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INSIDE HEALTH

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Programme 6.

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TX:听 10.02.15听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 ANNA BUCKLEY

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Porter

Hello.听 Coming up in today鈥檚 programme:听 sugar and puberty 鈥� we know too many sugary drinks can be bad for your teeth and your waistline but could they also be lowering the age that girls start having their periods?听 Aeroplanes and pregnancy 鈥� Margaret McCartney takes a closer look at new guidance on when it鈥檚 safe to fly.听 And female genital mutilation 鈥� FGM:

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Clip

The time they held you down in the floor and they cut you 鈥� that鈥檚 the time you need to fight for your life, so that鈥檚 what I did and lucky me I鈥檓 still here.

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Porter

A terrifying experience.听

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Awareness of FGM in the UK has never been higher but most people still don鈥檛 really understand what it involves. Later on we will be answering the questions people are often too afraid to ask.

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But first the state of our health service or more accurately the state of the people who work in it. The NHS is struggling to cope with demand at the moment thanks to the combination of winter pressures, limited resources and the biggest administrative overhaul it has faced in its 66 year history. And its staff appear to be struggling too.

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Clip

鈥淚鈥檓 a GP and I was crying on the way into work, completely exhausted.听 It鈥檚 just so stressful running a practice, you can鈥檛 trust people higher up and there just isn鈥檛 the money.听 What do I do?听 Not pay my receptionist?听 Drop services?鈥�

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Porter

According to the latest NHS Staff Survey:

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- 59% of those responding don鈥檛 feel valued

- 39% have felt unwell due to work related stress in the last year

- less than a third believe there are enough staff to enable them to do their job properly

- and a similar proportion are so concerned about standards of acute care that they would not be happy for a friend or relative to be treated in the unit where they worked.

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And that matters because 1 in 30 employed adults in the UK now works for the NHS and, more importantly, they care for the rest of us.

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Clip

鈥淚 am nurse. Management is unseen and unknown, a bit like the Hunger Games, though they are as confused and stressed as anyone. Managers do lots of floor walking and staff crap themselves鈥�

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Porter

Another candid quote from the NHS Listening Project - a new initiative that taps into the mood of听 NHS staff. It鈥檚 led by Dr Clare Gerada, a GP and, up until recently, the Chair of the Royal College of General Practitioners.

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Gerada

I think they鈥檙e actually new issues, I think what we鈥檙e seeing now is increased rates of bullying, whistle blowing, increased rates of doctors and others emigrating, early retirement. Unfortunately we鈥檙e also seeing a whole spate of suicides amongst doctors.听 So this is real pain and real distress today.

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Porter

It鈥檚 been a tough time for everybody these last five or six years economically.听 I mean I suppose one of the things about the NHS is it does insulate you slightly from the real world, most of us have still got our jobs, we鈥檝e seen some pay rises and some pay cuts but it鈥檚 a pretty safe place to work.听 Why is it that the NHS seems to be struggling particularly at the moment?

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Gerada

Well I don鈥檛 think it is a safe place to work actually, I think it鈥檚 one of the worst employers that we have and there鈥檚 evidence for that.听 I think it鈥檚 struggling at the moment because we鈥檝e seen massive reorganisation, the NHS is in constant transition.听 And transition leads to depression and loss.听 We also see anxiety 鈥� the name, shame, blame culture that has now been hard wired into the NHS.听 And what we鈥檝e found is that fear, fear of annihilation, fear of loss of your job, fear of exposure, of actually being vilified and ridiculed, literally, on the front pages of our newspapers is probably the single most common emotion expressed in these listening exercises.听 People are going into work now every day dreading what they鈥檙e going to have to be exposed to.

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鈥淎s a GP a colleague of mine had over 200 phone appointments in one day, even after redirecting to colleagues he still had a 133 to get through.听 Many of my colleagues bury their hostility and just work harder.鈥�

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Porter

You鈥檙e under that sort of pressure and you鈥檙e that angry, if you like, and hostile then it鈥檚 got to come out in your consultation as well.

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Gerada

I think it probably 鈥� what happens actually is the paradox is you work harder and things get harder, that鈥檚 why we see amongst doctors and nurses actually so much burn out depression and unfortunately in some cases suicide because instead of removing themselves from a toxic environment they think they can get through it by just burying their hostilities and working harder and harder and harder.听 And what鈥檚 happened in the NHS is something called splitting, which is that we鈥檙e all pitched against each other, so doctors versus managers, doctors versus nurses, this isn鈥檛 about managers putting policies on to doctors and nurses, they themselves are living in fear, living 鈥� having to get through the day.听 Other doctors told me about working was like a battlefield.听 And that actually their success was measured on surviving the day in that battlefield.

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Porter

But playing devil鈥檚 advocate here, a lot of people listening might say well actually I鈥檓 not particularly enamoured with my work at the moment, it鈥檚 pretty stressful, I work long hours, I鈥檝e had pay cuts, just might even be in jeopardy.听 Why should we have so much sympathy for the NHS?

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Gerada

Because the clinicians within the NHS are probably the only people 鈥� I mean there are others 鈥� who are exposed daily to death, despair and desperation.听 And if we鈥檙e expecting people to be exposed to that then we have to look after them.听 I鈥檓 not saying this is - my job鈥檚 harder than your job - but actually we have to look after the people who look after the most vulnerable in our society.

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Porter

We need resilient staff in the NHS.

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Gerada

Do you know I don鈥檛 like the word resilience, this isn鈥檛 about me as a clinician having to wear an extra flak jacket to survive my day at work, this is about making it safe for the clinicians, the managers, the staff who work in the NHS to feel psychologically secure.

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Porter

And it is not just the wellbeing of NHS staff that is at stake. New evidence has found a strong correlation between staff morale in an NHS Trust and the standard of care it provides to the public. Put simply - happy hospitals are more likely to have happy patients.

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The study was led by Martin Powell, Professor of Health and Social Policy at the University of Birmingham.

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Powell

What we鈥檝e done essentially is try to link two sets of data over about a three year period.听 So on the one hand we鈥檝e got data of staff satisfaction as measured by the NHS staff survey and on the other hand we鈥檝e got data of performance or outcomes in the NHS.

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Porter

How strong was that link between the two, was it a pattern you saw in nearly every hospital?

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Powell

We looked at the general pattern over all the trusts but we found basically that satisfied staff tend to work in better hospitals in terms of lower mortality, lower hospital acquired infection and more satisfied patients.

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Porter

But this is important because this is hard evidence then that staff morale can have an impact on clinical outcomes, it鈥檚 bad for patients if staff morale is low is the take home message?

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Powell

I think so yes.听 In some ways that鈥檚 been known for many years because if you go back through a lot of the NHS policies since about 1997 you can find something like that written in policies making that point.听 And I think things have improved over time, the NHS is I think clearly now taken engagement and involvement and health at work much more seriously.听 I think there are certainly some trusts out there who clearly are doing very well on this agenda but the problem is really how can we sort of bottle this and how can we spread it across the NHS to make sure that every trust is as good as the good ones?

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Porter

Martin, how hopeful are you that this study, the biggest of its type, to draw this relationship, is finally going to galvanise some action?

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Powell

Well I think it鈥檚 another drip in that sort of drip, drip, drip pattern of evidence but I think perhaps one reason for being hopeful at this stage is the idea that particularly when the NHS is very short of money then anything that tries to contribute towards reducing staff absenteeism or anything that does appear to link with increased performance must be worth taking very seriously.

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Porter

Professor Martin Powell confirming that what many other industries have known for years, also applies to the NHS.听 Clare Gerada:

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Gerada

I鈥檓 not surprised at all and it鈥檚 very good to hear the evidence and I鈥檝e mapped 86 recommendations that have been published over the last eight years but virtually none of them have been implemented.听 I think what we need now is from the very top, our politicians and our senior policy makers making sure that they take responsibility for the health and wellbeing of the staff that work in the NHS.

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Porter

But if they realise that there鈥檚 an issue, and this is such an important subject politically as well, as well as to the health and wellbeing of the nation, why isn鈥檛 something being done about it 鈥� you talk about eight years, I mean that鈥檚 an awfully long time?

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Gerada

I think it鈥檚 not being done because there鈥檚 some belief that those that work in the NHS looking after patients are different from those that they look after.听 There鈥檚 some dissonance between people realising we are the same people.听 Even using the term patients, we talk about a patient led health service, patient centred, immediately puts a distance between those that are patients and those that care for those.听 I think what we need to do now is to understand that if we don鈥檛 look after those that look after the most vulnerable we will lose the workforce.

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Porter

So we鈥檙e both very much aware of the financial constraints the service is under at the moment.听 Let鈥檚 assume whoever comes into government next says look we would like to give you more money but there simply isn鈥檛 more money to give to the service, are you suggesting that a simple attitude change and more support for the one million plus staff in the service could actually make a difference, without spending anymore money?

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Gerada

Mark, it makes a phenomenal difference, there鈥檚 a great deal of evidence looking at organisational compassion and things don鈥檛 cost a lot, this is about asking people how they feel, this is about managers and seniors understanding the pain that some of their staff might be exposed to.听 What the staff want, the majority of the staff want, they don鈥檛 want pay rises, what they want is to feel respected, they don鈥檛 want to wake up every morning to hear our leaders telling us we鈥檙e doing a bad job.听 Like the rest of us we want to be stroked, we want to be appreciated.听 It doesn鈥檛 cost money to be appreciative of staff, it doesn鈥檛 cost money to say thank you.

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Porter

Dr Clare Gerada. And there is a link to Professor Martin Powell鈥檚 research into the impact of staff morale on standards of clinical care on the Inside Health page of the Radio 4 website.

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Now if you are one of the half听 million or so women in the UK planning on becoming pregnant this year, fed up with the cold weather and leafing through the holiday brochures dreaming of a warm beach, then you might be interested in new guidance on pregnancy and flying.

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Dr Margaret McCartney is in our Glasgow studio.听 Margaret, where has this come from and does it change anything?

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McCartney

Well this is new guidelines from the Royal College of Obstetrics and Gynaecology, they鈥檙e saying that the safest time to fly, if you鈥檙e a pregnant lady, is before 37 weeks gestation, if you鈥檙e an uncomplicated 鈥� pregnancy and otherwise well.听 And if you have a twin pregnancy then you鈥檙e safer to fly before 32 weeks as opposed to 34 weeks, which is what they鈥檇 said before.听

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Porter

I mean that 37 week limit was that the pre-existing limit?

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McCartney

It was and after actually 鈥� if you look on the Ryan Air website, the BA website, EasyJet, they鈥檙e all pretty much saying the same thing 鈥� fly before 37 weeks.听 However, a lot of airlines will ask for a letter from your midwife to say that you鈥檙e fit to fly after 28 weeks, i.e. that you鈥檙e not a woman who鈥檚 got a complicated pregnancy in any way.

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Porter

So other than the change to 鈥� if you鈥檙e having twins 鈥� they鈥檝e dropped that limit a couple of weeks, there鈥檚 been no change to the guidance, the new evidence reinforces that the existing guidance was good?

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McCartney

Yeah, I think for many people who are expecting a baby and their partners there is a bit of anxiety around air travel and I find this as a GP, in the first trimester of pregnancy quite often people are a little bit worried or afraid of flying in case something bad might happen.听 And鈥�

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Porter

Miscarriage being the big problem there.

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McCartney

Exactly, that鈥檚 the big fear I think that many people have and of course sadly many early pregnancies do end in miscarriage.听 But the Royal College of Obstetrics and Gynaecology have looked at the evidence and found no evidence that flying in early pregnancy will increase that risk.

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Porter

The other concern that people often have is that of blood clots.

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McCartney

Yeah well there鈥檚 no doubt that blood clots are a problem in pregnancy, as well as for people who are not pregnant and of course flying does increase that risk.听 Now they have given quite a lot of information to women who are flying, suggesting that they are at a higher risk when pregnant and also for six weeks after giving birth.听 They suggest that if you have a flight of less than four hours you鈥檙e unlikely to need any special measures and are suggesting that over four hours of a flight then they鈥檙e recommending exercises on board the aeroplane, possibly compression stockings, possibly drinking fluids.听 I think the evidence for those things are a bit more hazy but they鈥檙e basically saying there is a bit an increased risk so do what you can to try and mitigate that risk.

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Porter

But the bottom line here is this sounds like a useful one stop shop for women who are either pregnant or planning on trying for a baby, they can look at everything that they need to know in one place here, it鈥檚 definitive knowledge.

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McCartney

Yes I think that鈥檚 the best summary of knowledge that we have at this present time.听 And I think it鈥檚 quite reassuring 鈥� pregnant women are told time and time again of all the things they can鈥檛 do in pregnancy, it鈥檚 quite nice to have some guidance that says that we think it鈥檚 pretty safe for you to do this.

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Porter

Hurrah, at last some advice on what pregnant women can do rather than what they can鈥檛 do.听 Thank you very much Margaret.

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And, as always, you will find useful links on Margaret鈥檚 blog - go to our website for more details.

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Sugar appears to be public enemy number one at the moment and its status is unlikely to be enhanced by new research from America suggesting that puberty in young girls may be influenced by how many sugary drinks they consume. In particular they may encourage an earlier menarche - the age at which periods start.听 Karin Michels is Associate Professor of epidemiology at the Harvard School of Public Health.

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Michels

We were looking at diet in general, we were looking at dietary patterns also and in particular I had my hypothesis that milk consumption and dairy consumption may actually promote early onset of menarche.听 But that was not the case.听 And then it was actually a little bit of a surprise finding to us that the sugar sweetened beverages stood out.听 So we didn鈥檛 necessarily expect this but we did find that these sugar sweetened beverages stood out and do predict an earlier age at menarche among the girls in our study.

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Porter

And looking at your results how pronounced was the effect?

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Michels

So for a girl who drank one can of soda, let鈥檚 say, per day or more, compared to a girl who only drank a can less than once a week there was a 2.7 months earlier onset of age at menarche.

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Porter

And was that taking into account other confounding factors that might have been influenced, for instance the girls鈥� weight?

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Michels

Yes that is after accounting for all the potential factors that we could think of.听 And you鈥檙e perfectly right to mention a girl鈥檚 weight because we know that weight is one of the most important determinants of a girl鈥檚 age at menarche.

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Porter

So the heavier she is the more likely she is to start her periods early?

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Michels

That is correct.听 And we accounted for that and that was not the explanation of our findings.

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Porter

What do you think the mechanism might be for the link?

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Michels

Well it鈥檚 important to note that we only found an association with drinks that have added sugar.听 So you have to think of spooning in tablespoons of white sugar, which is called sucrose.听 And this sucrose is what raises a person鈥檚 insulin level and this is also associated with a higher oestrogen level. Now this higher oestrogen level may signal the body 鈥� okay the girl is ready to go into menarche. So I think this may be an underlying mechanism, although I have to emphasise that our study was really observational, it was an epidemiologic study which means we only connect the sugar sweetened beverages with the onset of menarche, we did not really study the underlying mechanisms.

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Porter

Was it just with drinks like sodas because of course natural fruit juices 鈥� orange juice, apple juice in particular 鈥� also contain almost equivalent amounts of sugars?

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Michels

That is correct but it鈥檚 a different sugar.听 So we found associations only with the sodas and what are called fruit drinks.听 Now fruit drinks are drinks that may have a very low proportion of real fruit juice and a lot of added sugar.

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Porter

They鈥檙e more soda than fruit juice really.

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Michels

They are more soda than fruit juice.听 We did not find an association with real fruit juices, like 100% orange juice or 100% apple juice.听 Now the sugar in these more natural fruit juices that really are coming from fruit is a different sugar, it鈥檚 fructose and fructose does not raise your insulin levels even nearly as much as sucrose, which is this added sugar in these sugar sweetened beverages.

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Porter

Professor Karin Michels.听 And I should point out that fruit juices actually contain a range of sugars, including sucrose, but it is the fructose in them that lowers the spike that triggers insulin release. And there is more on Karin鈥檚 research on our website.

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What do you know about female genital mutilation - FGM? The practice has received a lot of coverage recently, including the acquittal just last week of a London doctor charged with performing the procedure.听 But most people, including many healthcare professionals, don鈥檛 know that much about it.

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Aissa Edon, a midwife who specialises in caring for women who have undergone FGM, knows more than most.听 At this stage I should warn you that the following interviews include some graphic imagery but such is the nature of the subject.

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Not only does Aissa have a professional interest as a midwife, she is also one of 140,000 women or so thought to be living with some degree of FGM in the UK.

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Edon

Nobody can say now they don鈥檛 know about FGM, nobody can say now they don鈥檛 know female mutilation is forbidden by the law, nobody can say that.听 But again I don鈥檛 think dealing with FGM by the law is obviously the right things to do, I think it鈥檚 more about raising awareness, it鈥檚 more about prevention and education.听 And for the community who are practising this practice is to understand the consequences of the practice.听 I鈥檓 a FGM myself and I like not to be called victim or survivor but I liked to be called as a fighter and I think like why I鈥檓 saying fighting is just because like the time they held you down in the floor and they cut you, that鈥檚 the time you need to fight for your life, so that鈥檚 what I did.听 And lucky me I鈥檓 still here.听 But again I was kind of lucky because FGM, the tools they use for me was a razor blade and sometimes they use the razor blade for a 1,000, 10, 11, two or three, little girls, so it鈥檚 the same razor blade for everybody.听 So I was lucky I didn鈥檛 get any HIV or anything like that.听 And also the clitoris is an organ with a lot of nerves inside, a lot of blood inside and lucky me I didn鈥檛 bleed to death, so I could have bled to death, so it didn鈥檛 happen.听 What鈥檚 happened to me is more very, very huge psychological impact but also a lot of urinary problems and I had pain on my scar tissue from my six old to my 23 years old, every day like a stabbing pain, every day for all these years.

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Porter

Aissa Edon.听

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NHS England has recently launched its first e-learning module on FGM for healthcare professionals. Its author is Professor Sarah Creighton, a consultant gynaecologist at University College London Hospitals. Why now?

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Creighton

I think that the increasing realisation that FGM is a problem that presents throughout the health service, that doctors need to know how to manage women with FGM but also how to protect girls that might be at risk of FGM.听 And until recently there鈥檚 been very little for health professionals 鈥� doctors, nurses, midwives 鈥� to look up and to find out a bit more if they鈥檙e faced with a patient.听 But more importantly I think we鈥檙e probably missing patients, we鈥檙e missing women that we could actually help.

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Porter

We hear a lot about FGM in terms of cultural settings, the legal setting but a lot of people must be wondering what it actually is 鈥� can you explain what we mean by female genital mutilation?

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Creighton

So it鈥檚 essentially any procedure that damages or removes the woman鈥檚 genitalia.听 And in 1995 the WHO 鈥� the World Health Organisation 鈥� developed a classification where FGM鈥檚 classified into four types.听 So type one would be removal of part or all of the clitoris.听 And type two is removal of part or all of the clitoris and the labia.听 Type three is narrowing of the vagina.听 And that鈥檚 often done by removing the labia and closing them together, either stitching or other methods to close the labia to make the vagina very narrow.听 And in type three the clitoris may also be removed but sometimes it鈥檚 not.听 And then type four is a kind of classification for everything else that isn鈥檛 one, two or three.

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Porter

And in general in a country like the UK who鈥檚 doing this procedure and when?

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Creighton

The women that are seen in the UK are by far and above women that have had FGM elsewhere.听 FGM is almost always performed on children, so FGM as a child somewhere else and are now seeking help with the health consequences in the UK.

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Porter

When you say a child what sort of age?

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Creighton

The most comprehensive data is from UNICEF and they say that almost all FGM is performed on children, about half - and that means under the age of 15 - about half of which is performed between birth and five years and the other half between the ages of five and 14.听 So it鈥檚 really rare to be performed on adult women for the first time.

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Porter

What are they using to do it?

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Creighton

It depends on where it鈥檚 done, so traditionally it may be razor blades, knives, glass to remove tissue and then the raw edges may be stitched together, maybe held together with thorns of pastes.听 If it鈥檚 done obviously in a medical setting it may well be the surgical instruments that you and I would know.

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Porter

Are the type of practices being done changing because there鈥檚 increasing awareness about this?听 I mean are people doing things 鈥� perhaps more subtle so that they鈥檙e not caught?

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Creighton

There鈥檚 little evidence, it鈥檚 a very underground practice but certainly there are trends that UNICEF have reported on internationally and that we are starting to see.听 So the trends are that types of FGM that cause less damage seem to be more common, so cuts around the clitoris rather than removing tissue and that means that there鈥檚 less tissue damage, it means that it鈥檚 harder to detect because children heal very well and if you have a small cut and you don鈥檛 see a child for several months or years it might be really hard to say whether FGM鈥檚 been done.听 The other trend is that perhaps it鈥檚 being done on children on a younger age, as children become more aware, because if they鈥檙e younger they鈥檇 be less likely to object but also less likely to disclose to someone else that they鈥檝e had it done.听 There鈥檚 not good UK data to back that up but those are trends that we think we鈥檙e seeing.

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Porter

Now as a surgeon you can鈥檛 reinstate a woman鈥檚 clitoris but I presume there鈥檚 things you can do if the vagina鈥檚 been scarred and narrowed 鈥� can you help?

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Creighton

So in type three FGM, where the vagina is narrowed, you can do a procedure called a de-infibulation and that opens the scar tissue across the vagina.听 So it鈥檚 sometimes called a reversal, which is not a correct term, you can鈥檛 restore tissue that鈥檚 been removed and you can鈥檛 remove scarring that鈥檚 there, there鈥檚 usual quite extensive scarring following FGM.听 But you can open the vagina so that sex is less painful and possible and delivery of a baby is safer.

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Porter

Do women in the UK come and ask for help or is it something that they present with when they鈥檙e pregnant and something that has to be dealt with?

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Creighton

I think there are two groups really, so in the UK women who are pregnant will always see a midwife or a doctor at some point in their pregnancy and so some women come because they鈥檙e pregnant and are found to have FGM.听 But there is certainly a group of younger women who are coming along who are not pregnant who are seeking help 鈥� I need to be examined, do I need anything doing, what鈥檚 happened to me.听 So there are women who are coming along to be seen not just because they are pregnant and they鈥檙e seeking advice.

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Porter

What are the implications for the girl or the woman immediately, is this a risky procedure to have done?

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Creighton

It鈥檚 a huge risky procedure, the difficulty is that there鈥檚 very little data on it and the reason for that is most of the studies looking at FGM are quite recent, they鈥檙e studies that are based on retrospective reports, so they鈥檙e asking women about what they remember from their FGM.听 And obviously if you鈥檙e dead you鈥檙e not there to be asked in the studies, so there are no good data on the number of women that 鈥� or girls 鈥� that would die from FGM.

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Porter

And presumably I mean that鈥檚 from haemorrhage and infection would be the two big killers.

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Creighton

Yeah, so haemorrhage 鈥� the clitoris has a very great blood supply 鈥� so haemorrhage from the clitoris in particular.听 But infection, so septicaemia, wound infections, tetanus and gangrene.听 There鈥檚 a risk of blood borne infections, so whether it increases the risk of hepatitis or HIV is difficult, I mean those infections are common in areas where FGM is common.

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Porter

Assuming the woman survives the initial procedure what are the common complications going forward?

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Creighton

You can break them down really into gynaecology problems, obstetric problems with delivery and clearly psychological and psychosexual problems.听 So if, for example, a woman has what I鈥檝e said is a type three FGM, where the vagina is narrowed, she will pass urine through a very tiny opening, she鈥檒l have a period through a very tiny opening.

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Porter

Can she have sex, vaginal sex?

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Creighton
It can be really difficult, so that鈥檚 often how women might present to a gynaecologist because they have a partner and they are unable to have sex, they have a very tiny opening that might be a few millimetres.听 So sex may be impossible or if it鈥檚 possible it may be very painful.听 Of course if the clitoris has been removed that鈥檚 part of the sexually sensitive tissue for women so even if sex is possible it may be less pleasurable because there鈥檚 less sensitive tissue there.听 So problems with sex are another area that women will come.听 You can get pregnant through a very small vaginal opening, even if you don鈥檛 have full penetration 鈥� sperm can go through.听 So we see women who are pregnant and the vagina is really narrow and it鈥檚 not safe to have a vaginal birth.听 And so women with FGM who are pregnant need to be seen by a midwife or an obstetrician who can assess what type of FGM they have had and see whether anything is necessary to make the delivery of their baby safer.

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Porter

Professor Sarah Creighton.听 And there is a link to the new FGM learning module on our website. Where you can also download the programme, read a transcript or listen again.

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Next week - hepatitis C and the latest generation of anti-viral drugs set to revolutionise treatment. And a new, rather unconventional approach to weight loss that is getting some striking results and it鈥檚 available on the NHS.听 Join me then to find out more.

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ENDS