this is only the start, care work needs to be regarded as a ‘career’ not ‘casual’ work. This can only be achieved by establishing a clear training and career path that can feed into the wider health and care sectors. In my view, care work needs to be better regulated and care workers registered, and more need to join unions and so have a collective voice and bargaining power. A more complex problem is the public perception of the value of care work. As a society we need to appreciate and value this work more by visualising ourselves in old age and imagining how we would like to be cared for and by whom.

Dr Shereen Hussein is Principal Research Fellow at the Social Care Workforce Research Unit in the Policy Institute at King’s. She speaks on this topic in this Policy Institute video.

The Social Care Workforce is currently undertaking a major project examining the workforce issues referred to in this post, the Longitudinal Care Work Study.

Reference

Hussein, S., Ismail, M. & Manthorpe, J. (in press) ‘Changes in turnover and vacancy rates of care workers in England from 2008 to 2010: Panel analysis of national workforce data’ Health & Social Care in the Community.

Who Killed Mrs X? The Global Threat of Antimicrobial Resistance

Post by Professor Jonathan Grant and Jirka Taylor. Originally posted on The RAND Blog on 18 September 2013.

When Sir Alexander Fleming accepted the Nobel Prize in 1945 for the discovery of penicillin he predicted the advent of antimicrobial resistance through a hypothetical illustration: “Mr. X. has a sore throat. He buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails. Mrs. X dies”.

As we enter the adolescence of the 21st century, Mrs. Xs are dying daily. In Europe, drug-resistant bacteria are responsible for 25,000 deaths a year, with related healthcare costs and productivity losses of €1.5 billion ($2 billion); over half a million people worldwide have drug resistant tuberculosis; in the United States, about 15 per cent of pneumococcal isolates are resistant to penicillin. The World Health Organization (WHO) estimates that, since their development, antimicrobial drugs have added around 20 years to our life expectancy — 20 years that we are in danger of losing.

Although widely used, the term “antibiotics” is a misnomer. Strictly speaking antibiotics only occur naturally and, as the vast majority of pharmaceuticals are manmade, we should describe them collectively as antimicrobials specifying the type of microbe that they intend to affect — antibacterial, antiviral, antifungal. Today 35 million courses of antimicrobial drugs are prescribed annually by family doctors in England and millions of additional doses are given in hospitals each day, with prophylactic use of antibacterials before surgery now a routine precaution for many types of operation.

But the antimicrobial drugs are no longer working as they once did. The bugs that they are supposed to attack are becoming increasingly resistant. Microbes follow the same rules of evolution as we do. Through reproduction and natural selection the fittest survive. The problem for us is that the “fittest” means the most resistant. Unlike humans microbes breed in days, not decades, thus amplifying Darwinian patterns of evolution.

The Chief Medical Officer for England, Professor Dame Sally Davies, highlighted this threat in a recent book, The Drugs Don’t Work. In the book Dame Sally and her co-authors, including Jonathan Grant, set out a “Microbial Manifesto” to address the threat of antimicrobial resistance. Three areas of action are identified. The first is the need to improve personal hygiene, behaviour and awareness. It is shocking to learn that only 1 in 20 people wash their hands for long enough to kill off all infectious bugs after going to the toilet. Given that each human has between 2 and 10 million bacteria between fingertip and elbow, and that some of these are infectious, then improved basic personal hygiene would reduce the demand for antimicrobial drugs. A similar antisocial behaviour is to demand antibacterial drugs from your doctor when you have a viral infection: they don’t work, waste a scarce resource, and contribute to resistance. Despite this, studies in Europe and the United States have consistently shown that the majority of people think that antibacterial drugs are effective in treating the common cold and influenza.

The second area of action is to incentivise innovation. No new class of antibacterial drug has been developed since 1987. This is not too surprising as it costs over $1.5b to develop a successful drug and the market for antibacterial drugs does not justify this level of investment. The returns are likely to be larger for chronic diseases, such as diabetes, than infectious disease — partly as medicines are prescribed over a longer period (sometimes for the lifetime of the patient). There is also a concern that if a new antibacterial agent was developed its use would be regulated, given the problem of resistance. In other words we want the new drugs, but don’t want to use them. There are a number of approaches to address this failure to innovate that can be structured around the “four Ps” of partnerships, prices, prizes and patents. Product development partnerships between the public and private sector could reduce the costs of research and development. Advanced market commitments where governments or foundations could promise to purchase a given quantity of a new antimicrobial drug at a price agreed in advance may provide an incentive for the private sector to re-invest in R&D. A prize fund could help promote the need for new drugs and provide early financial reward and revenues for a successful inventor. Finally, extending the patent life of new classes of antimicrobial drugs would extend its revenue stream. Some of these ideas are already being tried but we need to radically scale-up their use.

The third area of action requires an international agreement that: controls the use of antimicrobials; provides technical and financial assistance to poor and low-income countries in balancing access to essential drugs with action to curb resistance; monitors the emergence of drug-resistant microbes; and establishes systems to ensure compliance with the agreement. An analogous example would be the WHO Framework Convention on Tobacco Control, which came into force in 2005 “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”. The treaty’s provisions include rules that govern the production, sale, distribution, advertisement and taxation of tobacco. A similar approach is needed to address antimicrobial resistance.

We live in a time when there are many global threats — (in)security, terrorism, population ageing, and climate change. Antimicrobial resistance is a clear and present danger that needs to be added to this list. As with all these threats, a nuanced, multifaceted, evidence-driven and coordinated response is required. If we do nothing then within a generation the risk of catching an infection while having a routine operations such as a hip-replacement may be too dangerous to contemplate.

Originally posted on The RAND Blog on 18 September 2013.