We are revisiting some of the work we did when the proposals to close the Crown Street Site were first raised. The article was written some years ago. These ideas are still relevant.
ENVIRONMENT
Liverpool Women’s Hospital is a specialist hospital dedicated to the care of women, babies and their families in a safe friendly environment. It opened in 1995 and is located on Crown Street, Toxteth in a modern landmark building (NHS Choices).
In 2013 a new development of the reception area incorporated a comfortable seating area, cafe, shop and a play area for children. It opens up onto a landscaped courtyard with seating, a herb garden was planted for use by the hospital chefs and a memorial garden was opened to offer bereaved families a private space within the hospital grounds.
Another garden “The Garden of Hope and Serenity” was opened in 2016.
“This garden is a lovely area where our women, families and staff can relax in the sunshine and escape life on the wards”
(Kathryn Thomas, Chief Executive at LWH).
The idea for this garden came from nurses at the gynaecology unit who recognised that women and families visiting the Emergency department would benefit from a space away from but near to the department to have an area of calm to process their thoughts and feelings.
There is a wealth of literature that confirms the importance of trees and gardens for patient recovery and should not be ignored. A much-cited study, published in 1984, by environmental psychologist Roger Ulrich was the first to use the standards of, modern medical research to demonstrate that gazing at a garden can sometimes speed healing from surgery, infections and other ailments.
Although it is clear that this will not cure disease, it has been proven that just five or six minutes spent looking at views dominated by trees, flowers or water can begin to reduce levels of anger, anxiety, stress and pain. This can allow other treatments to help healing and induce relaxation that can be measured in physiological changes in blood pressure, muscle tension or heart and brain activity.
Studies have shown that loud sounds, disruptive sleep and other chronic stressors can have serious physical consequences and hamper recovery (Ulrich,1994).
Henry Marsh, the celebrated neurosurgeon and writer has stated:
“……… these big hospital are horrible places really, the very last thing you get in an English hospital is peace, rest or quiet which are the very things you need the most”. He goes on to say that the garden he created at St. George’s Hospital,” ….. is probably the thing I am proudest of.” (The Observer).
Not all gardens are equally effective. A study found that tree lined vistas of fountains or other water features, along with the greenery of mature trees and flowering plants appealed the most. The more greenery versus hard surfaces the better (Cooper Marcus and Barnes 1994).
The plan for the new Royal hospital includes a landscaped garden. According to Brian Zeallear from NBBJ:
“Through creating smaller buildings around the periphery and having public roads and pedestrian corridors through the site, we can stitch back the existing city. The centre will feel like a public square. The hospital is in a dense urban area but once the landscaping is done….it should make you feel you are in nature through the manicured grass, trees and water features”.
However sitting in a public square surrounded by public roads is hardly the restorative qualities of greenery, flowers and other nature content envisaged by Ulrich.
Liverpool Women’s Hospital is at present situated in a quiet, landscaped and safe environment. Although it is in a fairly central location it is protected from the sounds and pollution of traffic.
There is now substantial evidence on the adverse effects of air pollution on different pregnancy outcomes and infant health. The evidence for the impact of air pollution on infant mortality, primarily due to respiratory deaths in the post natal period seems to be solid (WHO 2005). There is now new evidence that shows air pollution particles from traffic affects the health of unborn babies ( Miyashita & Liu 2018).
Less consistent though still suggestive of a causal link to air pollution are lower birth weight, a higher incidence of preterm births and intrauterine growth retardation. Moreover, the evidence shows clearer relationships between particulate matter and traffic-related air pollution than other pollutants.
The intrauterine, perinatal and early childhood periods, during which the lungs are developing and maturing are very vulnerable times. These are times when the lungs are more susceptible to injury by air pollutants. Exposure during these periods reduces the maximal lung functional capacity achieved in adult life and can lead to increasing susceptibility, in adulthood, to infections and the effects of pollutants such as tobacco smoke and occupational exposures (Vierira 2015). Also there is sufficient evidence of a causal relationship between exposure to lead to neurobehavioural deficits in children in terms of cognitive impairment (WHO2005).
While it is impossible to avoid all air pollutants, advice from many sources include, remaining indoors when air pollution is high and even when air pollution is low it is best to avoid polluted roads (Greenpeace 20017). Campaigns to avoid exposure to air pollutants include moving school entrances from busy roads and the use of pram covers to protect babies from being exposed to harmful particles.
In the face of all the evidence of the harmful effects of air traffic pollutants on neonates, it is inconceivable that the environmental effects of building a hospital for women and babies in the middle of one of the most traffic-dense areas of the city have not been considered.
Liverpool City Council will discuss the new health service configuration called the ICS for the first time since we lost the battle against the Health and Care Bill in Parliament. The battle for our healthcare will now take a different more urgent form, and councils have a part to play. We list below some key issues Councillors should raise.
Mental health, CAMHS, maternity, dentistry, GP services, Accident and Emergency, waiting lists waiting times, staff pay, staff retention, and staff working conditions are all under dreadful stress. Covid is simmering away and we have to prepare for a further outbreak or a big winter of flu. This huge restructuring to favour the private sector adds fuel to the fire.
Liverpool Council will discuss the implementation of the Integrated (not) Care System on Wednesday (25 05 22). All the other Cheshire and Merseyside Councils will be having similar discussions.
The Cheshire & Merseyside ICS is item 16 on the agenda at the city council.
Life expectancy has fallen. Life expectancy in good health has fallen (figures from before the pandemic which caused further falls) Our people are dying and getting ill earlier and not just because of a badly managed pandemic, but because of austerity and the decline in the NHS under Conservative and ConDem governments. It is on their watch. They carry the responsibility.
The NHS has many intertwined crises that this reorganisation does not address. Please see below for more on these urgent health care issues.
Councillors can significantly help protect healthcare in our area by adopting these immediate demands, drawn up by health campaigners across England.
Immediate issues. Councils are the only democratically elected organisations with any direct influence on these new ICS structures. Councillors can report directly to their electorate to put these policies under the spotlight.
ICB Constitution. Each integrated Care Board must write its constitution.
We are asking councillors to please ensure the following commitments are written into the ICS constitution:
That the ICS in Cheshire and Merseyside will maintain a comprehensive health service, free at the point of need, accessible to everyone living in the area – including homeless people – at the time when they need health care or treatment.
That anyone needing emergency or urgent services while present in the ICS’s geographical footprint will receive the necessary treatment, whether or not they are registered with, or permanently reside within, the ICS area.
That ICSs should not include private sector representatives on any ICS boards or committees or any bodies with delegated powers from the ICB.
Privatising is a multilayered process. See this for a working definition.This new system is designed to limit care, and make a profit for private providers. However, this is rarely said in public. Privatising healthcare is still extremely unpopular. Government and NHS chiefs do not like discussing it. The Public does not want this to happen. Councillors though answer to their electorate and must speak up for them.
That NHS providers are the default providers of health services, care and treatment, and that as contracts with private sector companies come up for renewal the default position is that they will be awarded to NHS providers.
That if any contracts do continue to be awarded to the private sector, there must be vigorous scrutiny to ensure that this is conducted in a transparent and accountable manner.
That the Integrated Care Board include a councillor from each local authority covered by the ICS, not just one representative covering all the local authorities in an area.
That the Integrated Care Board must include representatives of professionals from Mental Health, Community Health, Maternity, Primary Care and Public Health, as well as from Acute services.
A commitment that maternity care will meet every aspect of Donna Ockendon’s report, including the required staffing
That Integrated Care Boards, Integrated Care Partnership body, place-based bodies, committees and sub-committees will include representatives of patients’ groups and of NHS staff trade unions.
That it be ensured that before a patient is discharged from the hospital, it is safe to do so and that any unpaid carers expected to look after the patient are both willing and capable of doing so, and that the operation of the discharge policy will be audited.
That nationally agreed pay, terms and conditions, including pensions, as negotiated with the NHS staff unions, will apply to all staff employed by any NHS provider within the ICS area.
That there must be a discussion with NHS staff unions about safe staffing levels and what is needed to ensure they can be implemented.
In item 16, there appear to be no councillors on the IC Board, only two executives from across the 9 Cheshire & Merseyside local authorities. These people will not be there to represent local authorities’ policies. Is this acceptable to Councillors?
The ICS structure has been tried in pilots and found wanting. The model has major faults.
Liverpool Policy
Liverpool City Council policy has been to oppose the introduction of the 40+ separate health systems (ICS=Integrated Care Systems) through the Health & Care Bill, now the Health & Care Act. This Act deliberately breaks up a national health service into these separate units, whose shadow structures (ICS) were set up ‘extra-legally’ before the Act became law.
Multiple Crises in Healthcare in May 2022
This new system starts with cuts. They talk the sweet words of Transformation but it is a brutal change they are implementing. Our hospitals, GP services, maternity, mental health and dentistry services are all struggling to cope, and at times failing. We are already so understaffed that maternity cannot provide one midwife to one woman giving birth.
Local mental health patients in crisis are being sent to distant cities just to get a bed.
Staff costs cover 46.6% according to The Kings Fund. Other surveys put it much higher. So, all cuts would hit staffing.
“Every health system has seen their core recurrent funding reduce in real terms in 2022-23, analysis by HSJ reveals;
An increase in recurrent allocations wiped out by inflation
The situation is likely to be worse than official figures suggest
Every health system subject to real terms cut in core spending per head”
The Government has come up with some more money or some services but by robbing Peter to pay Paul, not producing real increases
HSSF
The HSSF is a list of companies that can be given NHS work without the normal bidding and scrutiny process
“Huge US transnationals are accredited by NHS England through the Health Systems Support Framework, to gain NHS contracts.”
Hospital Closures
The Act allows the Secretary of State to interfere early to decide on local ‘reconfigurations’ including hospital closures, thwarting public consultation, and weakening the say local authorities and councillors have on NHS plans in their area.
“Moving specialised services commissioning from NHS England to integrated
care systems risk fragmenting provision, creating postcode lotteries and diluting quality and expertise” a group representing some of the largest tertiary trusts has told NHS England.
We have had enough of closures, reduction in bed numbers and the chaos of the Liverpool Royal Carilion building.
Public Questions
The public will have no right to ask questions and get answers from the ICB or its committees and can be excluded from meetings. Who will see if health care treatment is just adequate and fair?
The report on the ICS Joint Health & Scrutiny Arrangements recommends the setting up of a Joint Health Scrutiny Committee across all nine local authorities in the Cheshire & Merseyside area.
Questions that need answering:
Thanks to Black Lives matter demonstrators for this image Its just as true for the NHS
How can Ockendon’s report on Maternity failings be tackled if large cuts are involved before the system is even legally launched? How can it tackle the Mental Health crisis, the GP crisis, the A+E crisis, the workload and workforce crises and Ambulance crises with fewer funds? We weep for the babies who died unnecessarily yet allow the situation to deteriorate beyond what it was when Ockendon investigated. Already this city has the worst deaths under one year old, and that does not include stillbirths.
How is Maternity represented on the ICS? Who on the ICS will be responsible? Every hospital must now have an ‘Ockendon rep,’ but not the ICS?
How will the Council’s Social Care Budget be impacted? The Act gives the ICS significant powers that need to be clarified, if necessary, in law.
How will the ICS ensure probity in allocating services to the companies on the HSSF list
How will the ICB ensure no health worker is denied decent pay?
The ICS model is based on a specific US model designed to make money for the private sector, ration patient treatment, and reduce staff pay. It has widened health inequalities. These organisations are now being used to privatise even Medicaid in the US.
The effect of the passing of the Health and Care Bill will be harsh. It is now an Act and as such will be implemented creating forty-two distinct organisations. Ours is the Cheshire and Merseyside Integrated Care System (ICS). Exactly who sits on these boards has yet to be published. We do know their chairs and many other posts.
Our anger at what is happening is righteous and well informed. As we campaign we want people to focus their anger into action, not let that anger become, as the Conservatives wish, debilitating and without purpose.
We need people to help with the campaign to reinstate the NHS and to monitor what is happening locally. Please do get in touch if you can help even in the smallest way.
Each ICS organisation will be expected to keep to a set financial limit, and any financial risk-sharing will be within each ICS. This financial structure, in reality, is unworkable but it will be used to excuse and implement harsh cuts, which in turn will inflict death, pain, and suffering. It will mean worse pay for staff too. This is unless, of course, we can build a deep and wide protest movement. This has been done before. We need to do it now.
The ICS boards will control all spending in the Cheshire and Merseyside health area. Hospital trusts start this era in debt, not from being spend thrift, but because budgets were not adequate for the treatments they had to deliver.
The ICS system is supposed to insist on no overdrafts, and that any over spend has to come from other hospitals in the local system. Well that’s not going to work, is it? In fact, this system is very dangerous for maternity as many of the Trusts in Cheshire and Merseyside do not provide maternity care and may not therefore even have an Ockendon Rep on their boards. Donna Ockendon insisted that each hospital had a board member responsible for Maternity on their board because of the poor oversight in Shrewsbury We have found no Ockendon Rep on the ICS board, in the paperwork available to the public We would love to be proved wrong.
Maternity is in crisis as the Royal College of Midwives, somewhat belatedly, said recently and that crisis must be addressed, rather than cuts in spending enforced. This is the lives of mothers and babies and the working lives of maternity staff that we are talking about. What is more important than the lives of mothers and babies at birth?
Meeting all the Ockendon requirements for safety requires major investment not cutbacks, not just in the Liverpool Women’s Hospital, but in Arrowe Park Hospital, in Leighton, in the Countess of Chester, in Ormskirk, in Whiston and any other maternity service in Cheshire and Merseyside and beyond.
Liverpool Women’s Hospital Board Papers said
“The Trust is in underlying deficit, and faces additional pressures to maintain levels of workforce recommended by the (first) Ockenden report. There is a significant increase in clinical negligence costs which have not yet been funded.
Financial impacts of the second Ockenden review, and any funding available to support this, are being assessed. There are other significant cost pressures which will be managed through an ambitious and challenging 3% cost improvement plan plus additional non recurrent mitigations. .”
When the Banks needed bailing out huge amounts of money were conjured up for them. Sajid Javid the health secretary was a banker in those crazy times. Hey! Sajid, health needs a big investment that will pay for itself many times over.
This money shortage is serious. Researchers have gathered the figures from board papers from local hospitals.
Mid Cheshire hospitals Trust wrote “The system has £183m less resource than in 2021/22, which is a 3% reduction in funding after inflation has been applied. There are several factors which are influencing the movement and some key risks to receiving the funding in full.
“1. Convergence: C&M funding levels are currently above its calculated target allocation by £338.5m, and has a target to reduce this over time, leading to the additional reduction of £51.67m…..”
The UK is experiencing high inflation, especially from fuel costs. This will affect the NHS too. So we need to add inflation to the cuts described above.
NHS pay has acted to keep NHS inflation below the national average for some years. Low paid NHS staff who stay in the job because they are committed to the NHS will feel the increase in inflation still more.
Although the Act is called the Health and Care Act it does little for the mostly privatised Care sector. This letter is not focusing on that important issue. (A separate article will cover that). This situation is looking at the breakup of the NHS.
The problems in social care are impacting badly on hospitals which at present cannot easily discharge patients to care homes. The shadow of the Covid deaths hangs long over the care home sector and the Covid virus is far from spent.
The New ICS system introduced by the Act has been present in shadow form for some time and regional control of budgets increased during the pandemic.
This model of healthcare finance and delivery is based on the US Accountable Care systems. Accountable here means “for accounting,” not “answerable to.” It is designed to make money for the private sector. Designed to give our tax money not to the sick or the hard-pressed underpaid staff but to the rich.
Plans for this have taken many years, back to Thatcher and more recently work at Davos, the working groups of the globally rich.
We have lost a National Health Service. The national part of the health service is important for risk sharing, research sharing, national pay structures, and shared experience. These models will produce postcode lotteries and differential services. We can imagine that they will blame Merseyside for the effect of their cuts as they are now blaming Liverpool for the effect of 60% cuts in local government funding.
The huge health gaps in life expectancy will open wider. Remember more babies die in Liverpool under one year of age than anywhere else in the country. Working-class women have a life expectancy ten years less than those in rich areas. The Tory voting areas will get service though
If we can build a campaign we will deepen the commitment to the Bevan Model of the NHS in our areas.
In these new structures, the national part of our health service has gone. What we have now is more like a localised public-private partnership. We want to bring back a national health service.
Publicly delivered. We want to return to a national publicly delivered health service. Private companies are designed for profit, not for healthcare.
A health service, of sorts, is still functioning, hit and miss as to the treatment you get. Doctors, nurses, midwives, physios, scientists, porters. cleaners healthcare workers all continue to go to work, work hard and with skill, and many are delivering good services, but there are significant dangers. Some are wonderful services, but all are at risk. The Cheshire and Merseyside ICS has big problems with staff shortages, funding restrictions, poor organisation and the present major reorganisation but for now, for some a service is still there.
Major cuts in funding are underway. See the Lowdown The Lowdown article referred to £219m deficit in the C&M budget – practically every single hospital in the area has a deficit. So, in other words, the ICS will continue by making more cuts and demanding more from an ever-shrinking workforce who are paying the price of this reorganisation. The staff risk having their pay negotiated locally. It is a major leap forward for privatisation and healthcare for profit
Staff are poorly paid, understaffed, and worn out. Covid is still a factor so there has been no time to recover. Waiting times are long and harsh. The pressure to pay to jump the queue is very real. The private health sector has been given huge amounts of Government money. This is likely to continue especially as these companies will be influential on the ICS boards.
So when the going gets tough, the tough get going. Join the campaign to fight for the health service locally and nationally. Don’t make the NHS a dim and distant memory.
The NHS is both wonderful and damaged. Babies that stood but a slim chance of survival are saved and go on to live full lives despite the chaos of underfunding, understaffing and overwork. Yet at times birth can be a terrible experience and outcomes sad. This mix of awesome and appalling is seen in other services too. The passing of the Health and Care Bill causes real concern. You can see the detail of this here
Fantastic care and expert treatments are delivered by overworked and underpaid staff. This has kept the NHS afloat through a decade of cuts, underfunding, staff shortages, the pandemic, privatisations, and closures. However, as Ockendon showed, the damage being done is very real.
The Health Service Journal published an opinion piece saying;
“However, even before the first ICSs emerge blinking into the light, the seeds of their potential destruction are being sown”.
Some wonderful people fought this Bill In Parliament, and far more out of Parliament, but it was not enough. Campaigners wanted far louder opposition from Labour and Lib-Dems too. Many people still do not know what is going on.
The structures set out in the Bill will be cumbersome, costly, and designed to facilitate private company involvement and profit. It is designed to limit the care available,
World-class, Universal Comprehensive care, free at the point of need is at risk. A post code lottery is inevitable.
Not one of the pressing problems of the NHS is addressed in this Bill. The NHS needs £20 billion in additional funding now, and then an increase above inflation each year.
As the Bill finished in parliament TV and radio adverts for private health insurance became more common.
The NHS needs better funding, more staff, better pay for the staff, and better conditions to retain the staff we have
Mental health, maternity, and social care are all in difficulties from poor funding, poor staffing, cuts and privatisation.
Many nurses opened their payslips to see their take-home pay fell in the month their pay rise was paid.
We now need a big campaign to monitor the NHS so cuts cannot happen out of sight in the forty-two new ICS areas. Ours is Cheshire and Merseyside.
Campaigners worked hard to tell people about the Health and Care Bill, hoping we could together put pressure on Conservative (and Labour) MPs to vote against it. We did not shift the Conservatives and the vote went through. Nevertheless, they will face the ire of the people at the next elections. Let us make sure that by then we have reached millions more people.
This situation is partly because people don’t know about the Bill, partly because people really can’t believe the NHS would be harmed, but more and more people are waking up to the dangers.
The Bill causes real harm. Please see this for details.
Our campaigns will have to change focus to each of the 42 areas and their ICS boards. That’s going to be a bad thing for the NHS as a whole but in some ways easier for campaigners.
There has rarely been more chaos in parliament, but MPs must be held to account. If you have a Conservative MP please write to them. Labour MPs by and large voted against it but we feel they did not do enough, with some honourable exceptions including Margaret Greenwood MP and Justin Madders. Liverpool MPs worked closely with us too. Surely they had a duty to inform their constituents about this risk to our health care free at the point of need. We will publish a letter to Labour MPS soon.
The structure of the NHS in this new Bill is already out of date, cumbersome and costly.
Please fill in this form, sign it, post it / or give it in to your local Member of Parliament.
You can email instead of writing through this service
Dear Member of Parliament,
Our NHS is beloved by everyone throughout our countryside. Its underlying ethos that everyone is entitled to the same professional care and attention once they cross its threshold is a wonderful source of comfort and reassurance.
The NHS system is the envy of the world. It is important that it remains a public service, so that money can be spent on patient care, rather than going into the pockets of shareholders.
It continues to evolve and is nurtured by health care professionals who care deeply for the NHS.
However, the current Health and care Bill will fragment the NHS into 42 regions leading to a postcode lottery.
Representatives from private companies will be allowed to sit on decision-making boards and influence what services are provided. The government says it will prevent individuals with ‘significant interest’ in private health care from sitting on them. This is not good enough. Big businesses should not have a say in how public money is spent.
The bill provides for the NHS professions to be taken out of regulation – with implications for those who work in the NHS and the quality of care we can expect to receive.
The British Medical Association Has called for the bill to be rejected!
For the sake of the health and peace of mind of this and future generations, please vote against this bill.
Lift financial restrictions on hospitals, paramedics and GPs. This must include removing the ridiculous 5% savings and the suggestion of absolute cash limits. Financial restrictions imposed during this crisis will end up costing more lives and more money long term. Invest in our Health Service. It pays us back with health and wealth.
Approve emergency funding of £20 billion to save lives
Ensure maternity services have all the funds required to meet Ockendon’s recommendations.
Thank the staff who have worked through such tough times.
Discuss with frontline medical, nursing, midwifery, and ancillary staff about what they think would make an immediate difference. Find ways of making this consultation routine. Implement the most constructive suggestions. Put a full stop to bullying and silencing staff.
Tell Hospital management to forget the Internal Market, the ICS system and other wasteful bureaucracy. Put more time and effort into patient safety and staff retention, especially personalising shift patterns.
Pay patient-facing staff a premium rate pending full pay negotiations.
Put in as much non-medical support (cleaners, catering and care staff) as possible both for staff and patients so there is someone to keep anxious patients safe in A+E and anywhere else where this would help.
Provide excellent canteens so staff can eat well at work and, if tired, pick up a meal to take home.
Pay childcare when staff are willing to work extra shifts.
Recruit retired or qualified staff who have left, for regular short hours working.
Pay, as if at work, staff who have left to retrain.
Fund GP services and walk-in centres to provide more services to take pressure off A&E. Make sure these services can link directly by phone or video to expert advisors when necessary.
Consult with patients and their families about how their immediate experience could have been improved.
Introduce more Covid protections including encouraging mask use, improving mechanical ventilation in hospitals and schools, make use of public buildings to reduce class sizes. Provide excellent quality school meals.
Reinstate free Covid tests, nationalise testing & fund local public health.
Improve staff PPE.
Take over private facilities required to improve NHS services.
Nationalise care homes with existing staff protected. Make use of any suitable buildings to increase the provision.
Pay home visit carers a decent wage and try to win back experienced and qualified staff who have left.
Encourage migrant staff by lifting the NHS premiums.
Work to recognise overseas training, or provide additional training for migrants already qualified in medical skills to meet NHS standards.
Pay informal carers twice the current rate.
Provide more adaptations for disabled people currently living at home.
Tackle shortages of medicines such as HRT.
Bring private contracts/outsourcing back in house.
Fully fund & expand ambulance services, lift financial restrictions.
Engage in proper pay negotiations with all NHS staff.
Protect the NHS as a universal, comprehensive, publicly funded and run, health service.
Immediate actions are required to support the NHS through the April/May 2022 Crisis. We hear both through personal experience and through reports of the difficulties the NHS is facing. The situation must change.
AS true for the NHS as for Football clubs
These are some essential short term fixes. We need also to reverse the policies from the 2012 Act, ditch the Health and Care Bill, have a proper plan for the workforce and remove privatisation, the internal market and rationing of care.
Campaigns like ours will continue to fight for the NHS, including making it clear to Conservative MPs that the Health and Care Bill still being discussed in Parliament is utterly unacceptable. Detailed descriptions of the Health and care Bill and other privatisation issues have been covered in other blog posts. This is what needs to be done immediately. If you agree with us please send this to your MP and to your councillors. If you have suggestions as health or social care workers, patients or campaigners please let us know.
I am going to talk for a few minutes about women and health, with a particular focus on bias, given this year’s theme. As we all know your sex has a significant impact on your health, so let’s see if we can start to better recognise this bias and think of ways to BreakTheBias.
I think we all agree that roughly half the world is inhabited by women (49.6%), half by men (50.4%) (I’m excluding animals and plants here by the way), based on 2020 figures. However, that’s where the fairness of the divide ends.
In my talk I’m going to focus on the inequalities there are in access to healthcare and healthcare outcomes for women. I’m wanting to identify some of the bias that is present.
But before I do, I think we need to consider and acknowledge where the ‘evidence’ comes from / where our ‘knowledge’, where our ‘understanding’ comes from. Because recognising this goes some way to BreakTheBias, or we could call it unfairness or we should actually call it discrimination.
Most of our ‘knowledge’ about health, some would actually say pretty much everything we know uses data, and it is this data that is male-biased in other words the data favours men and does not reflect the true world we live in. So, our decision-making, healthcare treatments for example are based on data gathered from men and this is known as ‘the gender data gap.’ It is where a “one size fits all” approach has been used, however it has left gaps in our understanding of the experiences of women because it is male-biased. Women have basically been excluded. So, the upshot is that most of what we understand is skewed in the favour of men. It’s a male-default world we live and we need to Break this Bias.
If I can give you some examples. The one many of you will know and which is perhaps a little light-hearted, nevertheless annoying and one I think all of us can relate to is room temperature. I’m sure we know all about room temperature at home. And there is ample evidence that office environments are tuned to male biology. Air conditioning is often set according to a 1960s formula based on the metabolism of a 40-year-old man who weighs 11st. Previous studies have suggested that the average woman is most comfortable at about 25C, 3C higher than for men. Because women generally have a lower metabolic rate than men because of their body composition so they prefer warmer rooms and need less air conditioning. (Koch; National Geographic 2015). However, this has still not been corrected in many offices (or homes!).
Another light-hearted one… mobile phones. Like the standard piano keyboard, smartphones have been designed for male hands and therefore may be affecting women’s health adversely. It is a relatively new field of study, but the research that does exist is not positive. Within the studies, women were significantly under-represented and the vast majority of studies do not break down the data by sex. The few that did report a statistically significant difference in the impact of phone size on women’s hand and arm health as well as physical comfort (Kwon 2016). Speech-recognition software is trained on recordings of male voices: Google’s version is 70% more likely to understand men (Criado Perez 2019).
Here’s another one for you demonstrating the gender data gap: we all know that women even when in paid work still do the majority of the housework (McNunn 2018, UCL Epidemiology & Health Care). Yet it is documented that fitness monitors underestimate steps during housework by up to 74% and calories burned during housework by as much as 34% (Criado Perez 2019).
So why should we think these are just light-hearted examples, why should we not consider that these types of bias play out in much more important aspects of our lives, health, work, politics and political decision-making. The ‘gender data gap’ is everywhere. Let’s Break this Bias.
Regarding health, let’s talk about heart attacks.
Early diagnosis of a heart attack is essential for treatment and survival. Research by the British Heart Foundation (BHF) has shown that women having a heart attack are up to 50% more likely than men to receive the wrong initial diagnosis. Women are also less likely to get a pre-hospital ECG also. And someone who has an incorrect initial diagnosis of heart attack has a 70% higher risk of death after 30 days compared to someone who receives the correct diagnosis straightaway. So, this is serious.
This is because of how we have been informed (and by we, I mean everyone, healthcare workers too) as to what the signs and symptoms of a heart attack are. That’s because we are basing our knowledge solely on the male experience, on what male symptoms are. In fact, over a ten-year period, more than 8,200 women died needlessly following a heart attack. They could have been saved if they had received the same quality of care as men. The BHF call this ‘Bias and Biology’. Here is a quote from a woman who suffered a heart attack. She says… “Doctors thought my symptoms were due to asthma, stress and anxiety at a time when I was changing jobs. But on holiday I had a heart attack and the very next morning I was sent for heart bypass surgery” (Simone Telford 2022). We need to Break this Bias.
Some symptoms of a heart attack do differ between the sexes (British Heart Foundation May 2022). A study by the BHF (May 2022) found more women had pain that radiated to their jaw or back and women were also more likely to experience nausea in addition to chest pain (33 per cent vs 19 per cent). Whereas, the less typical symptoms, such as epigastric pain (heartburn), back pain, or pain that was burning, stabbing or similar to that of indigestion, were more common in men than women (41 per cent in men vs 23 per cent in women). Important to know that women tend to wait longer before calling 999 after first experiencing heart attack symptoms. And we know any delay can dramatically reduce your chance of survival. Additionally, heart attacks are often seen as a male health issue, but more women die from coronary heart disease than breast cancer in the UK. So we really need to Break this Bias, because this misconception is leading to avoidable suffering and loss of life (Pearson, BHF Associate Medical Director 2022). (An interesting video for anyone concerned about heart attacks in women from NHS Scotland here)
Let’s talk about women in research…
Think of another example, Alzheimer’s. In the UK Alzheimer’s disease is almost twice as common in women compared to men. Now, why is it more common in women than men? Well for a long-time clinicians and researchers put it down to the fact that women live longer than men, and didn’t explore it any further. It is only more recently that researchers have begun looking past this assumption, and early discoveries indicate that the impact of biological underpinnings may contribute to the underlying brain changes. Evidence demonstrates that women with dementia have fewer visits to the GP, receive less health monitoring and take more potentially harmful medication than men with dementia, new UCL research reveals (Dayantis 2016). So, for many years bias was present, we need to Break this Bias.
The under-representation of women in clinical trials stems from the long-held assumption that the male perspective represents the norm. For those of you with clinical interest, you will know that medical education textbooks typically default to the male in case studies and anatomical drawings, while women are represented only in matters specific to reproductive biology (Liu 2016).
Differences in pharmacokinetics of drugs between the sexes can be related to body composition and size (Wizemann T, Pardue 2001). Women typically have a lower body weight than men, so when taking the same dose of a drug, results in a higher level of the drug (Parekh 2011, Wizemann 2001). That’s why we see an increase in adverse drug reactions in women. In fact, data suggests women experience adverse drug reactions nearly twice as often as men (Zucker 2020)
However, women have been excluded from pharmaceutical research for many reasons (Yakerson 2019). Now we can’t ignore the thalidomide tragedy of the 1960s which prompted a protectionary ban on pregnant women and women of child-bearing age from participating in clinical trials. Other obstructions are the perceived complexity and higher costs of studies if women are included, women’s unwillingness to participate, and the pervasive treatment of the male body as the norm (Yakerson 2019). They also viewed women as confounding and more expensive to research because of their fluctuating hormone levels (Wizeman 2001). Well, all I can say is we’d be extinct without our ‘fluctuating hormone levels!
It was only in 1993 (29 years ago) that the landmark US National Institutes of Health (NIH) Revitalization Act changed the model from excluding women to recommending their inclusion in phase III clinical trials (Zucker 2020). So improvements are being made however, the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH brings together regulatory authorities and the pharmaceutical industry) has not recognised the need for specific, standalone guidelines on the inclusion of women, continuing to refer to women as a special subgroup to be considered when appropriate (https://admin.ich.org/sites/default/files/2019-04/ICH_Women_Revised_2009.pdf). We need to Break this Bias.
Less than 2.5% of publicly funded research is dedicated solely to reproductive health (“UK Health Research Analysis 2014 (UK Clinical Research Collaboration, 2015) http://www.hrcsonline.net/pages/uk-health-research-analysis-2014”), despite the fact that one in three women in the UK (34%) will suffer from a reproductive or gynaecological health problem (https://www.gov.uk/government/news/survey-reveals-women-experience-severe-reproductive-health-issues 2018). Endometriosis affects one in 10 women, which means it is as common as diabetes in women. The proportion of funding that goes into diabetes far exceeds the levels of funding that goes into endometriosis.
For more info on endometriosis see the end of the article Image is from John Hopkins
If I give an example of pregnant women in Covid research trials: The disparity in trial inclusion has been exacerbated in the covid-19 pandemic, in fact, pregnant women initially were not included in covid-19 vaccine trials. A recent review reported that of 927 trials related to covid-19, 52% explicitly excluded pregnancy, 46% did not mention pregnancy, and only 1.7% specifically included pregnancy (Smith 2020)
This initial exclusion evidently impacted the very slow uptake of the vaccine in pregnant women. In Dec 2021, the RCM and RCOG emphasised the urgency for pregnant women to receive the vaccine, that’s because at that time three-quarters of all ICU patients with Covid-19 were pregnant women. That’s the consequence of not Breaking this Bias. The default position should be to investigate and treat pregnant and breastfeeding women in the same way as non-pregnant women unless there are clear reasons not to (Knight 2019).
Time has not allowed, but I think we should return to this another time about the appalling under-representation of minority ethnic groups in research as well as women from deprived areas / lower socio-economic groups (Redwood and Gill 2013). Lots more can be said about these issues.
I’ll just end on, if we are going to achieve any kind of equality, then it is essential we have equal participation and leadership of women in political and public life. However, data shows that women are underrepresented at all levels of decision-making worldwide, and achieving equality in political life is far off. In our government, 35% of MPs in the House of Commons are currently women, and this, this is an all-time high. And in the House of Lords, it is 28% and around just 36% of local authority councillors in England are women.
If we are going to get anywhere with any of this we need to BreakTheBias
It is with great sadness that we read the findings from The Ockenden Review and we add our thanks to the families who fought so hard to bring their experiences to public attention. As midwives and campaigners for safe and compassionate maternity care we have a duty to reflect on the findings of this report and our thoughts are with the women, their families and staff working at The Shrewsbury and Telford Hospital NHS Trust. The Lancet commented that;
“The report found that around 200 babies and nine mothers would or might have survived if the trust had provided better care. The Royal College of Obstetricians and Gynaecologists (RCOG) called it a “dark day”. Criminal charges might still be brought against the Trust and individuals.”
BBC Photograph
Donna Ockendon gave great credit to the parents whose campaigning instigated the report;
“The work contained in this final report and the first report of the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust, came about from the exceptional efforts of parents Rhiannon Davies, Richard Stanton, and Kayleigh and Colin Griffiths, whose daughters died as a result of the care they received at the Trust. The deaths of Rhiannon and Richard’s daughter Kate in 2009, and Kayleigh and Colin’s daughter Pippa in 2016 were both avoidable. Owing to their unshakeable commitment to ensure the precious lives of their babies were not lost in vain, this review has implementation of meaningful change, not only in maternity services at The Shrewsbury and Telford Hospital NHS Trust – but also across England. As we publish this final report, we want to acknowledge and pay tribute to Rhiannon, Richard, Kayleigh and Colin.“
Shrewsbury is not alone. There have been other maternity scandals in Morecombe Bay, Essex and Nottingham.
The crisis in maternity staffing in 2022 is worse than the period covered by this report. Many hospitals did manage against the odds to avoid some of the damage done in Shrewsbury. Shewsbury’s managers and senior clinicians have serious questions to answer. The context does not excuse their actions but it is crucial to understanding what was happening.
Understanding and appreciating the context in which these failures happened is a vital step in working towards any type of prevention. What is prominent throughout the review is the catastrophic shortages of midwives, medical staff and other maternity healthcare workers and the impact these shortages have had on care. For many years we have known of these critical shortages and the tragic damage this would cause. Now, sadly, we are seeing it.
With this shortage comes poor supervision and training of staff, in particular preceptorship programmes for newly qualified midwives (NQM). Without enough qualified midwives, it is impossible to provide supernumerary status with protected learning time for NQMs. This is crucial if we want to grow a competent and confident workforce.
Donna Ockendon says;
“It is absolutely clear that there is an urgent need for a robust and funded maternity-wide workforce plan, starting right now, without delay and continuing over multiple years. This has already been highlighted on a number of occasions but is essential to address the present and future requirements for midwives, obstetricians, anaesthetists, neonatal teams and associated staff working in and around maternity services. Without this maternity services cannot provide safe and effective care for women and babies. In addition, this workforce plan must also focus on significantly reducing the attrition of midwives and doctors since increases in workforce numbers are of limited use if those already within the maternity workforce continue to leave. Only with a robustly funded, well-staffed and trained workforce will we be able to ensure delivery of safe, and compassionate, maternity care locally and across England.“
Yet, how can a maternity service be safe and compassionate if there aren’t enough staff? How can staff give women their time, time to sit and talk, time to listen. It is impossible. It cannot be done. As a consequence, women will not be provided with the safe and compassionate care they so justly deserve, not because staff don’t care, but because there simply aren’t enough of them.
In July 2021 the report on the Safety of Maternity Services from the Parliamentary cross-party Health and Social Care Committee said;
“With 8 out of 10 midwives reporting that they did not have enough staff on their shift to provide a safe service, it is clear that urgent action is needed to address staffing shortfalls in maternity services. Evidence submitted to our inquiry estimates that as a minimum, there need to be 496 more obstetricians and 1,932 more midwives. While we welcome the recent increase in funding for the maternity workforce, when the staffing requirements of the wider maternity team are taken into account–including anaesthetists to provide timely pain relief which is a key component of safe and personalised care – a further funding commitment from NHS England and Improvement and the Department will be required to deliver the safe staffing levels expectant mothers should receive.”
“We recommend that the budget for maternity services be increased by £200–350m per annum with immediate effect. This funding increase should be kept under close review as more precise modelling is carried out on the obstetric workforce and as Trusts continue to undertake regular safe staffing reviews of midwifery workforce levels.“.
Despite this recommended additional funding for maternity, the government produced only half of what the committee said was needed. The Government did not even respect a parliamentary committee.
A whole year has been lost that could have stopped the current situation from developing. That funding has still not been provided.
Donna Ockendon reported on maternal deaths, baby deaths and the injury to some of the babies. She wrote this of the Cerebral Palsy cases;
“All of the families in this group self-reported to the review. The diagnosis of cerebral palsy was often made some years following their maternity episode. On reviewing the medical records, where it was found that the neonatologists at the Trust had recorded a diagnosis of HIE [(hypoxic-ischaemic encephalopathy] in the early neonatal period, a small proportion of families were subsequently transferred to the HIE incident category. From the remaining cases of cerebral palsy, more than 40 per cent were identified to have significant or major concerns in maternity care which might have resulted in a different outcome.”
Mistakes will be made in any field of medicine, though few with such catastrophic results as mistakes, or carelessness, in maternity care. Lessons must be learned from every incident and changes implemented quickly. This failed disastrously in Shrewsbury and the fault is not with the midwives (though significant mistakes were made ), but with the hospital management.
The government has made and is still making appalling decisions in funding and managing the NHS and particularly in maternity. A quick check on MumsNet today found a mother refused an induction despite her concern about her near term baby’s reduced movements. We are told to Count the kicks yet even today after Ockendon has reported, women are not always heeded.
The bureaucracy of the NHS also bears responsibility, if only for failing to describe publicly the damages from Government policies including; the shortages of funds for the NHS, bad workforce planning, the closure of beds and maternity units, not calling out the disaster of the “internal market” and for “managing” the news around incidents. We saw a pretence that all was well, whilst embarking on expensive new initiatives, like Continuity of Carer, without adequate funding and thereby driving out still more midwives. A background of bullying and silencing staff is also important. The number of midwives quitting because they do not feel that the system is safe surely should have been a warning to all.
Donna Ockendon notes
“The key themes identified requiring improvement within maternity services at the Trust were: • The poor quality of incident investigations • Poor complaints handling • Local concerns with statutory supervision of midwifery investigations • Concerns with clinical guidelines and clinical audit
…the review team has identified the following concerns regarding governance in maternity services at the Trust: a) Incidents that should have triggered a Serious Incident investigation were inappropriately downgraded to a local investigation methodology known as a High Risk Case Review (HRCR), apparently to avoid external scrutiny. b) When serious incident investigations were conducted many were of poor quality. c) There was a lack of learning and missed opportunities to improve safety. d) There was a lack of oversight of serious incidents by the Trust’s commissioners. e) There were repeated persistent failings in some incident investigations as late as 2018-2019.
4.8 The review team has found a concerning and repeated culture at the Trust of not declaring adverse outcomes as an SI in line with the national framework. Instead, they were inappropriately downgraded and investigated by what the Trust termed a High Risk Case Review (HRCR). This method of investigating incidents, created by the Trust, was less robust, varied considerably in quality and lacked the rigour and transparency of an SI investigation. Notably, HRCRs were not reported to NHS England, the Clinical Commissioning Groups (CCGs) or the Trust Board, and therefore avoided external scrutiny.“
The Review also importantly recognises the damming consequence of Cumberlege’s National Maternity Review and the Midwifery Continuity of Carer model. With such poor staffing, such a programme not only cannot but should not have been implemented. We welcome The Reviews Essential Action for the suspension of this provision unless Trusts can demonstrate safe staffing levels on all shifts. The Review acknowledges the unprecedented pressures that the model places on services, services already under significant strain and the impact of which compromised the safety of pregnant women and their babies. We support the need for robust evidence to assess if it is a model fit for future maternity care. Currently, that evidence does not exist.
What is evident from The Review is the harm mothers and babies suffered from what appears to be withholding the use of caesarean sections. We will watch with caution the end of total caesarean section percentages as a metric for maternity services, as potentially we could see rates escalate and we urge continued careful monitoring.
Apparent in The Review, is the fear staff had to speak out about their concerns. There can be no transparency, and no openness to change if free speech is not allowed.
Save Liverpool Women’s Hospital Campaign has been working since 2016 to
Expose the flaws in the funding and structure of maternity provision and
2. To support all who continue to work in maternity despite the odds.
3. To demand excellent maternity care for all, (including migrant women, who face dreadful charges for maternity care).
4. To fight for women’s healthcare.
5. To protect our hospital, Liverpool Women’s Hospital, on its Crown Street site.
6. To campaign for the NHS to remain free at the point of need, funded by the government, providing universal and comprehensive care, publicly owned and publicly delivered.
A publicly provided, well funded, universal maternity service, free at the point of need is essential. There is no solution to the problems the NHS faces to be found in privatising it. Cuts, shortages, coverups of shortages, and bullying, cannot keep our mothers, sisters, daughters, friends and lovers and every precious baby, safe.
The figures for maternal deaths in the US privatised model quoted by The Commonwealth Fund, prove this:
“Key Findings: The U.S. has the highest maternal mortality rate among developed countries. Obstetrician-gynecologists (ob-gyns) are overrepresented in its maternity care workforce relative to midwives, and there is an overall shortage of maternity care providers (both ob-gyns and midwives) relative to births. In most other countries, midwives outnumber ob-gyns by severalfold, and primary care plays a central role in the health system. Although a large share of its maternal deaths occur postbirth, the U.S. is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period.
Conclusion: The U.S. has a relative undersupply of maternity care providers, especially midwives, and lacks comprehensive postpartum supports.“
Women were not heard or heeded in many of these tragic events, indeed some were themselves blamed by the hospital.
Importantly, we must not forget the blame for all of these lies squarely at the feet of the government. Continued cuts year on year are destroying maternity services and the NHS as a whole. Allowing chronic staff shortages, poor staff satisfaction, high staff attrition rates, and unsafe working conditions are all political choices made by this government. Now we see mothers and babies dying. These are all political choices.
Women have a right to excellent maternity services. It is the government’s responsibility to provide this. This is the contract between citizens and the government Women must have the right to choose how they have their baby. Women are entitled to have the best advice on these choices. Women have the right to expect emergency backup when this is required. Women have the right to be both heard and heeded, especially when things start to go wrong. Women have the right to be heard and to participate in all reviews of serious incidents. Ockendon will strengthen these rights.
There is a thread in the media saying that natural births were somehow to blame. There is nothing in Ockendon to say this. Ockendon does say that poor monitoring, failures to intervene early, failure to use cesarean sections when urgently needed, and failure to listen to mothers, were all faults.
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Midwives are a highly valued profession. Midwives can make mistakes, of course, but the faults described in Ockendon do not blame midwives as a profession. A service with a good supply of well trained, and well respected (and well paid) midwives, helps save lives.
The Royal College of Obstetrics and Gynaecology reported on staffing issues last year.
The NHS funding model included penalties for having too many cesareans in a hospital. Funding for maternity was already inadequate and complicated, relying, in many hospitals, on subsidies from other parts of the hospital budget.
Since “Austerity” started, Government funding for the NHS has been inadequate. Staff have kept the NHS afloat through hard work and determination. Staff are worn out. Too many midwives are leaving the profession because of working conditions.
The fight to found the NHS came in large part from the fight for universal maternity care. Let’s make the fight for excellent maternity care in the twenty-first century spur on all our campaigns to protect and improve the NHS
The government does not believe in the NHS. Look at what it is doing to maternity care. Since 2014 they have been working towards privatisation, a US-style model of healthcare. The loss of the NHS or further cuts and privatisation will affect women, babies and maternity. This is the future unless we campaign against it, please join our campaign group – as Nye Bevan said “The NHS will last as long as there’s folk with faith left to fight for it”
This is a report back from Parliament about to where we are right now with this pernicious Bill.
Margaret Greenwood MP for Wirral West is our first speaker
Rebecca Smyth a midwife and midwife educator is our second speaker. Her information on the gender divide in healthcare is well worth the listen
Because it is on International Women’s Day we are going to celebrate the blindingly obvious that women might hold up half the sky but they hold up far more of the NHS, and that there is no women liberation without healthcare
We are part of a group of organisations campaigning for the NHS stretching from Southport to Chester Ellesmere Port and Crewe, from Sefton to St Helens. That is the area covered by the new NHS pro-privatisation structures the ICS Boards.
On Saturday 26th February 2022 Greg Dropkin, a long term campaigner for Keep Our NHS Public spoke at the SOS NHS event in Liverpool against the Health and Care Bill, which is being put into place ahead of the legislation being agreed.
Greg described one of the vicious changes to our health care that is being developed.
“In an emergency, all of us expect to go to A&E and be seen, no matter who we are or where we’re from. In law, Clinical Commissioning Groups must ensure that emergency care is provided for every person present in the area. But it’s changing. In September, a badly burned Rochdale nurse went to A&E and was advised to go to Bury given the long delay in Rochdale. When she got there, staff told her “we don’t take patients from Rochdale”, due to a directive from the Northern Care Alliance.
(Image: UGC)
Lord Davies told this story when proposing an amendment to stop any provider from refusing treatment on the basis of which Integrated Care Board the patient belonged to. In response, government Minister Lord Kamall didn’t even# mention emergency care. He said no provider could be expected to provide treatment for which they were not funded, and each Integrated Care Board must be free to decide what treatment to commission. So it’s policy. Even in an emergency, funding flows will trump patient care. Bring an electricity bill and your passport to A&E. The National NHS is being broken into around 40 separate financial systems. Their budgets will be set with a new Payment Scheme. The cost of a treatment will depend on where it is given, who provides it, and who is being treated. And, providers including the private sector will be consulted on the prices to be paid. This means a postcode lottery rigged to suit private firms. If the Integrated Care Board is going over budget, NHS England can intervene to stop spending. With local budgets and a variable payment scheme, ICBs may say, why should staff in our area be paid the same as other places with better budgets? They may impose local pay and conditions for NHS staff in their patch. That would destroy national agreements, and unions should be screaming about this threat. Who profits? Around 240 organisations, most of them private companies, are accredited by NHS England to develop Integrated Care Systems through the Health Systems Support Framework. Several dozen are US transnational corporations supplying the health insurance market.
Operose, which controls dozens of GP surgeries, is wholly owned by US transnational Centene, a $100bn enterprise. Under the Framework, Operose is accredited for 22 topics, like population health management and payment reform. Its former boss Samantha Jones became Boris Johnson’s Expert Advisor for NHS Transformation and Social Care. She is now Permanent Secretary and Chief Operating Officer of 10 Downing Street. The Framework aims to transform the NHS into a digital and data-driven system, where clinicians rely on algorithms, remote monitoring, big data, and artificial intelligence. Labour peer Lord Hunt of Kings Heath tabled 7 amendments to the Bill promoting digital transformation. One requires all NHS organisations to spend at least 5% of their budget on digital transformation. Hunt also chairs the Advisory Board of Octopus Tenx Health, a health technology investment company. When Octopus took over, the Tenx Board included the husband of Samantha Jones. Tenx Health co-founder Joe Stringer stated at the start of lockdown that coronavirus could be the catalyst for the mass adoption of tech across the health system. He predicted venture capital funds would take it up. Despite Government spin, the private sector is not barred from Integrated Care Boards. They can sit on committees and the provider collaboratives where private companies and NHS Trusts will come together to carry out the functions of the ICB using delegated budgets. New procurement regulations will allow ICBs to award contracts without competition. Just like the crony covid contracts were handed out, overpriced, some to firms with no relevant experience, or which failed to deliver.
We should fight it all the way. But if the Bill becomes law, we want it repealed and the NHS restored as a universal, comprehensive service, publicly provided, publicly accountable, free at the point of need with decisions taken on clinical grounds, not ability to pay
Save Liverpool Women's Hospital 