Category: medicine

  • The Grand Irony of Nursing Education and Burnout in U.S. Health Care

    The Grand Irony of Nursing Education and Burnout in U.S. Health Care

    Nursing has long been romanticized as both a “calling” and a profession—an occupation where devotion to patients is assumed to be limitless. Nursing schools, hospitals, and media narratives often reinforce this ideal, framing the nurse as a tireless caregiver who sacrifices for the greater good. But behind the cultural image is a system that normalizes exhaustion, accepts overwork, and relies on the quiet suffering of an increasingly strained workforce.

    The cultural expectation that nurses should sacrifice their own well-being has deep historical roots. Florence Nightingale’s legacy in the mid-19th century portrayed nursing as a noble vocation, tied as much to moral virtue as to medical skill. During World War I and World War II, nurses were celebrated as patriotic servants, enduring brutal conditions without complaint. By the late 20th century, popular culture reinforced the idea of the nurse as both saintly and stoic—expected to carry on through fatigue, trauma, and loss. This framing has carried into the 21st century. During the COVID-19 pandemic, nurses were lauded as “heroes” in speeches, advertisements, and nightly news coverage. But the rhetoric of heroism masked a harsher reality: nurses were sent into hospitals without adequate protective equipment, with overwhelming patient loads, and with little institutional support. The language of devotion was used as a shield against criticism, even as nurses themselves broke down from exhaustion.

    The problem begins in nursing education. Students are taught the technical skills of patient care, but they are also socialized into a culture that emphasizes resilience, self-sacrifice, and “doing whatever it takes.” Clinical rotations often expose nursing students to chronic understaffing and unsafe patient loads, but instead of treating this as structural failure, students are told it is simply “the reality of nursing.” In effect, they are trained to adapt to dysfunction rather than challenge it.

    Once in the workforce, the pressures intensify. Hospitals and clinics operate under tight staffing budgets, pushing nurses to manage far more patients than recommended. Shifts stretch from 12 to 16 hours, and mandatory overtime is not uncommon. Documentation demands, electronic medical record systems, and administrative oversight add layers of clerical work that take time away from direct patient care. The emotional toll of constantly navigating life-and-death decisions, combined with lack of rest, creates a perfect storm of burnout. The grand irony is that the profession celebrates devotion while neglecting the well-being of the devoted. Nurses are praised as “heroes” during crises, but when they ask for better staffing ratios, safer conditions, or mental health support, they are often dismissed as “not team players.” In non-unionized hospitals, the risks are magnified: nurses have little leverage to negotiate schedules, resist unsafe assignments, or push back against retaliation. Instead, they are expected to remain loyal, even as stress erodes their health and shortens their careers.

    Recent years have shown that nurses are increasingly unwilling to accept this reality. In Oregon in 2025, nearly 5,000 unionized nurses, physicians, and midwives staged the largest health care worker strike in the state’s history, demanding higher wages, better staffing levels, and workload adjustments that reflect patient severity rather than just patient numbers. After six weeks, they secured a contract with substantial pay raises, penalty pay for missed breaks, and staffing reforms. In New Orleans, nurses at University Medical Center have launched repeated strikes as negotiations stall, citing unsafe staffing that puts both their health and their patients at risk. These actions are not isolated. In 2022, approximately 15,000 Minnesota nurses launched the largest private-sector nurses’ strike in U.S. history, and since 2020 the number of nurse strikes nationwide has more than tripled.

    Alongside strikes, nurses are pushing for legislative solutions. At the federal level, the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act has been introduced, which would mandate minimum nurse-to-patient ratios and provide whistleblower protections. In New York, the Safe Staffing for Hospital Care Act seeks to set legally enforceable staffing levels and ban most mandatory overtime. Even California, long considered a leader in nurse staffing ratios, has faced crises in psychiatric hospitals so severe that Governor Gavin Newsom introduced emergency rules to address chronic understaffing linked to patient harm. Enforcement remains uneven, however. At Albany Medical Center in New York, chronic understaffing violations led to hundreds of thousands of dollars in fines, a reminder that without strong oversight, even well-crafted laws can be ignored.

    The United States’ piecemeal and adversarial approach contrasts sharply with other countries. In Canada, provinces like British Columbia have legislated nurse-to-patient ratios similar to those in California, and in Quebec, unions won agreements that legally cap workloads for certain units. In the United Kingdom, the National Health Service has long recognized safe staffing as a matter of public accountability, and while austerity policies have strained the system, England, Wales, and Scotland all employ government-set nurse-to-patient standards to protect both patients and staff. Nordic countries go further, with Sweden and Norway integrating nurse well-being into health policy; short shifts, strong union protections, and publicly funded healthcare systems reduce the risk of burnout by design. While no system is perfect, these models show that burnout is not inevitable—it is a political and policy choice.

    Union presence consistently makes a difference. Studies show that unionized nurses are more successful at securing safe staffing ratios, resisting exploitative scheduling, and advocating for patient safety. But unionization rates in nursing remain uneven, and in many states nurses are discouraged or even legally restricted from organizing. Without collective power, individual nurses are forced to rely on personal endurance, which is precisely what the system counts on.

    The outcome is devastating not only for nurses but for patients. Burnout leads to higher turnover, staffing shortages, and medical errors—all while nursing schools continue to churn out new graduates to replace those driven from the profession. It is a cycle sustained by institutional denial and the myth of infinite devotion.

    If U.S. higher education is serious about preparing nurses for the future, nursing programs must move beyond the rhetoric of sacrifice. They need to teach students not only how to care for patients but also how to advocate for themselves and their colleagues. They need to expose the structural causes of burnout and prepare nurses to demand better conditions, not simply endure them. Until then, the irony remains: a profession that celebrates care while sacrificing its caregivers.

    Sources

    • American Nurses Association (ANA). “Workplace Stress & Burnout.” ANA Enterprise, 2023.

    • National Nurses United. Nursing Staffing Crisis in the United States, 2022.

    • Bae, S. “Nurse Staffing and Patient Outcomes: A Literature Review.” Nursing Outlook, Vol. 64, No. 3 (2016): 322-333.

    • Bureau of Labor Statistics. “Union Members Summary.” U.S. Department of Labor, 2024.

    • Shah, M.K., Gandrakota, N., Cimiotti, J.P., Ghose, N., Moore, M., Ali, M.K. “Prevalence of and Factors Associated With Nurse Burnout in the US.” JAMA Network Open, Vol. 4, No. 2 (2021): e2036469.

    • Nelson, Sioban. Say Little, Do Much: Nursing, Nuns, and Hospitals in the Nineteenth Century. University of Pennsylvania Press, 2001.

    • Kalisch, Philip A. & Kalisch, Beatrice J. The Advance of American Nursing. Little, Brown, 1986.

    • Oregon Capital Chronicle, “Governor Kotek Criticizes Providence Over Largest Strike of Health Care Workers in State History,” January 2025.

    • Associated Press, “Oregon Health Care Strike Ends After Six Weeks,” February 2025.

    • National Nurses United, “New Orleans Nurses Deliver Notice for Third Strike at UMC,” 2025.

    • NurseTogether, “Nurse Strikes: An Increasing Trend in the U.S.,” 2024.

    • New York State Senate Bill S4003, “Safe Staffing for Hospital Care Act,” 2025.

    • San Francisco Chronicle, “Newsom Imposes Emergency Staffing Rules at State Psychiatric Hospitals,” 2025.

    • Times Union, “Editorial: Hospital’s Staffing Violations Show Need for Enforcement,” 2025.

    • Oulton, J.A. “The Global Nursing Shortage: An Overview of Issues and Actions.” Policy, Politics, & Nursing Practice, Vol. 7, No. 3 (2006): 34S–39S.

    • Rafferty, Anne Marie et al. “Outcomes of Variation in Hospital Nurse Staffing in English Hospitals.” BMJ Quality & Safety, 2007.

    • Aiken, Linda H. et al. “Nurse Staffing and Education and Hospital Mortality in Nine European Countries.” The Lancet, Vol. 383, No. 9931 (2014): 1824–1830.

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  • Better access to medical school shouldn’t need a deficit model

    Better access to medical school shouldn’t need a deficit model

    Patients benefit from a diverse healthcare workforce. Doctors, particularly those from disadvantaged and minoritised backgrounds, play a crucial role in advocating for what is best for their patients.

    The NHS recognises this, linking workforce diversity with increased patient satisfaction, better care outcomes, reduced staff turnover, and greater productivity.

    A promising start

    Efforts to widen participation in higher education began at the turn of the century following the Dearing report. Over time, access to medical schools gained attention due to concerns about its status as one of the most socially exclusive professions. Medical schools responded in 2014 with the launch of the Selecting for Excellence report and the establishment of the Medical Schools Council (MSC) Selection Alliance, representing admissions teams from every UK medical school and responsible for fair admissions to medical courses.

    With medical school expansion under government review, institutions face increasing pressure to demonstrate meaningful progress in widening participation to secure additional places. Although medicine programmes still lag in representing some demographic groups, they now align more closely with wider higher education efforts.

    However, widening participation policy often follows a deficit model, viewing disadvantaged young people as needing to be “fixed” or “topped up” before joining the profession. Phrases like “raising aspirations” suggest these students lack ambition or motivation. This model shifts responsibility onto individuals, asking them to adapt to a system shaped mainly by the experiences of white, male, middle-class groups.

    Beyond access

    To create real change, organisations must move beyond this model and show that students from diverse backgrounds are not only welcomed but valued for their unique perspectives and strengths. This requires a systems-based approach that rethinks every part of medical education, starting with admissions. In its recent report, Fostering Potential, the MSC reviewed a decade of widening participation in medicine. Medical schools across the UK have increased outreach, introduced gateway year courses, and implemented contextual criteria into admissions.

    Contextual markers recognise structural inequalities affecting educational attainment. Students from low socioeconomic backgrounds often attend under-resourced schools and face personal challenges hindering academic performance. Yet evidence shows that, when given the chance, these students often outperform more advantaged peers at university. Contextual admissions reframe achievements in light of these challenges, offering a fairer assessment of potential.

    Despite progress, access remains unequal. Although acceptance rates for students from the most deprived areas have increased, their chances remain 37 per cent lower than those from the least deprived areas. Research indicates that a two-grade A-level reduction is needed to level the playing field—an approach several schools now adopt. Other policies include fast-tracking interviews, test score uplifts, and alternative scoring for widening participation candidates.

    Not just special cases

    These processes, however, are often opaque and hard to navigate. Many applicants struggle to determine eligibility. With no single definition of disadvantage, medical schools use varied proxy indicators, often poorly explained online. This confusion disproportionately affects the students these policies aim to support; those without university-educated parents, lacking insider knowledge, and attending under-resourced schools.

    A commitment to transparency is vital but must go beyond rhetoric. Transparency means all medical schools clearly outline contextual admissions criteria in one accessible place, provide step-by-step guides to applicants and advisors, and offer examples of how contextual data influences decisions. Medical schools could collaborate to agree on standardised metrics for identifying widening participation candidates. This would simplify eligibility understanding, reduce confusion, and promote fairness.

    Tools like MSC’s entry requirements platform are a good start but must be expanded, standardised, and actively promoted to the communities that need them most. Genuine transparency empowers applicants to make informed choices, selecting schools best suited to their circumstances and maximising success chances. This also eases the burden on schools, advisors, and outreach staff who struggle to interpret inconsistent criteria.

    Ultimately, moving away from the deficit model toward an open, systems-based approach is about more than fairness. It is essential for building a medical workforce that reflects society’s diversity, improving patient care, strengthening the profession, and upholding the NHS’s commitment to equity and excellence.

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  • When you feel sick but are embarrassed to say so

    When you feel sick but are embarrassed to say so

    When Annick Bissainthe was diagnosed with irritable bowel syndrome (IBS) in 2018 it destroyed her relationship with food and that affected her relationship with people. 

    She said it restricted social interactions and prevented her from doing activities she used to do before her diagnosis. “Like two days before, I would agree that, yes, I’m going to meet you at a certain point,” Bissainthe said. “But something happens one hour before that [gets me] sick and I can’t go anymore.”

    IBS is a common condition afflicting 5-10% of the world’s population but its symptoms are things few people want to talk about: abdominal pain, cramping, diarrhea, constipation, bloating and excessive gas. 

    Preventing these symptoms often requires adjustments to a diet. It is easy to explain to someone why you can’t eat certain foods if you are allergic to those foods. But many people find it embarrassing to explain that they can’t eat those foods because of an irritable bowel.  

    Dairy, added sugars and spices are among Bissainthe’s top triggers for IBS symptoms, but they comprised a large part of her diet prior to being diagnosed. 

    “Everyone else in your culture eats it,” said Bissainthe. “Food is not just about eating, but there’s also a sociocultural aspect … it’s difficult especially being in an environment where you’re not understood.” 

    Symptoms of IBS go untreated.

    IBS is particularly prevalent among young adults but often undiagnosed. Living with IBS as a young person can be especially difficult. “I was in my late 20s, so I was like, ‘I’m a healthy young adult but not able to eat [certain foods]’,” Bissainthe said. “I felt like my body was letting me down.”

    Dr. Miranda van Tilburg, professor of Health Systems Science at Methodist University in the U.S. state of North Carolina, said that IBS has no known physical cause, so it is often poorly managed, treatment efficacies vary widely and patients’ concerns are frequently dismissed. 

    “There are no tests that we can do, biomedical markers, no radiography, nothing we can do to look at your body and say, ‘You have IBS,’” van Tilburg said.

    Dr. Irma Kuliavienė, a gastroenterologist at the Lithuanian University of Health Sciences, said that while the symptoms are real and have biological underpinnings, unlike a tumor, they can’t be “seen” such through endoscopy or colonoscopy scans.

    Jeffrey Roberts, an IBS patient advocate, said that he often wondered whether he was the cause of his symptoms and if it would restrict what he could do in life. He said the diagnosis of IBS is often dismissed as “just IBS” or brushed off as “all in the head.”  

    In the media, when bowel problems are raised, it is often to produce laughs, he said. 

    No laughing matter

    Treating IBS as a joke can be detrimental to IBS patients’ mental health and quality of care. Van Tilburg said IBS can be the primary source of stress in someone’s life but telling people to reduce stress when they have these symptoms is counterproductive. 

    The reasons why IBS occurs are unclear, although several possible contributing factors have been proposed. They include the interaction between the gut and the brain, known as the gut-brain axis, and the gut microbiome — the ecosystem of microorganisms in your gut.

    Because many potential biological mechanisms could be at play, it is difficult to identify a common therapy that will work for everyone, Kuliavienė said.  

    Dr. Shefaly Shorey, associate professor at the National University of Singapore, said that talking about gastrointestinal symptoms such as flatulence, diarrhea and constipation is considered taboo, especially in many Asian cultures. Shorey was diagnosed with IBS in 2017 and said this avoidance of open conversations about bowel problems can hinder needed care. 

    “These are not glamorous topics to talk about,” Shorey said. Lack of support and acceptance, especially from family members, can lead IBS patients to avoid opening up about their symptoms. 

    Finding the right treatment

    In some countries, dieticians and access to lab tests are not widely available and that can also affect whether someone can get properly diagnosed. Van Tilburg said that a key first step to helping people who have IBS is for doctors and nurses to accept symptoms as genuine. “We need to do a better job of educating physicians on how to talk to these patients,” she said. 

    This is important because IBS is a chronic condition that many patients will deal with for life, and while there are different therapies that can help reduce or eliminate symptoms, there is no one-size-fits-all treatment.

    Extensive trial-and-error is often needed to find what approaches will work best for each individual, a process that requires close collaboration between the patient and practitioner. Bissainthe still lives with IBS but having tried so many different treatment options over the years, is better aware of what management strategies work for her.

    Kuliavienė said that to find the right treatment there needs to be a trusting relationship between doctor and patient.

    “When we talk with our patients, when we hear our patients, we can see which pathway is better and choose specific treatments for specific patients,” she said. 

     

    Questions to consider:

    1. What is irritable bowel syndrome?

    2. Why are people embarrassed to talk about IBS?

    3. What things are you embassed to talk about with a doctor? 

     

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  • Call an ambulance! But be ready to pay.

    Call an ambulance! But be ready to pay.

    Quick-commerce service Blinkit — best known in India for delivering groceries in 10 minutes — rolled out an ambulance service last winter promising the same speedy service and setting the nation off on a new debate about privatized medicine.

    Five ambulances equipped with lifesaving medical equipment, emergency medicines and a three-person team, including a paramedic, are now operating in Gurgaon, a relatively wealthy city north of Delhi, at 2,000 rupees or about US $23 per trip. That’s affordable for less than a third of the population.

    Touted as India’s first app-based private emergency healthcare service, this has set off a debate about its implications for a sprawling public health system that is notoriously overstretched, with only one ambulance per five million people.

    A few weeks after the service launched, one of its ambulance teams was able to stabilize a trauma patient on the way to the emergency department. This led neurosurgeon Deepak Agarwal at All India Institute of Medical Sciences, a premier medical college and hospital to laud the new service on social media. He called it a “healthcare revolution” that offers care he had only read about happening in developed countries.

    It was a stark contrast, though, with the experience of Roopa Rawat Singhvi, a regional nursing lead in emergency and trauma care, who encountered a road accident victim near the hospital on 3 March.

    “I continued to call 108 and 102 (India’s version of 911) to reach ambulance services,” she said. “However, the calls were not going through.”

    After call finally went through, it took half an hour for the first responders to arrive and they were police, not an ambulance, she said.

    Healthcare for those who can pay

    This contrast — one patient whisked away with ventilatory support and trained staff, another left waiting while vital minutes passed — captures the growing debate around Blinkit’s entry into emergency healthcare.

    This contrast shows the need to explore India’s first app-based private ambulance initiative as more than just a tech innovation story, but as a symptom of a deeper tension between privatization and public neglect.

    As India’s public health infrastructure is eroding, private players are stepping into the vacated spaces under the guise of innovation. The question is: Will this be a temporary fix or a long-term threat to equitable emergency care?

    It wasn’t meant to be this way. In 2007, P.V. Ramesh was the principal health secretary of the Indian state of Andhra Pradesh and worked on the first National Health Mission project to establish emergency ambulance services.

    He said that the public sector ambulance services that evolved into the current nationwide emergency service started as a partnership in Andhra Pradesh between the government and a not-for-profit entity, Byrraju Foundation.

    There was a clear understanding, he said, that it would be operated strictly as a public service without a profit motive.

    “It combined the ambulances equipped with essential emergency care infrastructure, trained human resources and a call center provided by the Byrraju Foundation with the funding, hospital network and effective oversight from the public sector that served all citizens of Andhra Pradesh in case of medical or surgical emergencies,” Ramesh said.

    A dire need for ambulances

    That not-for-profit plan quickly collapsed.

    “Ambulance drivers started taking money from the private hospitals to take patients there and the private sector companies that oversaw the operations also began to cut corners,” Ramesh said. “Even doctors became complicit in the slow rotting of the system. The system deteriorated when the political and bureaucratic masters stopped monitoring the system after awarding the contracts to their favorites.”

    Pre-hospital care is far from ideal in both the public and private sectors in India, says Gayatri, an emergency medicine physician in Mumbai. Gayatri, who asked that her last name not be used, has worked in both public and private hospitals.

    “I used to work in villages in Chhattisgarh and Bihar,” she said. “In some areas, we used to call the government ambulance, but they would often refuse to come, either because it was a conflict-ridden area or because the road was in poor condition. If we put pressure and keep calling, the ambulance would come, but then the driver would ask for 3,000 to 5,000 rupees from the patient to transfer them.”

    Gayatri said that because many of her patients feel scared and disempowered, they agree to pay. “Sometimes we have to fight with the ambulance drivers and tell them not to ask for money,” she said.

    Stalling for time when saving lives

    Gayatri vividly remembers a night when she was transferring a patient in a vehicle and the patient had a cardiac arrest. She called for an ambulance, but it arrived without essential medications or even an oxygen cylinder. They had to borrow an oxygen cylinder from a referral center in a nearby village, losing time.

    “In emergencies, every minute counts,” she said. “And not having access to even an oxygen mask or cylinder in the ambulance was shocking and distressing for me.”

    But even private sector hospitals where she has worked used to send doctors trained in traditional medicine who are not qualified to administer emergency care in place of paramedics to attend home emergencies or to transport patients from emergency sites to the hospital.

    India currently has an almost non-existent emergency response system.

    According to Indian government data, there are a total of 28,250 ambulances across its states and Union Territories such as Jammu and Kashmir. This includes ambulances with advanced medical services and paramedics, vehicles that only transfer patients in non-emergency conditions, even bicycles.

    Meeting international standards

    While international standards recommend one ambulance for every 50,000 population, with one basic life support ambulance or BLS and one advanced cardiac life support ambulance or ACLS per 100,000 population, India has one ACLS ambulance for every five million people — the number in the United States is one per 25,000 population — and one BLS ambulance for every 100,000 people.

    Meanwhile, quality is a more persistent issue than quantity. According to a 2020 study by the All India Institute of Medical Science in Delhi and the National Institution for Transforming India, 90% of ambulances lacked essential medical equipment and 95% were operated by untrained professionals.

    “The corruption and deterioration of the service, coupled with a lack of infrastructure to provide adequate emergency referral systems, has created a vacuum that has invited private players to reframe this as a business opportunity,” Ramesh said.

    That’s why, he said, it makes sense for Blinkit to fill that hole. They recognized that the current system doesn’t meet the demand for reliable ambulance service in case of medical and surgical emergencies and realized they could develop a service to cater to those with the means to pay for it.

    Singhvi believes there are lessons to be learned from Blinkit’s efficiency. “They’ve hired trained paramedics, optimized logistics and used technology effectively,” Singhvi said. “Public systems could adapt these strategies to improve accessibility and response times.”

    Profits and regulations

    Ramesh said that with the current public infrastructure in shambles, he only hopes that the private ambulance companies run this service ethically and that there isn’t a monopoly that will allow them to charge unreasonable rates.

    But Gayatri does not offer them the benefit of the doubt. “Blinkit is a private company and private companies operate on the principle of making a profit,” she said. “It is unreasonable to expect that they will function in a way that keeps the welfare of the people in mind.”

    Gayatri believes that the gap is intentional. It is because of lobbying by the private sector that has made the public sector reluctant to invest in strengthening its health systems. Good regulatory oversight from the government, could prevent private companies from charging too much, but Ramesh is not optimistic it will happen.

    “Even if robust regulations are formulated and a law is enacted, does the government have the capacity to enforce it?” he said. “Regulations have not been successful in the health sector.”

    Instead, Ramesh said that the emergence of private ambulance services should be seen as a wake-up call to the government to strengthen public sector ambulance services.

    Ramesh acknowledges that Blinkit fills a need. But ultimately, while Blinkit’s initiative may cater to a small, affluent population segment, it underscores the urgent need to address the systemic inadequacies plaguing public healthcare.

    “If they provide equitable, high-quality service at a fair price, without bias toward certain hospitals, they could complement existing healthcare services,” he said. “But private models inherently exclude the poor. In a country where universal health care isn’t prioritized, do people have an alternative?”

    Questions to consider:

    1. What are the concerns some people have over private ambulance services?

    2. How can a government ensure that an ambulance service won’t gouge people in need?

    3. Do you know how to call for an ambulance and do you know how long it might take to reach you if you needed one?

     

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  • How Labour’s 10-year health plan for England joins up with higher education and research

    How Labour’s 10-year health plan for England joins up with higher education and research

    The government wants to reinvent the NHS (in England) through three radical shifts – hospital to community, analogue to digital, and sickness to prevention.

    Whether like the chief executive of the NHS you believe Labour’s 10-year health plan for England is about creating “energy and enthusiasm”, whether like the secretary of state you believe this is about building a NHS which is about “the future and a fairer Britain,” or whether across its 168 pages you find the government’s default to techno-optimism, AI will solve everything, one more dataset will fix public services, approach to governance to be somewhere between naive and unduly optimistic, it is clear that the NHS is expected to change and do so quickly.

    This is a plan that is as much about the reorganisation of the economy as it is about health. It is about how health services can get people into work, it is a guide to economic growth through innovation in life sciences, it is a lament for the skills needed and the skills not yet thought about for the future of the NHS.

    Elsewhere on the site, Jim Dickinson looks at the (lack of) implications for students as group with health needs – here we look at the implications for education, universities, and the wider knowledge economy.

    Workforce modelling

    One of the premises of the plan is that the 2023 Conservative long-term workforce plan was a mistake. The NHS clearly cannot go on as it currently is, and to facilitate this transformation a “very different kind of workforce strategy” is needed:

    Until 2023, [the NHS] had never published a long-term workforce plan. The one it did publish did little more than extrapolate from past trends into the future: concluding there was no alternative than continuation of our current care model, supported by an inexorable growth in headcount, mostly working in acute settings.

    A new workforce place is being put together, to appear “later this year” and taking a “decidedly different approach”:

    Instead of asking ‘how many staff do we need to maintain our current care model over the next 10 years?’, it will ask ‘given our reform plan, what workforce do we need, what should they do, where should they be deployed and what skills should they have?’

    The bottom line is that, therefore, “there will be fewer staff in the NHS in 2035 than projected by the 2023 workforce plan” – but these staff will have better conditions, better training, and “more exciting roles”.

    So one immediate question for universities in England is what this reduced staffing target means for recruitment onto medical, nursing and allied health degrees. Places have been expanding, and under previous plans were set to expand at growing rates in the coming years, including a doubling of medical school places by 2035. There were questions about how optimistic some of the objectives were – the National Audit Office last year criticised NHS England for not having assessed the feasibility of expanding places, in light of issues like attrition rates and the need to invest in clinical placement infrastructure.

    We won’t get a clear answer of what Labour is proposing until the new workforce plan emerges – especially as there is an accompanying aspiration in today’s plan to reduce the NHS’ dependence on international recruitment. But there are some clear directions of travel. Creating more apprenticeships gets a mention – though of course not at level 7 – but the key theme is a tight link between growing medical student numbers and widening participation:

    Expansion of medical school places will be targeted at medical schools with a proven track record of widening participation… The admissions process to medical school will be improved with better information, signposting and support for applicants, and more systematic use of contextual admissions.

    This is accompanied by endorsement of the Sutton Trust’s recent research into access disparities. And in one of those “holding universities to account” measures that everyone is so keen on, part of reinforcing this link will be done via work with the Department for Education to “publish data on the relevant background of university entrants, starting with medicine.” If you are thinking that we already did that – yes we did. The UK-wide HESA widening participation performance indicator was last published in 2022 – each regulator now has their own version (for example this from the Office for Students) which doesn’t quite do the same thing.

    Education and students

    Of course, creating more pathways into working in the NHS is one mechanism to grow its workforce. The other is to unblock current pathways that prevent people from getting into and getting on with their chosen careers in health.

    For example, there is a (somewhat tepid) commitment on student support: the plan commits to “explore options” on improving the financial support on offer to medical students from the lowest socioeconomic backgrounds.

    For nursing students, the offer is slimmer still – a focus on the “financial obstacles to learning”, including faster reimbursement of placement expenses, and tackling the time lag between completing a course and being able to start work. This latter measure will involve working with higher education institutions to revise the current approach to course completion confirmation, and is billed for September 2026. The Royal College of Nursing has suggested that these “modest” changes go nowhere near far enough.

    Nursing and midwifery attrition also comes under scrutiny – the government spots that reducing the rate of non-continuation by a percentage point would result in the equivalent of 300 more nurses and midwives joining the NHS each year. But rather than looking deeper at why this is a growing issue, the buck is handed over to education providers to “urgently address attrition rates.”

    Elsewhere the interventions into education provision are more substantial. There’s an already ongoing review of medical training for NHS staff, due to report imminently. On top of this, the plan sets out how the next three years will see an “overhaul” of education and training curricula, to “future-proof” the workforce. There’s lots of talk about faster changes to course content as and when needed, to reflect changes in how the NHS will operate. This comes with a warning:

    Where existing providers are unable to move at the right pace, we may look to different institutions to ensure that the education market is responsive to employer needs.

    Clinical placement tariffs for undergraduate and postgraduate medicine will be reformed – the plan suggests the tariff system currently “provides limited ability to target funding at training where it is most needed to modernise delivery,” and wants to do more in community settings and make better use of simulation. There will also be expansion of clinical educator capacity, though this will be “targeted” (which is often code for limited).

    And course lengths could fall – the plan promises to “work with higher education institutions and the professional regulators as they review course length in light of technological developments and a transition to lifelong rather than static training.” While this does not explicitly suggest shorter medical and nursing programmes – and a consequent growth in provision aimed at professionals – the preference is pretty obvious.

    On that last point every member of NHS staff will get their own “personalised career coaching and development plan” which will come alongside the development of “advanced practice models” for nurses (and all the other professional roles in the NHS: radiographers, pharmacists, and the like).

    Data and (wider) employment

    The plan stretches much wider than simply making commitments on training though and, as the plan makes clear, if the answer isn’t always going to be more money there has to be more efficiency.

    There’s a fascinating set of commitments linking health and work – one of those things that feel clunky and obvious until you note that “getting the long-term sick back into work” has just been a soundbite with punitive vibes until now.

    Of course, everything has a slightly cringeworthy name – so NHS Accelerators will support local NHS services to have an “impact on people’s work status”, something that may grow into specific and measurable outcomes linking to economic inactivity and unemployment and link in other local government partners. And health support in the traditional sense will link with wider holistic support (as set out in the Pathways to Work green paper) for people with disabilities.

    There’s also a set of commitments on understanding and supporting the mental health needs of young people – although the focus is on schools and colleges, there is an expectation that universities will play a part in a forthcoming National Youth Strategy (due from the Department of Culture, Media, and Sport “this summer”) which will cover support for “mental health, wellbeing, and the ability to develop positive social connections.”

    All these joined up services will need joined up data, so happy news, too, for those looking for wrap-around support in transitions between educational phases – there will be a single unique identifier for young people: the NHS number. And for fans of learner analytics, a similar approach (with a sprinkling of genomics) will “tell [the NHS] the likelihood of a person developing a condition before it occurs, support early detection of disease, and enable personalised prevention and treatment”.

    For some time, universities and other trusted partners have benefited from access to deidentified NHS healthcare administrative data via ADRUK – which has been used for everything from developing new medicine to understanding health policy. This will be joined by a new commercially-focused Health Data Research Service (HDRS) backed by the Wellcome Trust. This is not a new announcement, but the slant here is that it will support the private sector – and as such there will be efforts to “make sure the NHS receives a fair deal for providing access”, which could include a mix of access charges and equity stakes in new developments.

    Research, research, research

    In effect, the government’s proposals set out how improving the conditions, configurations, and coordination of the NHS workforce, and the information provided to them and their partners, can improve healthcare. The next challenge then is targeting the right kinds of information in the right places, and this depends on the quality of research the NHS can access, make use of, and produce.

    The health of the nation does not begin and end at the hospital door. As The King’s Fund points out, “we can’t duck the reality that we are an international outlier with stagnating life expectancy and with millions living many years of life in poor health.” The point of this plan is not only about making health services better but about narrowing health inequalities and using life sciences research to grow the economy.

    The plan talks about making up for a “lost decade” of life sciences research. In doing so, it cites an IPPR report (the author is now DHSC’s lead strategy advisor) which demonstrates that the global research spend on life sciences in the UK has reduced and that this has had an impact on life sciences GVA. Following this line of thought suggests that if the UK had maintained levels of investment the economy would have got bigger, people’s lives would have been better and because of the link between poverty and ill health, the NHS would be under less pressure.

    The issue with this citation is that the figures used are from 2011–16 and some of the remedies, like association to Horizon Europe, are things the UK has done. Though the plan makes clear that “the era of the NHS’ answer always being ‘more money, never reform’ is over,” it is in fact the case that the government has ploughed record levels of public money into R&D without fundamental reform to the research ecosystem. The premise that economic growth can be spurred by research and leads to better health outcomes is correct – but it isn’t necessary to reference research carried out in 2019 to make the case.

    This isn’t merely an annoyance – it speaks to a wider challenge within the plan which oscillates widely between the optimism that “all hospitals will be fully AI-enabled” within the next ten years (80 per cent of hospitals were still using pagers in 2023 despite their ban in 2019), and the obviously sensible commitment to establish Health Innovation Zones which will bring health partners within a devolved framework to experiment in service innovation.

    The fundamental challenge facing innovation within health is the diffusion of priorities. There are both a lot of things the NHS and life science researchers might focus their time on, and a lot of layers of bureaucracies that inhibit research. The plan attempts to organise research priorities around five “big bets” (read missions but not quite missions). These include the use of health data, the use of AI (again), personalised health, wearables, and the use of robots. One of the mechanisms for aligning resources will be:

    a new bidding process for new Global Institutes. Supported by NIHR funding, these institutes will be expected to marshal the assets of a place – industry, universities, the NHS – to drive genuine global leadership on research and translation.

    It’s very industrial strategy – the government is setting out big ideas with some incentives, and hoping the public and private sector follows.

    There are some more structural changes to research aside from the political rhetoric. Significantly, there is a proposal to change the funding approaches of the Medical Research Council and National Institute for Health and Care Research to pivot funding toward “prevention, detection and treatment of longterm conditions”. The hope is this approach will drive private investment. Again, like the industrial strategy, the rationale is that the state can be an enabling force for growing the economy.

    Ten years’ time

    The ten year plan, if it is to mean anything, has to be focused on delivering a different kind of health service. The fundamental shift is about moving toward personalised community orientated care. The concern is that the plan is light on delivery, which would tally with reports that a ninth chapter on delivery is missing all together.

    The NHS is stuck in a forever cycle of reform, failing to reform, entering crises, and then being bailed out from crises. The mechanisms to break the cycle includes changes to the workforce, new skills provision, using data differently, and reorientating life sciences research toward prevention and economic growth.

    The higher education sector, research institutes, and companies working in research are not only central to the new vision of a NHS but with the amount of investment placed on their capacity to bring change they are no less than the midwives of it. The government’s biggest bet is that it can grow the economy, improve people’s lives, and in doing so reduce pressure on public services. Its biggest risk is that it believes it can do this without fundamental reform to higher education or research as well.

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  • Defunding level 7 apprenticeships in health and care may backfire on lower levels

    Defunding level 7 apprenticeships in health and care may backfire on lower levels

    Well, it finally happened. Level 7 apprenticeship funding will disappear for all but a very limited number of younger people from January 2026.

    The shift in focus from level 7 to funding more training for those aged 21 and under seems laudable – and of course we all want opportunities for young people – but will it solve or create more problems for the health and social care workforce?

    The introduction of foundation apprenticeships, aimed at bringing 16- to 21-year-olds into the workforce, includes health and social care. Offering employer incentives should be a good thing, right?

    Care is not merely a job

    Of course we need to widen opportunities for careers in health and social care, one of the guaranteed growth industries for the foreseeable future regardless of the current funding challenges. But the association of foundation apprenticeships with those not in education, employment or training (NEETs) gives the wrong impression of the importance of high-quality care for the most vulnerable sectors of our society.

    Delivering personal care, being an effective advocate, or dealing with challenging behaviours in high pressured environments requires a level of skill, professionalism and confidence that should not be incentivised as simply a route out of unemployment.

    Employers and education providers invest significant time and energy in crafting a workforce that can deliver values-based care, regardless of the care setting. Care is not merely a job: it’s a vocation that needs to be held in high esteem, otherwise we risk demeaning those that need our care and protection.

    There are already a successful suite of apprenticeships leading to careers in health and social care, which the NHS in particular makes good use of. Social care providers (generally smaller employers) report challenges in funding or managing apprenticeships, but there are excellent examples of where this is working well.

    So, do we need something at foundation level? How does that align with T level or level 2 apprenticeship experiences? If these pathways already exist and numbers are disappointing, why bring another product onto the market? And are we sending the correct message to the wider public about the value of careers in health and social care?

    Career moves

    The removal of funding for level 7 apprenticeships serves as a threat to the existing career development framework – and it may yet backfire on foundation or level 2 apprenticeships. The opportunity to develop practitioners into enhanced or advanced roles in the NHS is not only critical to the delivery of health services in the future, but it also offers a career development and skills escalator mechanism.

    By removing this natural progression, the NHS will see role stagnation – which threatens workforce retention. We know that the opportunity to develop new skills or move into advanced roles is a significant motivator for employees.

    If senior practitioners are not able to move up, out or across into new roles, how will those entering at lower levels advance? Where are the career prospects that the NHS has spent years developing and honing? Although we are still awaiting the outcome of the consultation around the 10-year plan – due for publication this week with revisions to the long-term workforce plan to follow – I feel confident in predicting that we will need new roles or skill sets to successfully deliver care.

    So, if no development is happening through level 7 apprenticeships, where is the money going to come from? The NHS has been suggesting that there will be alternative funding streams for some level 7 qualifications, but this is unlikely to offer employers the flexibility or choice they had through the levy.

    Could level 6 be next?

    Degree apprenticeships at level 6 have also come in for some criticism about the demographics of those securing apprenticeship opportunities and how this has impacted opportunities for younger learners – an extrapolation of the arguments that were made against level 7 courses.

    Recent changes to the apprenticeship funding rules, requirements of off the job training and the anticipated changes to end-point assessment could lead to pre-registration apprenticeships in nursing and allied health being deemed no longer in line with the policy intent because of the regulatory requirements associated with them.

    The workforce plan of 2023 outlined the need for significant growth of the health and social care workforce, an ambition that probably is still true although how and when this will happen may change. Research conducted by the University of Derby and University Alliance demonstrated some of the significant successes associated with apprenticeship schemes in the NHS, but also highlighted some of the challenges. Even with changes to apprenticeship policy, these challenges will not disappear.

    Our research also highlighted challenges associated with the bureaucracy of apprenticeships, the need for stronger relationships between employers and providers, flexibility in how the levy is used to build capacity and how awareness of the apprenticeship “brand” needs to be promoted.

    A core feature of workforce development

    The security of our future health and social care workforce lies in careers being built from the ground up, regardless of whether career development is funded by individuals themselves or via apprenticeships. However, the transformative nature of apprenticeships, the associated social mobility, the organisational benefits and the drive to deliver high quality care in multiple settings means that we should not be quick to walk further away from the apprenticeship model.

    Offering apprenticeships at higher (and all) academic levels is critical to delivering high quality care and encouraging people to remain engaged in the sector.

    So, as Skills England start to roll out change, it is crucial that both the NHS and higher education remain close to policymakers, supporting and challenging decisions being made. While there are challenges, these can be overcome or worked through. The solutions arrived at may not always be easy, but they have to be evidence-based and fully focused on the need to deliver a health and social care workforce of which the UK can be proud.

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  • Why some viruses are so difficult to stamp out

    Why some viruses are so difficult to stamp out

    The United States is fighting an unexpectedly big measles outbreak, with hundreds of cases in the state of Texas alone. Health experts expect it will last for a year or longer, because the virus has a long incubation period — people can be infected for days before they begin to show symptoms. That, in turn, means it can spread silently.

    Another virus that’s spreading silently right now is polio. Tests of wastewater around the world have turned up alarming levels of the virus, notorious for paralyzing children, in Afghanistan and Pakistan, according to the World Health Organization (WHO), but also in Europe, in Spain, Poland, Germany, the United Kingdom and Finland.

    These two viruses should not still be around. They only infect human beings, and mass vaccination campaigns have been ongoing for decades to try to wipe them out. And the medical profession keeps coming so close to success. 

    And where do these viruses come from that keep returning despite our attempts to wipe them out? The answer is from us — from other people.

    Smallpox is the only human disease to have been completely eradicated. That was done with a dedicated global vaccination effort in 1972. Because the smallpox virus doesn’t infect any other animal, there wasn’t another place for it to survive and come back to reinfect people. 

    The same should be true for measles and polio, but war, disruption, poverty and a mistrust of vaccines make it difficult.

    Where viruses hide

    So even as vaccine campaigns come close to succeeding, the viruses can still hide out in unvaccinated and undervaccinated people. Travel and human contact do the rest to keep both measles and polio circulating. When an infected traveler hits a community of unvaccinated people — say a neighborhood of ultra-Orthodox Jews in London or a rural West Texas county full of vaccine skeptics — a contagious virus such as measles or polio can take off. 

    With both measles and polio, it takes immunization rates of more than 90% to protect a population. When rates drop below that, a community becomes vulnerable to outbreaks. A virus can take hold and spread among people, picking up steam.

    That’s happened in Pakistan and Afghanistan with polio, where efforts to reach remote populations fall short because of geography, conflict and mistrust. And in Gaza, where continuous Israeli attacks have destroyed virtually all healthcare facilities, United Nations agencies have struggled to vaccinate Palestinian children against polio outbreaks. 

    Polio is also complicated because of the different vaccine types. One of the vaccines is given orally, and it’s made using a live, but weakened, form of the virus. This gives good immunity but in rare cases the virus can mutate in someone’s body and return to infectious strength — becoming what’s called vaccine-derived virus. 

    A follow-up vaccination with a second type of vaccine made using a fully killed virus will protect against this, but when vaccine campaigns can’t be completed, vaccine-derived viruses can emerge.

    How viruses spread

    In Europe, no cases of polio have been seen, but wastewater evidence suggests the virus is surviving in people’s bodies, and could burst out to cause sickness if it gets to someone unvaccinated. Polio spreads via the fecal-oral route — in contaminated water, via poorly washed hands, on surfaces and also via sneezes and coughs.

    Fully vaccinated communities are safe but in 2022, an unvaccinated man in New York State became paralyzed after he caught polio. Investigation showed a vaccine-derived strain had been spreading quietly in the state.

    Measles is the most infectious disease known and that makes it particularly hard to eradicate. In a podcast interview I did for for One World, One Health, Dr. Peter Hotez, a pediatrician and vaccine scientist at the Baylor College of Medicine, explained just how infectious it is. 

    “If someone has measles, and especially before they get the virus and stop feeling very sick, they’re releasing the virus into the atmosphere,” Hotez said. 

    Even if they leave the room, that virus will linger in the atmosphere for a couple of hours.

    “So you can walk into an empty room that has the measles virus from someone who was there a couple of hours before and become infected,” he said, noting that one measles patient will infect up to 18 other people.

    A virus reemerges.

    Nine out of 10 unvaccinated people who are exposed to the measles virus will become infected. What is disappointing to public health experts in the latest U.S. outbreak is that so many people have become infected when measles was eliminated in the United States in 2000 and in all of the Americas in 2016.

    But pockets of people who are not vaccinated against measles can act like tinder. The spark is usually a traveler who goes to a country where measles is still common because vaccination rates are low — usually due to poverty. 

    In a November 2024 report the WHO said that measles is still common in many places, particularly in parts of Africa, the Middle East and Asia.

    “The overwhelming majority of measles deaths occur in countries with low per capita incomes or weak health infrastructures that struggle to reach all children with immunization,” the report said. Measles kills more than 100,000 people a year, mostly children. But before the vaccine was introduced in the early 1960s, it killed 2.6 million a year.

    The COVID-19 pandemic badly hurt all childhood immunization efforts, WHO and other global health authorities say. Routine childhood vaccines have not caught back up to where they were before the pandemic, leaving children and adults susceptible to vaccine-preventable diseases including measles and polio but also meningitis, hepatitis, tetanus, cervical cancer and rotavirus — a disease that causes diarrhea and vomiting in babies and young children. 

    The retreat of the United States from global health efforts — the dismantling of the U.S. Agency for International Development, its plan to cut $1 billion in funding to Gavi, the Vaccine Alliance, and its withdrawal from the World Health Organization — will further weaken global vaccination, experts say.

    And that means many more children will likely die who might otherwise live healthy lives. 

     

    Three questions to consider:

    1. How can vaccines help prevent the spread of diseases?

    2. What role should personal choice play in being vaccinated against deadly diseases?

    3. How can global cooperation help in fighting the spread of disease?

     

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  • Diversifying medicine by widening participation

    Diversifying medicine by widening participation

    Medicine is an elite profession, traditionally dominated by white, male, middle- or upper-class people, frequently from medical families.

    In 2014, the Medical Schools Council (MSC) created a Selection Alliance (SA), and published Selecting for Excellence (SfE), to address inequities in access to medical degrees in the UK for those from “widening participation” backgrounds.

    Fostering Potential: 10 years on from Selecting for Excellence , published in December of 2024, reports on progress made, with welcome achievements that are testament to the commitment of the community. The report rightly notes that focus on widening access has meant support for diverse students once they commence studies has been neglected.

    Recently, medical student activism – #LiveableNHSBursary , and #FixOurFunding – have highlighted the peculiar funding situation medical students find themselves in , and the financial pressures they experience during their studies.

    Fostering Potential asserts that WP needs to be reconceptualised away from a deficit framing of individuals as lacking ambition or aptitude to excel, to understanding lack of participation as the product of systemic and institutional failures around inclusion. For me, one of the main barriers to success for students from a disadvantaged socio-economic background studying medicine is the degree was designed and developed for a financially comfortable student. Its current structure excludes students from diverse backgrounds, and part of this is financial.

    The earnings gap

    One might argue that the financial hardship experienced by student medics is the temporary cost of what will become a lucrative career. However, once qualified, doctors from a lower socio-economic background will experience an average class pay gap of £3,640. This means their degree is both harder won and less remunerative.

    Current research and initiatives on financial barriers to success mostly treat money as a discernible object that can be quantified. It is a thing we either have enough of, or not; something we earn for ourselves as individuals. Hence proposed solutions tend to focus on maximising individual students’ abilities to earn alongside studies, while recognising that lack of time due to part-time work or caring responsibilities means some students cannot take advantage of extracurricular career development opportunities.

    I find this contradictory and suggest it misses a key point – money is also a relationship; it shapes our experiences of the world far beyond how much we have. It is a condition of success, not a result of it. Developing support for a student from a financially disadvantaged background should be informed by research that explicates how poverty impacts students’ opportunities to learn and exploit the advantages higher education allegedly offers.

    A student’s-eye-view

    I lead a project at Lancaster Medical School called Medicine Success, providing funds to mitigate the hidden costs of a medical degree for students from diverse backgrounds – purchasing a stethoscope, professional attire and funding the compulsory elective.

    Five years of project evaluation data reveal much about the role money plays in students’ sense of belonging and success. A student’s-eye-view of the degree reveals how unexpected its hidden costs are, how difficult it is to cover the cost of living and studying without financial support, and how choices about career development are constrained by cost. Further, the data shows students with scarce resources are keenly aware of how wealth is a vector of exclusion and inequity shaping their experience of the degree differently to their wealthier peers:

    Receiving these funds made a massive difference as it took me by surprise how much of a financial burden studying at university was. It seems that every aspect of it requires you to spend money that you don’t have and I feel at times it’s not all inclusive (2nd year, 2024)

    Their evaluations of the funding show that money transforms our lived experience of the world, and in turn, shapes our thoughts and feelings. They explain how scarcity can impact mental health and mental bandwidth, and the funding alleviates financial anxiety and paid-work commitments so they may focus on their studies.

    But it means more than just being able to afford essentials, it means being able to participate equally and with pride in their degree in comparison to their wealthier peers. This directly impacts self-esteem and addresses feelings of unworthiness or lack of belonging.

    A good example of this is the professional attire fund:

    I know professional attire might not seem serious but not having the right attire when it’s necessary leads me to overthink about how I’m dressed and feeling insecure during sessions. It’s often to the point where instead of focusing on learning I can’t help but to think about my appearance. (1st year, 2020)

    It is well-established that class can be read through a multitude of symbols. Respondents describe how their “lower” social status feels revealed through clothing, making them feel insecure in the learning environment. Students relate having their cheap and tired-looking clothes pointed out to them by peers, others worried about wearing the same outfit every day and what that said about their finances, while some feel that their patients have less respect for their opinion when they don’t present well-dressed. Meanwhile, ill-fitting clothing and shoes also interfere with the ability to focus on studies, causing pain and making long shifts additionally exhausting.

    Widening participation initiatives that focus on belonging from a social, cultural or academic skills perspective miss this crucial element – money. One student articulates a point made repeatedly by many of their peers:

    Funds like these make students like myself feel more heard and seen and gives us the opportunity to come from a lower socio-economic background and not feel as if we don’t belong here simply due to lack of finance. It gives us the confidence and the ability to work hard for what we want as we know there is always support available for students like us. (1st year, 2022)

    Recipients of Medicine Success funding attest that financial support levels the playing field with their more privileged peers in numerous, significant, and yet, subtle ways. Providing financial support is essential to make the learning environment, social activities, and career development accessible to students from all backgrounds. Belonging is in part financial; you can’t participate fully without money.

    Wider Context

    Recent reports show that the government is making a loss on student loans due to higher interest rates . This means private lending institutions are making a profit from the scheme funded by tax-payers and graduate repayments. In Why We Can’t Afford the Rich, Andrew Sayer explains that our current political system “supports rentier interests, particularly by making the 99 per cent indebted to the 1 per cent” , in which wealthy people are less likely to earn money through paid work, but accrue wealth through financial activities. The student loans scheme is one example.

    Higher education is presented as a means of social mobility, while extracting wealth into a financial sector that shores up its and its investors power. It does so by making already poor people pay to access education but without the conditions to participate fully. The promise of breaking the cycle of poverty with a university degree is so powerful that it deflects attention from what is really happening, despite extensive evidence that education has yet to prove itself as a solution to class inequalities. For these reasons, even with WP policies, HE has financial injustice embedded within it, resulting in deleterious effects on students’ mental health, degree experiences and outcomes.

    I see this as an example of “financial trauma,” defined by Chloe McKenzie as “the cumulative effect of being required to experience economic violence, financial abuse, financial shaming, and/or (chronic) financial stress to attain or sustain material safety”.

    Social mobility is a problematic term; it requires individual people to increase their position in an established hierarchy that is itself integral to maintaining socioeconomic inequality. This is why I welcome the MSC’s push to reconceptualise improving participation as a systemic issue, not one focussed on changing individuals to fit into the status quo. At the same time, we must apply this thinking to financial barriers to success, by recognising that money is far from a private issue but a matter of justice.

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  • What’s all the flap about bird flu?

    What’s all the flap about bird flu?

    Avian influenza has scared doctors and scientists for a generation. But its arrival in the United States might finally give the H5N1 bird flu virus the combination of factors it needs to cause a global pandemic.

    Those factors include a new carrier; dairy cattle; a regulatory system that protects farmers at the expense of human health; and a government bent on taking down an already weak public health infrastructure.

    The H5N1 avian influenza virus making headlines around the world — and driving up the price of eggs — in the United States is no youngster. It’s been around since at least 1996, when it was first spotted in a flock of geese in Guangdong in southern China.

    Since then it has spread around the entire world, tearing through flocks of poultry in Asia, Europe and the Americas and wiping out birds and mammals on every continent, including Antarctica. H5N1 bird flu only rarely infects people but as of the end of January 2025, the World Health Organization reported 964 human cases globally and 466 deaths, although many milder cases are likely to have been missed.

    Vets and virus experts have had their eyes on H5N1, in particular, for decades. It didn’t look like a serious threat when it killed geese in 1996. But the next year the virus caused an outbreak in people just over the border from Guangdong in Hong Kong.

    It infected 18 people and killed six of them before it was stopped. That got people’s attention. A 30% fatality rate is exceptionally high for a virus — something approaching the mortality of smallpox.

    Mutations and swap meets

    The virus gets its name from two prominent structures: the hemagglutinin, or H designation, and the neuraminidase, or N. All influenza A viruses get an HxNx name. The current circulating viruses causing human flu misery right now are H1N1 and H3N2, for example, as well as influenza B, which doesn’t get any fancy name.

    But influenza viruses are exceptionally mutation-prone, and even the extra designation doesn’t tell the whole story about the changes the virus has undergone. Every time a flu virus replicates itself, it can make a mistake and change a little. This is called antigenic shift. As if this wasn’t enough, flu viruses can also meet up inside an animal and swap large chunks of genetic material.

    The result? The H5N1 viruses now circulating are very different from those that were seen back in 1996 and 1997, even though they have the same name.

    This is what’s been going on over the past 30 years. H5N1 has been cooking along merrily in birds around the world. So, after the 1997 outbreak, not much was seen of H5N1 until 2003, when it caused widespread outbreaks in poultry in China. Researchers discovered it could infect wild waterfowl without making them sick, but it made chickens very sick, very fast. And those sick chickens could infect people.

    The best way to control its spread among poultry was to cull entire flocks, but if people doing the culling didn’t take the right precautions, they could get infected, and the virus caused serious, often fatal infections. Doctors began to worry that the virus would infect pigs. Pigs are often farmed alongside chickens and ducks, and they’re a traditional “mixing vessel” for flu viruses. If a pig catches an avian flu virus, it can evolve inside the animal to adapt more easily to mammals such as humans. Pigs have been the source of more than one influenza pandemic.

    Pandemic planning

    In the early 2000s, scientists and public health officials took H5N1 so seriously that they held pandemic exercises based on the premise that H5N1 would cause a full-blown pandemic. (Journalists were included in some of these exercises, and I took part in a few.)

    But it didn’t cause a pandemic. Vaccines were developed and stockpiled. Pandemic plans were eventually discarded, ironically just ahead of the Covid pandemic.

    However, flu viruses are best known for their confounding behavior, and H5N1 has always been full of surprises. It has evolved as it has spread, sometimes popping up and sometimes disappearing, but never causing the feared human pandemic. It has not spread widely among pigs although it has occasionally infected people around the world, as well as pet cats, zoo animals, wild seals, polar bears, many different species of birds and, most lately, dairy cattle.

    It’s this development that might finally be a turning point for H5N1.

    For a virus to start a human pandemic, it must acquire the ability to infect people easily; it must then pass easily from person to person; and it must cause significant illness.

    Competing interests

    So far, this hasn’t happened with H5N1. It has infected 68 people in the United States, mostly poultry or dairy workers. Mostly, it causes an eye infection called conjunctivitis, although it killed one Louisiana man. But it is spreading in a never-before-seen way — on milking equipment and in the raw milk of the infected cattle.

    “The more it spreads within mammals, that gives it more chances to mutate,” said Nita Madhav, a former U.S. Centers for Disease Control and Prevention researcher who is now senior director of epidemiology and modeling at Ginkgo Biosecurity. I interviewed her for a podcast for One World One Health Trust. “As it mutates, as it changes, there is a greater chance it can infect humans. If it gains the ability to spread efficiently from person to person, then it would be hard to stop,” Madhav said.

    And while some states are working to detect and control its spread, the federal government is not doing as much as public health experts say it should. Two agencies are involved: the U.S. Department of Agriculture (USDA) and the Centers for Disease Control (CDC).

    Dr. John Swartzberg, a health sciences clinical professor emeritus at the University of California, Berkeley said in an interview with the UC Berkeley School of Public Health that the USDA is charged with two responsibilities that only sometimes work in concert.

    “One of the responsibilities they have is to assure a healthy agricultural industry for the United States,” Swartzberg said. “The second responsibility is to assure safety of the human beings who consume agricultural products in the United States.”

    More information, not less, is needed.

    Dairy farmers feared they’d lose money if their farms were identified as sources of infection. And it’s a lot more expensive to cull cattle than it is to cull chickens.

    “And I think what we’ve seen with this bird flu problem is that the USDA is tilted in favor of protecting the industry, as opposed to protecting the health of humans,” Swartzberg said. “CDC is also involved, but the CDC has no authority to go into states and tell them what to do. It has to be done state by state.”

    On top of that, U.S. President Donald Trump has ordered the CDC to take down websites reporting on avian flu and other issues. He is withdrawing U.S. membership from WHO, crippling the ability to coordinate with other countries on controlling outbreaks of disease.

    He notably tried to suppress reporting about Covid during his previous presidency and promoted unproven and disproven treatments.

    His newly confirmed Health and Human Services Secretary, who will oversee CDC and other agencies charged with human health, Robert F. Kennedy, Jr, is a vaccine denier, proponent of raw milk and has no public health qualifications.

    The stubbornness of people in the United States doesn’t help. When public health officials warned against drinking raw milk last year, raw milk sales actually went up.

    “Food safety experts like me are just simply left shaking their heads,” Donald Schaffner, a Rutgers University food science professor, told PBS News.

    The big fear? That in flu season, someone will catch both seasonal flu and H5N1, giving the viruses a chance to make friends in the body, swap genetic material and make a deadly new virus that can infect people easily.

     

    Three questions to consider:

    1. How can politics affect public health risk?
    2. How does public understanding and trust affect the risk of disease?
    3. Countries often blame one another for the spread of disease, but should they?

     

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  • The barriers that must be removed for degree apprenticeships to meet NHS workforce targets

    The barriers that must be removed for degree apprenticeships to meet NHS workforce targets

    The recent notion that level 7 apprenticeships will be ineligible for support from the apprenticeship levy has caused consternation amongst training providers, especially in healthcare.

    Training providers and employers are urgently seeking clarity on the government’s position – the current “announcement without action” leaves stakeholders unclear about next steps and further risks the reputation and role of apprenticeships in skills development.

    The development of advanced roles in health or shortened routes to registerable qualifications significantly relies on level 7 apprenticeships. The NHS Long Term Workforce Plan is full of examples of how advanced and new roles are needed now and in the future.

    Once again, decisions are being made by the Department for Education without consulting or collaborating with the Department of Health and Social Care, which means that questions are left unanswered. It is not the first time that training providers and University Alliance have called for joined up thinking and, unfortunately, it certainly won’t be the last.

    Expansion of opportunity

    Health apprenticeships at the University of Derby started small with level 5 provision about ten years ago (subsequently expanding to levels 6 and 7) – we could not have foreseen the enormous expansion of opportunity both in health and other industries that would follow.

    I am proud to say that “I was there” when the nurse degree apprenticeship standard was approved in 2017 – the culmination of two years’ collaboration between the Nursing and Midwifery Council, government, Skills for Health, employers and training providers.

    There were challenges, but we made it, and it opened the door to transformation in how healthcare professionals are educated.

    A bumpy road

    But the journey remains bumpy, and apprenticeships seem to be experiencing a particular period of turbulence. New research conducted by the University of Derby on behalf of University Alliance demonstrates the need for change in how the levy is utilised, the importance of partnership working, and the support that those involved with apprenticeship delivery need in order to secure successful outcomes.

    While the NHS Long Term Workforce Plan of 2023 is itself being refreshed, we can be confident that apprenticeships will continue to have a significant part to play in workforce development. However, our new research has shown how and where employers and training providers need support to make this happen.

    Employers told us how expensive they find it to support apprenticeships, with apprentice salaries, backfill and organisational infrastructure contributing to the financial burden. We know that apprentices need significant support through their learning journey, taking time and investment from employers.

    To make apprenticeships truly successful, the support required is over and above that normally expected in healthcare programmes, yet apprenticeships are specifically excluded from the NHS Healthcare Education and Training tariff. This feels like a double whammy – no support from the tariff and no flexibility in how the levy could be utilised differently, meaning that the responsibility remains with the employer to resource.

    Equally, training providers reported the additional activities and responsibilities associated with the delivery of apprenticeships. The University of Derby has recently successfully completed its inspection by Ofsted. The week of the inspection required input from teams across the University, but the enduring responsibilities of compliance and record keeping make this a continuous activity for a skilled and specialist team.

    The Education and Skills Funding Agency then came hot on the tails of Ofsted – while this is not unexpected, it has again required teams from across the University working long hours to be audit ready. These inspections have served as a reminder of the regulatory burden placed on training providers, especially in healthcare.

    A matter of commitment

    Today marks the start of National Apprenticeship Week. At the University of Derby, we are hosting a week of activities and events, encouraging aspirant apprentices and a range of employers to come and find out more about what apprenticeships can do for them. It is heartening to hear that the number of young people coming to the campus this year has more than doubled since last year’s event.

    Finally, the word is beginning to spread about apprenticeships, and we find school leavers are increasingly well informed about their post-16 and post-18 options.

    The week’s events will be ably supported by our employer partners and apprentices, truly reflecting the partnerships that have developed over the years. These partnerships take a significant amount of investment on all sides – anyone in the vocational education and training world will know that strong partnerships take time and effort to build and maintain. But even the briefest of conversations with apprentices will tell you that it is all worth it. Their confidence, passion and knowledge (their skills and behaviours too) shine through. In a city like Derby, the awareness of the positive difference you are making not only to the apprentice, but also to their family and friends, is never far from your thoughts.

    It is difficult to know how the advent of Skills England will impact the pace and scale of reform, but the present inertia may set the country back – and it certainly will if a blanket approach to level 7 apprenticeship funding is adopted, and lack of join-up between DfE and DHSC remains the status quo.

    National Apprenticeship Week 2025 has the potential to be a force for good – and should be the week that all stakeholders commit to making a difference.

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