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INSIDE HEALTH – Programme 8.

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TX:Ìý 26.02.19Ìý 2100–2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Hello. Coming up today:Ìý Deconditioning – can spending 10 days in hospital really age people 10 years?

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Clips

Inadvertently what hospitals often do is they decompensate, not intentionally but by the very nature of caring for people we’re actually sometimes, in many cases, exacerbating their problems.Ìý So, it’s about a cultural change really, the NHS is very good for caring, which means in a bed, which is the complete wrong thing for frail older adults, so what we do is really, as soon as they arrive, if they’re able to, we mobilise them, try and put them in their own clothes and just sort of put in that culture which is about they should be as independent as possible.

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The classic one is somebody who gets admitted with a fall and a background of dementia and this person is then deemed at high risk of falls, the cot sides are put up, their mobility is reduced, they might be catheterised because they’re being incontinent and they’re being constrained within their bed.Ìý And what we know is that you can lose 2-5% of muscle power in the first 24 hours of unnecessary bed rest.

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Porter

And the alcohol harm paradox – why is it that less affluent drinkers tend to develop more problems than their better off peers even if they drink exactly the same amount?

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But first, matters of the heart.

Heart beating

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The sound of a baby’s heart beating in the womb. ÌýEvery parent remembers the first time they heard it, and now there’s a growing number of devices that allow mothers to listen themselves at home. ÌýIndeed, the latest advert for the Samsung Galaxy includes a pregnant woman using a fetal scanner on her smartphone.

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But Samsung’s vision of the future has upset some midwives and doctors amid concerns that the burgeoning use of home fetal heart monitors could be harmful.Ìý And a Private Members Bill currently going through Parliament is examining the need for tighter regulation of their sale and use.

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Antoinette Sandbach is one of the MPs behind the bill.

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Sandbach

Fetal Dopplers are widely available online and they are used by expectant mums but we don’t know how many mums are buying them and we don’t know whether or not they are causing problems around stillbirth.Ìý There are a number of medical concerns around them and that’s one of the reasons that I got involved.

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Porter

And can you explain what a Private Members Bill actually is?

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Sandbach

Well a Private Members Bill is a way of an MP bringing before Parliament a bill that will introduce a law.Ìý And my bill is currently in the process.Ìý It’s passed its first stage.Ìý And what the government have agreed to do is to review the use of these fetal dopplers because there’s concerns, largely anecdotally, from midwives that the use of fetal dopplers may be preventing parents from seeking medical help when they should be going to hospital.

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Porter

So, a woman might, for instance, notice that the baby’s not moving or kicking as much as normal, uses her fetal monitor on her tummy, thinks oh well that’s okay, I can hear a heartbeat, everything’s fine.

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Sandbach

Yes, and unfortunately, it’s quite common for the mother’s heartbeat or for blood vessels in the placenta to give the impression of a heartbeat when actually that heartbeat isn’t there.Ìý Midwives go through an extensive amount of training and use very, very expensive equipment.Ìý They train for at least three years on how to use their own fetal dopplers and the ones that are being sold over the internet are £40, they’re not the quality and level of the ones being used by midwives and clearly midwives have the training that mums to be just don’t have.

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Porter

Dr Margaret McCartney has been listening in our Glasgow studio.

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McCartney

Well I think there’s three main problems.Ìý The first is that of false reassurance.Ìý So, this might be a woman who thinks that there might be something wrong, their baby’s not moving as usual, somehow there’s reduced movement, sometimes she’s not feeling unwell, might use the monitor reassurance, feels reassured because she thinks she’s found a good heartbeat but actually there is a problem and the baby is unwell.Ìý And there have been, very sadly, case reports of exactly this happening – women seeking reassurance from their scan, thinking that they’ve got a good heartbeat but actually then ending up having a miscarriage or a stillbirth.Ìý So, that’s the first problem.Ìý The second problem is converse to what we might think.Ìý Rather than decreasing anxiety, for many women, actually, it ends up increasing anxiety when they can’t find a heartbeat or are concerned about it.Ìý And actually, it can be pretty difficult to find a heartbeat that is the true fetal heartbeat rather than just blood flow through the placenta or actually the mother’s heartbeat itself.

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Porter

And it can be hard sometimes for experienced professionals to tell the difference.

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McCartney

Oh it can be very, very hard, I’ve certainly spent a long time trying to find a fetal heartrate and not being happy to do one, despite being a GP for a couple of decades now.Ìý And then the other issue is that of safety.

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Porter

And what are those concerns?Ìý I mean we use ultrasound, similar technology, to do full scans for dating a baby, for monitoring its growth, and we regard those as safe.

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McCartney

Yeah and ultrasound has a long tradition of being used in maternal medicine because it’s not ionising radiation, it’s thought of being as safe for the mother and fetus.Ìý And that’s absolutely fine.Ìý The problem is that this is now being used in a different way.Ìý The ultrasound is not being used for a medical purpose, it’s really being used for a leisure purpose, what some companies call bonding reasons and women may be using it for extended periods of time, rather than the few minutes that a midwife would be using to do a scan or to check a fetal heartbeat.Ìý So, it’s a completely different use.Ìý And there are concerns that this could cause, in prolonged use, warming of the tissues, heating of the tissues and also small bubbles can also occur in some tissues and these have been concerns raised by the Food and Drugs Administration in America, for example.Ìý Now, I don’t think, for a moment, that this is a big issue but I do think it is of concern and I think it is of increasing concern if women are using these for prolonged periods at home in a way that we just do not have the data to tell us is safe.

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Porter

And what’s your view on whether we should regulate this more – would you like to see more regulation?

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McCartney

Yeah, I mean part of me always think oh banning stuff is bad but actually if you’ve got products that are not doing any good and could actually be doing harm why would you want them to be on sale?

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Porter

And what would you say to women who say well look, this is – this is a storm in a teacup, these are harmless bits of fun that I use to listen to my baby’s heartbeat once in a blue moon?

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McCartney

Yeah and for some women that will be their experience and they will feel it’s worked out well for them.Ìý But there are also women who it’s worked out really badly for – they’ve been falsely reassured, they’ve ended up having a miscarriage or a stillbirth and it’s worked out badly for them and for their families.Ìý So, I really think we have to listen to all sides of the argument.Ìý There may be some women who’ve had previous experience of miscarriage or stillbirth and who want to have a monitor like this.Ìý I think in that situation there might be a case for doing further studies to find out whether that does help to reduce anxiety.Ìý But that’s the kind of thing that should really be done between a professional midwife, maybe training a woman how to use it, showing her and guiding, advising and making sure there’s really stringent follow up in place.Ìý Certainly not something that I think should be done over-the-counter in a commercial situation.

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Porter

So, what does Antoinette Sandbach hope to achieve with her bill?

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Sandbach

Well we need to actually see what the evidence is.Ìý And one of the issues is around whether or not the guidance has been appropriate and for there to be a question asked in stillbirths about whether mum had used a fetal doppler before seeking medical help from the hospital and whether or not they had received false reassurance.Ìý Because if it proves that mums are not going to hospital when they really should do then I would argue that these devices should be restricted, only for use by qualified medical professionals.

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Porter

And how easy, in practice, would that be to do, given that most women are buying these things over the internet, it’s very difficult to track down who’s buying what and where?

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Sandbach

Well I think – I mean you know we could make it an offence to sell one of these devices to anyone who was not legally qualified.Ìý But the Department of Health agreed to undertake a review and that is what’s happening.Ìý So, the Medical Devices Council is looking at what advice and guidance companies are giving to parents who are using these devices and that review is ongoing at the moment.

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Porter

And to not pre-empt the results of that review, it might show that there isn’t any harm, we don’t know that yet.

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Sandbach

We don’t know that but anecdotally I’ve had a lot of evidence and of course I publicised the fact that I was bringing forward this bill and I had quite a high response from midwives who’d had personal experience from dealing with parents who’d had false reassurance from these fetal dopplers and had not sought medical advice.Ìý And of course, there’s that horrible guilt that is associated with that afterwards and to my mind we may be having higher stillbirth rates than necessary because these devices are not being sold with the appropriate warnings or in fact there may be considerable evidence to say that they shouldn’t be sold at all.

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Porter

Antoinette Sandbach MP.Ìý And there is a link to her Private Members Bill on the Inside Health page of the Radio 4 website.

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Now, everyone knows someone who has come out of hospital looking much older and frailer than when they went in. ÌýHardly surprising if you’ve been sick, or undergone major surgery, but that is not the whole story. ÌýJust being immobilised can make you weaker and the older you are the bigger the effect. ÌýIndeed, there is a popular medical adage used in the care of elderly that a 10-day stay can add 10 years to your age.Ìý It may be popular but is it true?

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Thomas

My name’s Dan Thomas and I’m a Medicine for Older People Registrar based in Liverpool.

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I’ve lost count of the amount of times that I’ve used the fact that 10 days in a hospital bed leads to 10 years’ worth of loss muscle mass in people aged over 80.Ìý I’ve used it when I’m on the ward rounds when teaching medical students, I’ve used it when giving presentations to other doctors, I’ve even used it when speaking to patients and relatives about the risk of coming into hospital and the harm that might arise from their admission.

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Porter

I’m with you, in fact at one stage I got so confused I actually thought I might have coined the term myself, because I’m sure I’ve been using it for 10 years in various articles.Ìý So, is there any evidence behind this, where did it actually come from?

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Thomas

The first thing to say, it’s actually quite difficult to find the original sources because often this statement is used and referenced.Ìý But when you do eventually find a reference it tends to be three separate studies that are cited.Ìý But it’s very difficult to extrapolate the findings from these studies.Ìý So, the studies are carried out in healthy people living in the community.Ìý Some of the studies exclude a lot of the patients that we would be looking after, so people who already struggle with activities of daily living like washing, dressing, getting up from a chair.Ìý They exclude people with serious cognitive impairment and they exclude people who may be in the last 12 months of life and this is the hospital population that we would normally be looking after.Ìý The studies are also very small.Ìý Two of the studies don’t have any more than 12 people in them and one of the studies actually doesn’t have anyone over the age of 80 within it.Ìý So, you can see how extrapolating that to 10 days of hospital admission leads to 10 years’ worth of harm in an 80-year-old person, it’s a very difficult conclusion to reach.

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Porter

Essentially, it’s not really a difficult conclusion, it’s a conclusion you can’t reach, isn’t it?

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Thomas

Yeah, exactly, it’s a conclusion you can’t reach.

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Porter

Does it matter if it’s not scientifically accurate because it gets the message across, doesn’t it?

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Thomas

We, as healthcare professionals, we practice evidence-based medicine and particularly if we’re using this type of catchy statement then it needs to be backed up by robust data.Ìý And my gut feeling is actually, although these studies don’t include older people who are currently in hospital, the chances are that if you did do a type of study in someone who’s in hospital the data’s probably worse.

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Porter

So, if it’s even worse than we think what are we doing about hospital related deconditioning? Not enough, according to Dr Ian Sturgess, an elderly care consultant for 20 years and past regional medical director for NHS improvement.

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Sturgess

It’s probably the biggest epidemic of harm internationally.Ìý It’s under-recognised and not reported.Ìý If we talk about healthcare associated infections, that we talked about 10, 15, 20 years ago, this is numerically ten to a hundred times bigger.Ìý The easiest way for people to ask the question is if they think about a patient coming out of hospital, do they come out of hospital worse than when they went in?

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Porter

Is it simply a matter of weakness, is this a direct result on a musculature from being stuck in bed or stuck in a chair?

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Sturgess

It’s physical, so it’s muscles, circulating volume, lung function.Ìý It’s cognitive, so the quickest way to convert incident delirium to persistent delirium is to keep somebody in hospital and move them two or three times.Ìý It’s psychological – people become very depressed.Ìý Then we have sleep deprivation, which creates havoc with people’s psychological state.Ìý And then there’s social deconditioning.Ìý If you remain in hospital for a lengthy time unnecessarily waiting for things to happen, not just at the end of the journey but right at the beginning of the journey, your social support fragments.

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Porter

How do you prevent it, what does the evidence tell us?

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Sturgess

We could be here a very long time.Ìý There is so much evidence and yet it’s not being applied.Ìý The evidence is not being applied.Ìý And let’s be honest – would we do to children what we do to older people in hospital?Ìý We wouldn’t, there’d be a national outcry.Ìý We make assumptions about older people.Ìý There are some excellent examples out there of organisations that have really started to address this, nobody’s done it perfectly yet – Poole Hospital, Bournemouth Hospital, South Warwickshire have done some fantastic work on this.

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Porter

So, to South Warwickshire we have come, specifically to Warwick Hospital, to learn more about what the team here is doing to combat deconditioning.Ìý I’m on the busy Squire Ward, which is hosting a special event today, to meet Dr James Reid, Clinical Director of Care of the Elderly.

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Reid

Inadvertently what hospitals often do is they decompensate, not intentionally but by the very nature of caring for people we are actually sometimes, in many cases, exacerbating their problems.

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Porter

What were you noticing?

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Reid

Hospitals are often really set up for people who are quite physically able.Ìý So, the people that I’ve been seeing for the last 10, 15 years generally are a little bit older, frailer and what we see day to day from looking after these people is that the system’s not really designed to look after their needs.Ìý What they really need is a very rapid assessment as soon as they arrive at the front door and early mobilisation.Ìý And what I was seeing was that often they are difficult to really get to the bottom of what the problem is, so therefore they were often put into a bed and then the situation then evolves that their mobility, after you get them out of bed after a day or so is not as good, they then need further physiotherapy, they then need further rehabilitation and things just sort of spiral downwards essentially.

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Porter

So, the consequences for the individual is that they’re not getting home as quickly as they would do and that has implications for both them and you as a busy unit as well.

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Reid

The people you care for, you want them to do the best they can.Ìý By seeing them deteriorate, literally in front of your eyes, day after day, and having a lack of real momentum in their journey, made me want to really try and change things.

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Williams

Hello, my name is Rachael Williams, I’m the Associate Director of Emergency.Ìý We’re here on Squire Ward, which is one of our frailty wards today, and we’re hosting the Wasps rugby team visit.Ìý So, we do lots of events about getting patients up, dressed and moving and the Wasps team have come to meet our frail older patients and to do exercises with them as well, playing skittles, hoopla and it’s all about making sure that that deconditioning doesn’t take place.

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Miller

My name’s Rob Miller, play fullback for Wasps.Ìý Doing a sort of walk around the hospital and obviously been here on the frailty ward and it’s been awesome for us to come down and chat to them and engage.Ìý We’ve played a few sort of games with the occupational therapists.

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Porter

Gently I hope.

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Miller

Of course, gently.Ìý Actually, James Gascoigne actually got beat chucking the skittles on top of the rings, so I think the boys need to practise a bit more if they want to win.

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Porter

But you won’t be ribbing him about that at all?

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Miller

Oh no, no, of course.

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Porter

My name’s Mark Porter, I work for Radio 4.

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Patient

Pleased to meet you.

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Porter

You look far too fit to be in hospital.

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Patient

I know, I’m 80.

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Porter

Yeah, well you look remarkably well too.Ìý So, what’s happened – it’s just your leg?

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Patient

Just this leg really, yeah.

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Porter

It’s swollen up has it?

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Patient

Might be a blood clot in the vein or something.

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Porter

So, you’re sitting next to the bed here, you’re not sitting in it.

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Patient

I’m not sitting in it now.

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Porter

You’re in a chair fully dressed.

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Patient

Yeah, yeah.

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Porter

You’ve got no intention of getting into bed, by the look of it.

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Patient

I hope not.Ìý I’ve always been active.

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Porter

And you want to stay that way?

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Patient

Yeah, hopefully, please God.

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Williams

It’s about making sure that the patients, when they leave hospital, aren’t deteriorated, haven’t got that muscle wastage, actually that we promote their independence and also events like this helps with socialisation and loneliness, as well, which I think is really good.

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Sandler

My name is Martin Sandler, I’m a Consultant Physician and Geriatrician at South Warwickshire Foundation Trust.Ìý It takes about a week for you to lose 10% of your muscle power if you’re not active.Ìý So, if you’ve got a 75-year-old lady who gets a dose of flu, stays in bed for five to seven days, you will then find that she struggles to get up and stand out of bed.Ìý That is deconditioning, loss of muscle power.Ìý And it’s interesting looking at medicine over the last couple of decades where people used to be in hospital and spend long periods of time in bed, increasingly people spend shorter and shorter times in bed and that’s what we’ve been promoting.

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Porter

And how easy is that on a busy ward where the staff are all running around?

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Sandler

It’s much more difficult and it is much more time intensive.Ìý And it is – some people would say it’s slightly risky because the more you mobilise people the more you risk falls in hospital and while you can’t avoid falls in hospital, and in fact falls in hospital are a marker of attempts to rehabilitate and encourage people to recover, but actually it does require care and attention.

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Reid

So, it’s about a cultural change really, the NHS is very good for caring, which means in a bed, which is the complete wrong thing for frail older adults.Ìý So, what we do is really as soon as they arrive, if they’re able to, we mobilise them, try and put them in their own clothes and just sort of put in that culture, which is about – they should be as independent as possible.Ìý If they shave themselves at home, they should be shaving themselves in hospital.Ìý If they’re dressing themselves at home they should be dressing in hospital.Ìý So, it’s stepping away from that caring for people, which actually is incidentally sort of detrimental to the sort of people we’re seeing.

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Porter

But some of these patients are quite poorly…

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Reid

Yeah, absolutely.

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Porter

…so you can’t get everybody in a chair, you can’t mobilise everybody.

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Reid

But when they are poorly, if they’re still frail, they’re still just as important.Ìý The important thing is that if they can’t get out on day one, you don’t forget about it.Ìý So, when they are ready, when there’s that little window of opportunity, you get them straight out of bed, you get them mobile, you get them dressed and you get them back to normality as quickly as possible.

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Williams

We’re sending 44% of our patients home the same day as attendance, which for them is great because actually they’re back in their own homes, we’re reducing confusion and actually we’re not getting them into the backdoor of the hospital.

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Porter

Whereas before, what would have happened, these people might have come in and spent a day or two here being assessed with things like chest infections and everything but the idea is to treat them and get them home quickly.

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Williams

Absolutely and we’ve managed to reduce our length of stay in our frailty areas from seven days to three days by having a pitstop approach as soon as they go into assessment and also from there it’s about getting them up, getting them dressed, having that mindset of actually don’t go into your pyjamas, actually let’s get you feeling normal and let’s get you doing those normal activities.

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Porter

The idea is to admit fewer people, but if they are admitted they’re here for shorter times and you keep them more active.

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Williams

Absolutely, yes.Ìý I mean you’ll find as well that our OTs and our physiotherapists, as well, have all got that mindset about actually we need to get them up and mobile as quickly as possible.

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So, what we’ve done is we’ve just put it as business as usual within our plan because very busy, shortages of staff, actually if you’re there sat with them, asking them to do some exercise, walking them to the toilet, you can have those general conversations and get to know them more…

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Porter

It’s part of the job.

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Williams

…and actually, it’s just part of the job.

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Porter

Rachael Williams talking to me at Warwick Hospital. ÌýAnd there is more information on deconditioning on our website, where you can also sign up for our weekly podcast and find out how to get in touch.

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Louise emailed following last week’s item on pre-eclampsia.

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Louise (read)

Please discuss the lesser known postpartum pre-eclampsia as well. ÌýOur daughter gave birth to twins by C-section in January and for a few days, due to high blood pressure and swollen limbs, the doctors suspected postpartum pre-eclampsia which can affect mothers for weeks following the birth of their child.

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Porter

Funny you should mention that Louise. ÌýWe often cover a lot more with our interviewees than we have time to broadcast, and my chat with Dr Manu Vatish at Oxford was no exception.

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Vatish

So, actually, if you were to look at the distribution of eclampsia or these seizures quite a number of them occur in the postnatal period and there’s a potential that their placenta leaves a slight legacy of the disease with the mother.Ìý And there are reports of eclampsia occurring for as long as six weeks after but we know that actually most women who will have a seizure postnatally will do it in the first 48-96 hours and that’s more in keeping with the placenta playing a role.

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Porter

Manu Vatish.

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Now you don’t need me to tell you that drinking alcohol can be bad for your health, increasing the risk of a number of problems ranging from cancer to liver disease.Ìý But you may not be so familiar with the fact that your socioeconomic group appears to influence that risk.Ìý It’s known as the as the alcohol harm paradox.Ìý But what does that mean?

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Professor of Hepatology Sir Ian Gilmore.

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Gilmore

Well it’s a wonderfully attractive phrase but unfortunately it probably means different things to different people.Ìý I use it to highlight the fact that less affluent people seem to suffer disproportionately more harm from alcohol, although if you look at the statistics, the consumption is roughly the same across the social strata but it’s the poor that seem to suffer the harm.Ìý So, the paradox is that you’d expect the harm to be roughly the same across the social scale and it isn’t.

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Porter

So, put that another way – unit for unit alcohol appears to be more dangerous for health if you come from a more disadvantaged sector of society?

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Gilmore

That’s correct.

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Porter

And why is that?

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Gilmore

There’s probably, you won’t be surprised to hear, no single explanation.Ìý But the first thing is looking at average consumption probably isn’t the best way of doing it because most people in the upper socioeconomic groups drink and possibly drink a bit more than they should.Ìý If you look at poorer communities there are quite a lot of teetotallers, people who drink very little, and those that do drink in a poorer background often drink in a more destructive way, in difficult social circumstances where alcohol is often a real prop.

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Porter

So, just to be clear, the average consumption may be the same in different ends of the social spectrum but there are more teetotallers at the lower end, so those who are drinking are drinking more.Ìý

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Gilmore

Yes, averages hide what’s going on across the spectrum.

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Porter

And just put the difference in context – how big is the gulf between the more affluent and the less disadvantaged in terms of the impact of alcohol on it?

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Gilmore

It is quite stark and so alcohol is really yet more one reason why we have to tackle health inequalities.

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Porter

Margaret McCartney, we know that your socioeconomic status has a significant impact on your long-term health.

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McCartney

Well it does and a fascinating thing about this paradox is that I had never heard about it until we were going to do it for this programme.Ìý And it’s really something that’s become known, I think, really only in the last few years in the academic community.Ìý And I think there’s two ways of looking at it.Ìý Either poorer people are more likely to suffer the consequences of the adverse effects of alcohol or richer people are protected against the adverse effects of alcohol.Ìý So, there may be two sets of circumstances that are contributing to what we’re seeing.Ìý And what it tells me is that health inequalities are just so unfair, you can be drinking the same but suffer far more of the adverse effects if you come from a deprived background.

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Porter

Ian, can we just pick up on that, that Radio 4 might have some listeners who say well I drink half a bottle of claret a day, very fine stuff it is too, it’s too much but I’m protected, that’s the message that they may take home.

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Gilmore

I don’t think they would be wise to take home that message and certainly the Chief Medical Officer guidelines did not make any recommendations over different socioeconomic groups.

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McCartney

It is something that does worry me, people sometimes write off their knowingly high alcohol intake on the basis that it’s high quality alcohol, therefore it can’t possibly harm me, almost sort of bordering on the sort of delusional idea that just because I’ve spent a lot of money on this bottle of wine then it can’t possibly harm me in any way.

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Porter

Yes, I’ve heard that from patients who say the person who drinks White Stripe, well that’s going to rot your liver isn’t it, whereas a bottle of Chablis won’t.Ìý And alcohol is alcohol is alcohol.

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McCartney

You can get alcohol that comes with fewer calories, and I’m a bit of an expert in selecting my gins and tonics on that basis.

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Gilmore

Well you’re being very clever because at the moment there’s more nutritional information on a bottle of milk about what’s in it than there is in a bottle of wine.Ìý And at the moment because of European regulations we cannot put, for example, the calorie content of a bottle of wine.

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Porter

Which might be interesting from a health education point of view.

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McCartney

Well absolutely and especially if we’re looking at the reasons why people in some social groups seem to suffer more adverse consequences than others.Ìý One of the problems that people are trying to disentangle the statistics about is for this idea of downward social mobility, so the reason why people are in more difficult socioeconomic groups is because…

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Gilmore

Is because they’ve got a drink problem.

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McCartney

Yes, and I think it’s difficult to know what’s going on, whether there’s cause and effect or effect and cause.

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Porter

Well it’s unlikely that drinking too much is going to propel you up the social spectrum but it could very well cost you your job, for instance, and propel you down the social spectrum.

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Gilmore

Yes, that’s a very interesting point Margaret and it fits with another of the confounding factors that when you’re comparing the health impact of drinking, the fact that moderate drinking seems to be beneficial to health but that’s bedevilled by the fact that those who don’t drink at all contain a percentage of those so-called sick quitters, who don’t drink because they’re ill already and so they’re not really a comparable group to compare with.Ìý

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And then there are other risk factors.Ìý We know that obesity is more common in poorer people, their diet may not be so good, may not be so much activity, more smoking.Ìý And however hard you try to control for these factors in trials you probably can’t.Ìý Then there’s the response rate in surveys – do people from more educative backgrounds cooperate more or do they tell lies more about what they drink or do poorer people tell more lies.Ìý There are all sorts of potential factors.Ìý But I think the big one is there’s probably more harmful patterns of drinking in poorer groups.Ìý I think the binge drinking is important, I think there’s quite a lot of the excess mortality is in younger people who are victims of mental illness, suicide related to alcohol, accidents, violence.Ìý And those are certainly seen disproportionately in the poorest in society.

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Porter

Margaret, what about these people coming to seek help?Ìý I mean the other thing we know about the discrepancy across the social spectrum is that the better off you are, the better educated you are, the more likely you are to access help and to get diagnosed and to get good care.

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McCartney

Well absolutely and that’s one of the problems with looking at the studies so far, people try and control for these kinds of things, they try and control for things like binge drinking – there was a Lancet public health paper that tried to do that – so there’s a lot of disentangling to be done.Ìý But certainly, I think, we’ve known up until now that health inequality’s bad news and now we know they are really bad news.

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Porter

Margaret McCartney and Professor Sir Ian Gilmore.

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Just time to tell you about next week’s programme when I meet the team behind a new pitch side test for concussion. ÌýAnd learn more about what is being done to reduce over use of opioid painkillers, including the latest research into how to help long term users come off the drugs.

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ENDS