Section 47 : The compulsory removal of old people from their homes

The objective of the research presented in the thesis was to review the use of the powers of compulsory removal contained in Section 47 of the National Assistance Act of 1948. These powers do not require the person to be mentally ill, as the Mental Health Act does. All that is required is that he or she is either suffering from "grave chronic disease" or is "aged, infirm, or physically incapacitated", and that they are living in insanitary conditions. Such persons can be removed by a community physician acting for the local authority if "they are not devoting to themselves or receiving from other persons proper care and attention" provided that he applies to a magistrate or a court. The Department of Health no longer collects information about the use of Section 47 so it was necessary to write to all the responsible community physicians in England. From the 90 per cent response, the frequency of use of these powers was calculated. In most cases elderly people in crisis were removed. Most of them went to hospitals rather than to old people's homes. There is a considerable variation in the frequency with which the powers are used and 25 per cent of the community physicians did not use them at all during the four years under consideration, which were 1974-78. The possible reasons for this are analysed and the effects of compulsory removal on the elderly people are discussed. Two disturbing themes emerged from the research. First, there is considerable evidence to suggest that the powers are not used often enough; that many elderly people are coerced, deceived, or "persuaded" from their homes without Section 47 powers of compulsory removal being invoked. There are many admissions which can in no way be considered to be voluntary admissions although they are not covered by Mental Health Act or Section 47 orders. The implications for professional training and practice are outlined and the need for greater legal protection for elderly people is considered. The second disturbing theme is that the manner in which the Act has been drafted and is currently interpreted defines the "need" only in terms of personal incapacity. Criteria are laid down with respect to the degree of the person's disability but nothing is said about the degree of community support he should be entitled to expect before he is deemed to need institutional care. Where the need is for treatment which can only be obtained in hospital, for example operative repair of a fractured neck of femur, such definition is unnecessary. However, where the person's requirement is for more care of the type he could receive in his own home if more resources were available, such a definition of "need" evades the basic issue of resource shortage. The implications of this particular definition of need for professionals who meet elderly people and for those who plan services are discussed, using examples from other areas of health care, for example, renal transplantation. The research summarised in the thesis had two broad aims. One was to determine whether the law was still relevant or whether it should be repealed and the conclusion reached is that it should not be repealed. It is argued that the existence of these powers of compulsory removal is, paradoxically, a means of safeguarding liberty, although their use does infringe the liberty of those individuals who are compulsorily removed. If it were repealed those who would at present be removed using Section 47 would not all be left in liberty at home; many would be coerced, persuaded, drugged, or deceived into an institution without any legal control over the professionals and without any means of appeal. The second of these more general aims was to analyse paternalistic attitudes towards old people. This relates closely to the former am because the law, as a whole, is more than a collection of legal instruments. It is an expression of certain attitudes and values and a reflection of certain beliefs, and the function of a law is as important as the manner in which it is used. The methods used in studying this aspect of the subject were drawn from the closely related methodologies of history and anthropology. It is this aspect of the thesis which is, in my opinion, the most significant for the practice of medicine and other professions because it is an appreciation of the attitudes towards old people which prevail in society which is of fundamental importance in understanding public pressure on professionals and the manner in which professionals themselves analyse, classify and attempt to solve the problems of elderly people

Geographical variation in certification rates of blindness and sight impairment in England, 2008-2009

To examine and interpret the variation in the incidence of blindness and sight impairment in England by PCT, as reported by the Certificate of Vision Impairment (CVI). Design: Analysis of national certification data. Setting: All Primary Care Trusts, England. Participants: 23 773 CVI certifications issued from 2008 to 2009. Main Outcome measures: Crude and Age standardised rates of CVI data for blindness and sight loss by PCT. Methods: The crude and age standardised CVI rates per 100 000 were calculated with Spearman's rank correlation used to assess whether there was any evidence of association between CVI rates with Index of Multiple Deprivation (IMD) and the Programme Spend for Vision. Results: There was high-level variation, almost 11-fold (coefficient of variation 38%) in standardised CVI blindness and sight impairment annual certification rates across PCTs. The mean rate was 43.7 and the SD 16.7. We found little evidence of an association between the rate of blindness and sight impairment with either the IMD or Programme Spend on Vision. Conclusions: The wide geographical variation we found raises questions about the quality of the data and whether there is genuine unmet need for prevention of sight loss. It is a concern for public health practitioners who will be interpreting these data locally and nationally as the CVI data will form the basis of the public health indicator ‘preventable sight loss’. Poor-quality data and inadequate interpretation will only create confusion if not addressed adequately from the outset. There is an urgent need to address the shortcomings of the current data collection system and to educate all public health practitioners

Writing in Britain and Ireland, c. 400 to c. 800

No abstract available

Innate immunity in cystic fibrosis lung disease.

Chronic lung disease determines the morbidity and mortality of cystic fibrosis (CF) patients. The pulmonary immune response in CF is characterized by an early and non-resolving activation of the innate immune system, which is dysregulated at several levels. Here we provide a comprehensive overview of innate immunity in CF lung disease, involving (i) epithelial dysfunction, (ii) pathogen sensing, (iii) leukocyte recruitment, (iv) phagocyte impairment, (v) mechanisms linking innate and adaptive immunity and (iv) the potential clinical relevance. Dissecting the complex network of innate immune regulation and associated pro-inflammatory cascades in CF lung disease may pave the way for novel immune-targeted therapies in CF and other chronic infective lung diseases