Education And Training

Ministers want to turn the NHS in England into "the largest social enterprise sector in the world". They envisage a network of small co-operatives and mutuals run by doctors and nurses not managers. But would that be a good thing? And is it even practical?

The exact form varies but in general, such organisations are run and owned by their members, control their own funding and direction, and have clear social rather than commercial objectives.

"There's nothing hugely different, culturally, which means the co-operative model couldn't work here, but big changes are needed to legislation and attitudes.

"At the moment we're in the rhetoric phase – there has to be a lot more work to actually build capacity and there's a vital role for government in taking the lead.

"People need help building up the skills, they need access to capital, tax breaks, and so on. Councils have to change their thinking too because if they just keep on procuring from the same big supplier, small co-operatives will never get a look in.

"In general, nothing is really joined up. It's the government's job to deal with this fragmentation and I don't think they're taking that seriously enough yet."

One of the biggest challenges faced by Italian co-operatives is recruiting senior managers with good business acumen and a social conscience – not least because co-operatives are often seen as offering insufficient status and salaries.

Chris Tully agrees that the right people are key, adding: "You have to really want to make a difference and you've got to have a lot of stamina."

While the devolution of power is one of the key tenets of the government's plans for the NHS, it's also one of the most controversial.

The government sees a future in which co-operatives deliver our babies or treat our addictions – some funded by, but independent from, local authorities, others funded by those who use them.

Geoff Walker wants the government to be "bolder" still, and insist that before a local authority closes any health or care service it should have to look at whether a social enterprise could do it instead.

Unions, however, see a deeply worrying fragmentation and monetisation of the NHS – privatisation by the back door.

Christina McAnea, head of health at Unison, has called social enterprises "a leap in the dark that could have damaging implications for patients, staff and the future of the health service".

Unison and the British Medical Association both say the majority of NHS staff aren't keen, and they warn there is nothing to stop a social enterprise ultimately being sold to a profit-making company and prioritising users who are willing to pay – not those in greatest need.

Ultimately, they fear mutuals and co-operatives will fail to survive in a competitive market – and when they do, patients will be left high and dry.

There has been a significant fall in the number of people having their tonsils removed in the UK over recent years, partly as a backlash against the procedure's overuse and, more recently, as a cost-saving exercise for the cash-strapped NHS.

But in this week's Scrubbing Up, consultant ENT surgeon Andrew McCombe, honorary secretary of ENT UK, warns the cuts have gone too far and patients are paying the price.

Tonsillectomy – cutting out the two lumps of lymphoid tissue found at either side of the back of the throat – is an operation that was described first over 3,000 years ago.

Its popularity grew throughout the ages and became so favoured in the UK that in the 1950s over 200,000 were performed in any given year.

Certainly, this rate was too high and surgeons set about refining the indications for carrying out this potentially risky operation, reserving it only for those patients most likely to benefit.

However, over the last 15 years the rate of tonsillectomy has continued to fall, so much so that we are now in danger of too few procedures being carried out.

In 1994-95 some 77,600 tonsillectomies were carried out in the UK. By 2009 this had dropped by 37% to 49,000.

At the same time, we are seeing increasing rates of diseases and conditions that tonsillectomies can prevent or cure, like infections, and even cancer, of the tonsils.

The number of people who develop cancer of the tonsils is still small, but it has certainly jumped significantly.

In 2000-01, there were 30,942 tonsil-related admissions for emergency medical treatment. By 2008-09, the figure had risen to 43,641, an increase of over 41% in 8 years.

The economic impact of tonsillitis is considerable. Overall, 35m days are lost from school or work each year due to sore throats in the UK. GP consultations for sore throat cost around £60m per year.

As tonsillectomy rates fall, it is predictable that hospital admissions for severe tonsillitis and its complications will rise, and this is borne out by the data available.

Admissions for quinsy – an extremely painful complication of acute tonsillitis – is rising. At the start of 2000 there were 6,352 UK hospital admissions for this condition. This increased to 7,683 in 2008-09, a rise of over 20% and equating to 11,865 hospital bed days.

Any further reduction in the rate of tonsillectomy is likely to be associated with a further worsening of this trend.

Tonsillectomy rates are lower in the UK than in any other country in Europe.

In fact the data trends of increasing hospital activity for tonsillar problems seem to suggest that rather than performing too many tonsillectomies in the UK, we are now performing too few.

There is lots of advice around about breastfeeding, but relatively little about weaning babies onto food, says Dr Helen Coulthard from Leicester's De Montfort University.

In this week's Scrubbing Up the psychology expert calls for parents to be given free cookery classes so they don't rely on packets and jars.

A recent study that I was involved in, using data collected from the ALSPAC study based at Bristol University, revealed a fifth of babies were having less than one exposure a day to fruits or vegetables. And babies who were given more home-cooked fruits and vegetables at six months were more likely to be eating more fruits and vegetables at seven years.

Although we can't say for sure if it is this early exposure to these foods that makes the difference or whether it is learned behaviour from the feeding habits of the whole family that is important, it makes sense that fresh is best.

Ready prepared baby foods are designed to be homogenised in taste and texture. One particular brand of apple puree will always taste the same. However, if you make your own apple puree, the variety of the apple, the amount of water added and the extent to which it is mashed will vary each time. This variation gives babies an important lesson in the tastes of food; small variations are acceptable.

So it is important that babies are given foods that vary in taste and texture, and ultimately represent the foods that the family eat. Really babies should be eating foods that not only taste like the foods that the family are eating, but visually resemble them. It is actually quite a large jump from the appearance of carrot puree on a spoon to whole carrots, so food in its recognisable form needs to be introduced.

A good rule of thumb when feeding children is to never give your child something you would not be prepared to eat yourself. If you would not eat a jar of baby food, then why give it to your child?

As the main problem seems to be that parents lack the confidence to make fresh homemade foods, then I propose that free baby food cookery courses should be offered to the parents of babies. A lot of effort is spent on increasing breast-feeding rates, however little is dedicated to the early provision of fruits and vegetables, which are just as important for lifelong health.

Current free weaning courses tend to merely involve the health visitor talking to parents, and practical courses are limited to expensive private courses run in big cities. Children's centres could easily adopt such courses to reach those parents who need the most help, and kick-start a fresh approach to feeding babies.

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Both marriage and divorce can trigger weight gain, according to research being presented at the American Sociological Association.

In women, marriage increased the risk of a small increase in weight (up to a three point increase in BMI) by 33%. There was a 48% higher risk of large weight gains (more than a three point BMI increase).

Newly-divorced women had a 22% increased risk of small weight gain.

Men were 28% more likely to have small increases in weight after marriage and 21% after divorce.

The report concludes: "All marital transitions act as a weight shock, encouraging small weight gains regardless of the destination marital state."

Lead author, Dmitry Tumin, said: "To some extent, marriages for women promote weight gains that may be large enough to pose a health risk."

Helen Riley at the British Nutrition Foundation charity said: "These are significant changes in someone's life. It can change their living situation and the types of food they eat.

"But different people deal with it in different ways and it can be positive for some people."

An ethnic community in Nepal's remotest Himalayan district bordering Tibet says it has been struggling to save its unique Buddhism culture from being uprooted by floods from a glacial lake.

The locals of Halji village in Humla district of western Nepal practise the Drikung Kagyu school of Tibetan Buddhism which has an 11th century monastery at its heart.

They are very worried that the Rinchenling monastery – one of the oldest in Nepal and highly revered in Tibet – could be swept away or damaged by floods and mudslides caused by the outburst of a glacial lake on the mountain overlooking their village.

For the past five years, Halji has been hit by glacial lake floods almost every summer and the last one nearly two months ago damaged two houses and swept away four horses.

Several crop fields were washed away and many remain covered with sands, rendering them barren for many years to come.

Villagers say the historic monastery now stands only around 15m away from the river bank that has been eroded by flood waters.

They fear the next time the Tak Tsho lake bursts out like it did this year, it may hit the 1,000 year-old sacred site.

"It is our identity," says Kojuk Objang Tamang, the head of Halji village. "We cannot even imagine about our community without the monastery which is the base of our religious culture," he told the BBC.

So strong is the community's creed on the monastery that they are convinced that it has saved them from the floods and mudslides so far.

"It is because of the blessings of the monastery that the village is hit by floods at day time only and so there is no loss of human lives because we can run to safety during daylight," says Tamang. "Had it happened in the night when we are asleep, god knows how many of us would have been dead by now.

Astrid Hovden of the University of Oslo, who has been conducting her PhD research in Halji, has witnessed how central the monastery is to the community of around 100 households.

"At the night of the flood (last June), after the water level in the river started to get back to normal, the monks performed an elaborate ritual in the monastery to pray for the safety of their village.

"Since the villagers got aware of the problem they have invited important lamas (priests) from outside to perform rituals to protect their village."

Prayers apart, the villagers have also done whatever they could to save the monastery and their settlement.

Although almost all of them are uneducated, they have knocked on the doors of the prime minister's office in the capital Kathmandu, the local authority and the national planning commission.

Those efforts had secured some funding which they used to build defences using rocks and gabion wires to tame the flood waters.

"Every family in our village worked free of cost for the constructions of those infrastructures," says Tamang.

But villagers say every year the floods and mudslides hurtling down from the glacial lake at the height of around 5,300m on the Gurla Mandhata mountain become increasingly dangerous.

"Our effort to save the village is proving to be no match for the force of the floods," said Mangal Lama, a social worker from the region.

Lama and other locals said they hiked up to the area where the Tak Tsho glacial lake is located and found that it is hidden behind a hanging glacier.

"And we saw huge cracks on the glacier, and that explained why we used to hear big sounds around the same time in June every year before we were hit by floods.

"Apparently, it appears that the huge pieces of ice sheet from the cracked parts of the glacier might have fallen into the glacial lake which then overflowed, causing floods and mudslides downstream."

Some scientists say climate change has accelerated glacial meltdown in the Himalayas, creating many new glacial lakes and filling up existing ones to dangerous levels.

Most of the 4,000 or so glaciers and their lakes in the Nepalese Himalayas are not monitored, like the one above Halji in Humla district.

The National Adaptation Programme of Action (NAPA) Nepal has prepared under the United Nations climate convention has rated the district's vulnerability to glacial lake outburst flood as "very low" – something which has been disputed.

Social worker Lama said some villagers are so frustrated that they are considering going to Tibet across the border to become refugees.

"Because it takes five days walk to reach the nearest local authority of Nepal while Taklakot (the nearest Tibetan market) is only 12 hours away and moreover the villagers speak the Tibetan language and follow all traditions of Tibet."

Locals say they cannot also move the monastery and their settlement to a safe place.

"The moment we move the monastery, its religious and historic value will drop to zero," says Tamang. "And that, in turn, means our century old intact religious and cultural community will break and it will all be over."