Roger Watson
East Yorkshire
Saturday 26 December 2020
The letter that did not get published in the Daily Telegraph
Monday 12 October 2020
Masks: the questions people should be asking
Niall McCrae, freelance journalist
Kevin Corbett, healthcare consultant
Amidst the current coronavirus epidemic, suddenly it has become a social norm in Western society to wear a face covering. How did this dramatic transformation arise - is it motivated by science, collective spirit or mere compliance?
Covid-19 is the name given to a disease attributed to the genetic viral sequence SARS-CoV-2 (severe acute respiratory syndrome coronavirus; the first outbreak was in 2002). In an effort to curtail the contagion, the British government made wearing of masks mandatory on public transport in July 2020. This was extended to shops in September, and in October to pubs and restaurants (except when seated). Since schools reopened in September, many teachers and pupils are wearing masks, despite no legal requirement. Masks have generally proliferated, with people choosing to wear them whenever they are outdoors.
There is much debate about the effectiveness of facial coverings to prevent infection. But as masks are expected to be worn throughout the coming winter season, will they also protect people from influenza?
As we will explain, a ‘yes’ or ‘no’ answer to this question is elusive. Despite widespread mask-wearing, incidence and mortality of influenza is currently at normal levels for autumn. In England and Wales, deaths from influenza and pneumonia have exceeded those from Covid-19 continually since June. From 20th June to 4 September 20836 death certificates stated influenza or pneumonia compared with 6302 mentioning Covid-19. Influenza mortality is lower in summer; it is now increasing as expected in line with annual trends.
The Office for National Statistics (8 October 2020) reported an exceptionally low number of influenza deaths from January to August 2020, a period when most people did not cover their faces. In England and Wales there were 48,168 reported deaths due to Covid-19, 13,619 due to pneumonia and 394 from influenza. It is highly likely, however, that many more died from influenza, as Public Health England data show that the annual average of deaths in England from this disease in winter seasons 2014-2015 to 2017-2018 was 16156 (ranging from 11875 to 28330). It is also probable that a high proportion of Covid-19 fatalities were misdiagnosed: many were not tested for Covid-19, and false positives are a major problem with the widely-used test (which was not designed for diagnosing infectious disease). Although SARS-Cov-2 is known as a ‘novel coronavirus’, the associated disease Covid-19 has no distinct symptoms and may easily be mistaken for influenza or vice versa.
For a wearer to believe that a mask protects people from coronavirus but not flu is equally dubious. Both types of virus are microbes of potential aerosol transmission. A mask may guard against droplet infection from other people coughing, but an airborne upper respiratory tract epidemic is so pervasive that people [the ‘host’ in immunological terms] living in normal social conditions rely on their immune systems to thwart adverse bacteria and viruses. As accepted by leading virologists, the relationship between host, viruses and symptoms is not fully understood. Fortunately, a high proportion of people appear to exhibit immunity, and a high proportion of people testing positive for SARS-CoV-2 are asymptomatic. The size of the pores in masks exceeds that of particles thought to comprise SARS-CoV-2, possibly explaining the demonstrable lack of efficacy in randomised controlled trials of masks.
In the journal Emerging Infectious Diseases, a World Health Organisation working group on interventions for an influenza pandemic stated:
WHO has recommended that mask use by the public should be based on risk, including frequency of exposure and closeness of contact with potentially infectious persons; routine mask use in public places should be permitted but not required.
The authors noted the observation of a medical officer in Alberta in Canada that cases increased after mandating of masks during the Spanish flu pandemic in 1918. The order was subsequently ridiculed. Although that paper was published in 2006, scientific evidence has not really changed since then. At the peak of the Covid-19 pandemic, authorities advised against universal mask use. Interviewed on the US television series Sixty Minutes (8 March 2020), Anthony Fauci, a leading member of the US government’s Coronavirus Task Force, said: -
People should not be walking around with masks. There is no reason for wearing a mask.
Fauci believed that masks should be reserved for healthcare workers and infected patients. Jenny Harries, deputy chief medical officer to the British government, stated in March 2020 that masks do more harm than good, because wearers repeatedly touch their faces, and the virus is likely to be trapped in the mask thereby increasing the risk of inhalation.
A rapid review of the effectiveness of masks by the Royal Society and the British Academy, which persuaded the UK government to promote mask-wearing, explicitly stated a lack of robust RCT evidence for prevention of aerosol transmission. A rather biased article in Nature (6 October 2020), which included plenty of anecdotal reports but limited scientific research to support its argument in favour of masks, nonetheless accepted that the evidence was inconclusive. Author Lynne Peeples noted that studies finding masks to be ineffective had been retracted from journals; this has been a troubling trend of censorial group-think. Indeed, the new mask orthodoxy has entailed disciplinary proceedings, as in the disciplinary investigation by New York University into Professor Crispin Miller for simply encouraging students to critically review research on mask efficacy.
So, contrary to the scientific evidence, governmental health advice has drastically changed, but like other Covid-19 policies, mask enforcement is now more of a political than a scientific decision. John Lee, retired pathologist and lockdown sceptic, said on TalkRadio (28 September 2020): -
We have politicians doping amateur science and scientists doing amateur politics. Mix the two together and it’s an awful brew.
We concur, and suggest that people should be routinely asked about their expectations of masks: Will it protect them from influenza? Either an affirmative or negative response would expose faulty thinking: masks do not appear to prevent flu, and a belief that such a permeable barrier stops coronaviruses only is scientifically baseless.
Editorial note: articles in JAN interactive are not reviewed and are published at the discretion of the Editor-in-Chief. We welcome replies, rejoinders, comments and debate on all entries provided they are not offensive or personal and these will be published on JAN interactive.
Saturday 5 December 2015
Kick out overseas nurses...
...seems to be the message coming from two recent publications.
Both publications - one a report and the other a scientific paper - were published at the end of 2015. The report is Supplying the demand for nurses by Edmund Stubbs and published by Civitas, in November, which claims to be the Insitute for the Study of Civil Society. The second, published by Germack et al. in BMJ Open titled: 'Patient satisfaction and non-UK educated nurses' was published in December. Both publications report the employment of overseas nurses in the UK National Health Service (NHS) in a poor light; one (Stubbs) from what appears to be a position of sheer prejudice and the other (Germack et al.) on the basis of scientific inquiry. The Stubbs report goes much further than recommend a reduction in overseas nurses, as I will explain below. The Germack et al. paper is concerned solely with overseas nurses. The timing could not be better...if you think overseas nurses are at the heart of the problem in the UK NHS.
The Stubbs report
Edmund Stubbs is eminently qualified to comment on the nursing workforce, in addition to a biosciences degree he worked for four years as a healthcare assistant and...er, no further relevant qualifications. His report was commissioned to address the current shortage of nurses - on the face of it - but, in fact, is about the shortage of UK 'trained' nurses (he refers to training as opposed to education consistently throughout). The recommendations of the Stubbs report include an end to nursing student bursaries, something with which I agree as explained in The case against bursaries and fee payments for nursing students. He also recommends removing the cap on the training places at universities for nursing students (mainly referred to by Subbs as 'student nurses'), as has already been done for other student places. This could be problematic for the NHS as it has to provide clinical placements for nurses, an issue that Stubbs does not address directly but does seem to address indirectly in his claim that the extra students will be cheap pairs of hands for the NHS as they will work, essentially, as healthcare assistants. There is no mention of the supernumerary status of nursing students and I can only assume that, from his perspective as a former healthcare assistant, that this is something he did not realise or - worse - he means that the supernumerary status of nursing students should end. The UK Council of Deans of Health should clarify that point as a matter of urgency. If the intention of the report is to end supernumerary status for nursing students then the cause of nursing education in the UK will be set back by nearly 20 years. The end of bursaries and the lifting of the cap are already UK government policy, influenced by Stubbs, and I expect we will see the cheap labour recommendation implemented before too long. This is all shaping up nicely for the enemies of university education for nurses.
Overseas nurses
Stubbs and Germack et al., I predict, will become a combined force for an end to the employment of overseas nurses in the UK. Thus, seemingly reasonable people will become a voice for the British National Party and its anti-immigration clones. Stubbs provides the facts and figures regarding overseas nurses and his message is that we employ vast numbers of them, costing vast amounts of money when nursing programmes are oversubscribed. Now, that does seem anomalous and, clearly, if we had more 'home grown' nurses, we would need fewer overseas nurses - logical; but we don't have enough and we have gone and actively sought overseas nurses to meet the demands of our health service; it's our fault they are here, we offered them the jobs. The information is not new but Stubbs does not cite one of the most valuable sources of information on the nursing workforce - Jim Buchan. Stubbs cites the most recent Royal College of Nursing review of the nursing workforce (An uncertain future), which they now produce by themselves but which, until 2012, was the work of Jim Buchan and Ian Seccombe. Buchan and Seccombe's final report Overstretched. Under-resourced addressed the issue of the number of overseas nurses in the workforce but also produced a very interesting chart (Figure 6, page 15) which showed that the percentage of overseas nurses entering the nursing register (presumably to work in the UK) increased until 2001/02 when the number of overseas registrants exceeded the number of UK registrants (I don't recall a hue and cry at the time) but has since been steadily declining with a slight increase since 2009/10. Of course, these are registrants and only a proxy indicator of employment in the NHS which will be cumulative as many of those registering until the decline will still be employed in the NHS. Nevertheless, the registration trend of overseas nurses is declining and the problem which Stubbs purports to be fixing has already, largely, been addressed.
It is what Stubbs has to say about overseas nurses that is worrying, for example (page 11): 'Staff recruited from overseas often, through no fault of their own, decide to return to their home countries and some are forced to do so by the application of immigration restraints. With many such staff entering and leaving the clinical workforce, it seems almost inevitable that the quality and safety of patient care must suffer.' Let's break this one down. Overseas nurses 'often...decide' to return home 'through no fault of their own' - now, there's a surprise and a contradiction. Do we want them or not; if they return home then is that not what we want? What is the issue here? It seems to be turnover - but there are no comparable figures about turnover of UK nurses which is also high and has been of concern and cost to the NHS since at least 1986 as reported in Staff Turnover in the NHS, at a time when the percentage of overseas registrants was less than 10%. So, turnover is not a problem unique to overseas nurses, it is a also a problem for UK nurses and will not be solved by getting rid of the overseas nurses. Stubbs claims that: 'it seems almost inevitable that the quality and safety of patient care must suffer' - really TWO qualifiers 'seems' and 'almost' before the 'inevitable'. To me it is certain that Stubbs has no evidence to substantiate his claim - no qualifiers necessary. Earlier in the report Stubbs raises the old moralistic and spurious spectre about depriving countries of their own nurses; he says (page 4): 'The morality of expensively recruiting nurses trained overseas to the probable detriment of the health services of those countries is also highly questionable.' Again, he's not sure - ' probable'? We have no evidence that this is the case. While it is frustrating for some countries, especially in Europe as revealed in this interview of an Italian nursing leader with the BBC's Jane Dreaper (which I helped to set up), to see their nurses disappear, the fact is that it is the NHS that has actively pursued these nurses and they leave because their own countries are in dire financial straits. The Philippines deliberately over produces nurses (no cap there!) so that they can seek employment overseas and, along with millions of expatriate Filipinos and Filipinas, make a major contribution to their economy by sending money home. I can provide concrete evidence that stopping the employment of nurses from the Philippines will have a detrimental, if indirect, effect on the health service there because they will be less able to finance it. Saint Nelson Mandela - he who must always be listened to and obeyed - did once ask the UK to stop 'poaching' third world nurses which is often used as evidence against us. The answer, Saint Nelson, is to create freer, democratic and economically strong countries where nurses - black or white - are well paid (something you, singularly, failed to do). If some countries are hard-pressed for good nurses then we could encourage some of our new registrants to go there for experience, but Stubbs has a fix for that too - bribe them to remain in the UK by allowing the NHS to repay their student loans...but only if they remain in the UK in the NHS. This is the most petty-minded and 'little Englander' of suggestions I have ever encountered. We are a global community and we should be educating nurses to think and to work globally and also value their international experience which they bring back to the NHS. I am eternally grateful to the NHS which has, literally, saved my life on one occasion but it is not the only nor is it necessarily the best healthcare system in the world.
BMJ Open to the rescue
I said above that Stubbs had no evidence to back his assertions about overseas nurses; none...until now. The Germack et al. article provides just the evidence he needs and will greatly satisfy the smug neo-Stalinists (whichever party is in power) of the UK Department of Health; another cause to promote, another metric to beat the downtrodden masses of the NHS, another report on the NHS websites and another reason to send more hard-pressed NHS managers to the Gulag Archipelago if they don't comply. Germack et al. report that there is lower patient satisfaction where there are higher percentages of overseas nurses employed in the NHS. The results are quite striking and I do not doubt them. The sample seems representative and the statistics sophisticated taking various factors into account to isolate the effect of overseas nurse employment. Worrying stuff. But wait a minute... I know the authors of this report - personally - and they are not right wing fascists; far from it. They are scientists, they had an issue to investigate and they report as they find. They make the excellent point, with which I agree, that the NHS must move to a more centralised system of workforce planning, not to be even more Stalinist, but only because the current system is patently not working. That employment of overseas nurses varies markedly across the UK indicates a problem. As good scientists they do not speculate but they cannot be so naive as to think that their data will not be misused, misquoted and - quite possibly - lead to some brutality towards and further bullying of overseas nurses in the NHS. We academics have terrific problems getting our stuff 'out there' but, believe me, this article 'has legs'.
What is the problem?
I don't know. If the implication of these reports is that overseas nurses are in some way less competent than UK nurses then people need to think again. For example, as shown by my Hull colleague Gloria Likupe in her PhD thesis, nurses from Africa coming to work in the NHS think UK nurses are a joke (admittedly, not Gloria's exact words). They come with prescribing, phlebotomy and intravenous skills and find that the most advanced procedure a UK nurse at the point of registration can do is give an injection. Why there should be an association - and, as robust as it is, the effect seen by Germack et al. is just that: an association and not a cause and effect relationship - between the percentage of overseas nurses and low patient satisfaction is not clear. But I will speculate. Is it not possible that those areas of the NHS where there are higher percentages of overseas nurses are the areas where there are most problems - anyway? By dint of the fact that there are so many overseas nurses are these not the areas most hard-pressed financially, the worst managed and where the UK as well as the non-UK nurses provide the poorest care?
As my email signature says, 'the plural of anecdote is not data' but I must say, having trained as a nurse in London I trained alongside many nationalities and worked alongside them too. Some of them were shocking, and some of them were brilliant - just like my UK classmates and colleagues. Overseas registrants are over represented in Nursing and Midwifery Council disciplinary hearings, but so are men. Is there a call to have fewer men in nursing? No, quite the opposite. It cannot have escaped anyone's notice that we have increasing numbers of overseas patients; by whom do they prefer to be cared? I have just returned from the Middle East; where once expatriates stocked their health services, they are talking about 'Saudi-isation', 'Bahraini-isation', 'Qatari-isation' and 'Omani-isation' of their workforces. It is natural and right to want to educate and employ your own people. But these are, largely, mono-cultural societies. We are not.
Some of my best friends and colleagues in nursing are non-UK educated, I wonder how these reports make them feel? Inevitably, there will be some qualification by UK health ministers about aspects of the Stubbs report on overseas nurses, but I think we will lose a valuable contribution to our NHS workforce if we target overseas nurses. As for the Germack et al. article, if Jeremy Hunt can make use of one article on weekend working then he can make use and mis-use of this one.
You can listen to this as a podcast.
(c) Yould Publications Ltd
Both publications - one a report and the other a scientific paper - were published at the end of 2015. The report is Supplying the demand for nurses by Edmund Stubbs and published by Civitas, in November, which claims to be the Insitute for the Study of Civil Society. The second, published by Germack et al. in BMJ Open titled: 'Patient satisfaction and non-UK educated nurses' was published in December. Both publications report the employment of overseas nurses in the UK National Health Service (NHS) in a poor light; one (Stubbs) from what appears to be a position of sheer prejudice and the other (Germack et al.) on the basis of scientific inquiry. The Stubbs report goes much further than recommend a reduction in overseas nurses, as I will explain below. The Germack et al. paper is concerned solely with overseas nurses. The timing could not be better...if you think overseas nurses are at the heart of the problem in the UK NHS.
The Stubbs report
Edmund Stubbs is eminently qualified to comment on the nursing workforce, in addition to a biosciences degree he worked for four years as a healthcare assistant and...er, no further relevant qualifications. His report was commissioned to address the current shortage of nurses - on the face of it - but, in fact, is about the shortage of UK 'trained' nurses (he refers to training as opposed to education consistently throughout). The recommendations of the Stubbs report include an end to nursing student bursaries, something with which I agree as explained in The case against bursaries and fee payments for nursing students. He also recommends removing the cap on the training places at universities for nursing students (mainly referred to by Subbs as 'student nurses'), as has already been done for other student places. This could be problematic for the NHS as it has to provide clinical placements for nurses, an issue that Stubbs does not address directly but does seem to address indirectly in his claim that the extra students will be cheap pairs of hands for the NHS as they will work, essentially, as healthcare assistants. There is no mention of the supernumerary status of nursing students and I can only assume that, from his perspective as a former healthcare assistant, that this is something he did not realise or - worse - he means that the supernumerary status of nursing students should end. The UK Council of Deans of Health should clarify that point as a matter of urgency. If the intention of the report is to end supernumerary status for nursing students then the cause of nursing education in the UK will be set back by nearly 20 years. The end of bursaries and the lifting of the cap are already UK government policy, influenced by Stubbs, and I expect we will see the cheap labour recommendation implemented before too long. This is all shaping up nicely for the enemies of university education for nurses.
Overseas nurses
Stubbs and Germack et al., I predict, will become a combined force for an end to the employment of overseas nurses in the UK. Thus, seemingly reasonable people will become a voice for the British National Party and its anti-immigration clones. Stubbs provides the facts and figures regarding overseas nurses and his message is that we employ vast numbers of them, costing vast amounts of money when nursing programmes are oversubscribed. Now, that does seem anomalous and, clearly, if we had more 'home grown' nurses, we would need fewer overseas nurses - logical; but we don't have enough and we have gone and actively sought overseas nurses to meet the demands of our health service; it's our fault they are here, we offered them the jobs. The information is not new but Stubbs does not cite one of the most valuable sources of information on the nursing workforce - Jim Buchan. Stubbs cites the most recent Royal College of Nursing review of the nursing workforce (An uncertain future), which they now produce by themselves but which, until 2012, was the work of Jim Buchan and Ian Seccombe. Buchan and Seccombe's final report Overstretched. Under-resourced addressed the issue of the number of overseas nurses in the workforce but also produced a very interesting chart (Figure 6, page 15) which showed that the percentage of overseas nurses entering the nursing register (presumably to work in the UK) increased until 2001/02 when the number of overseas registrants exceeded the number of UK registrants (I don't recall a hue and cry at the time) but has since been steadily declining with a slight increase since 2009/10. Of course, these are registrants and only a proxy indicator of employment in the NHS which will be cumulative as many of those registering until the decline will still be employed in the NHS. Nevertheless, the registration trend of overseas nurses is declining and the problem which Stubbs purports to be fixing has already, largely, been addressed.
It is what Stubbs has to say about overseas nurses that is worrying, for example (page 11): 'Staff recruited from overseas often, through no fault of their own, decide to return to their home countries and some are forced to do so by the application of immigration restraints. With many such staff entering and leaving the clinical workforce, it seems almost inevitable that the quality and safety of patient care must suffer.' Let's break this one down. Overseas nurses 'often...decide' to return home 'through no fault of their own' - now, there's a surprise and a contradiction. Do we want them or not; if they return home then is that not what we want? What is the issue here? It seems to be turnover - but there are no comparable figures about turnover of UK nurses which is also high and has been of concern and cost to the NHS since at least 1986 as reported in Staff Turnover in the NHS, at a time when the percentage of overseas registrants was less than 10%. So, turnover is not a problem unique to overseas nurses, it is a also a problem for UK nurses and will not be solved by getting rid of the overseas nurses. Stubbs claims that: 'it seems almost inevitable that the quality and safety of patient care must suffer' - really TWO qualifiers 'seems' and 'almost' before the 'inevitable'. To me it is certain that Stubbs has no evidence to substantiate his claim - no qualifiers necessary. Earlier in the report Stubbs raises the old moralistic and spurious spectre about depriving countries of their own nurses; he says (page 4): 'The morality of expensively recruiting nurses trained overseas to the probable detriment of the health services of those countries is also highly questionable.' Again, he's not sure - ' probable'? We have no evidence that this is the case. While it is frustrating for some countries, especially in Europe as revealed in this interview of an Italian nursing leader with the BBC's Jane Dreaper (which I helped to set up), to see their nurses disappear, the fact is that it is the NHS that has actively pursued these nurses and they leave because their own countries are in dire financial straits. The Philippines deliberately over produces nurses (no cap there!) so that they can seek employment overseas and, along with millions of expatriate Filipinos and Filipinas, make a major contribution to their economy by sending money home. I can provide concrete evidence that stopping the employment of nurses from the Philippines will have a detrimental, if indirect, effect on the health service there because they will be less able to finance it. Saint Nelson Mandela - he who must always be listened to and obeyed - did once ask the UK to stop 'poaching' third world nurses which is often used as evidence against us. The answer, Saint Nelson, is to create freer, democratic and economically strong countries where nurses - black or white - are well paid (something you, singularly, failed to do). If some countries are hard-pressed for good nurses then we could encourage some of our new registrants to go there for experience, but Stubbs has a fix for that too - bribe them to remain in the UK by allowing the NHS to repay their student loans...but only if they remain in the UK in the NHS. This is the most petty-minded and 'little Englander' of suggestions I have ever encountered. We are a global community and we should be educating nurses to think and to work globally and also value their international experience which they bring back to the NHS. I am eternally grateful to the NHS which has, literally, saved my life on one occasion but it is not the only nor is it necessarily the best healthcare system in the world.
BMJ Open to the rescue
I said above that Stubbs had no evidence to back his assertions about overseas nurses; none...until now. The Germack et al. article provides just the evidence he needs and will greatly satisfy the smug neo-Stalinists (whichever party is in power) of the UK Department of Health; another cause to promote, another metric to beat the downtrodden masses of the NHS, another report on the NHS websites and another reason to send more hard-pressed NHS managers to the Gulag Archipelago if they don't comply. Germack et al. report that there is lower patient satisfaction where there are higher percentages of overseas nurses employed in the NHS. The results are quite striking and I do not doubt them. The sample seems representative and the statistics sophisticated taking various factors into account to isolate the effect of overseas nurse employment. Worrying stuff. But wait a minute... I know the authors of this report - personally - and they are not right wing fascists; far from it. They are scientists, they had an issue to investigate and they report as they find. They make the excellent point, with which I agree, that the NHS must move to a more centralised system of workforce planning, not to be even more Stalinist, but only because the current system is patently not working. That employment of overseas nurses varies markedly across the UK indicates a problem. As good scientists they do not speculate but they cannot be so naive as to think that their data will not be misused, misquoted and - quite possibly - lead to some brutality towards and further bullying of overseas nurses in the NHS. We academics have terrific problems getting our stuff 'out there' but, believe me, this article 'has legs'.
What is the problem?
I don't know. If the implication of these reports is that overseas nurses are in some way less competent than UK nurses then people need to think again. For example, as shown by my Hull colleague Gloria Likupe in her PhD thesis, nurses from Africa coming to work in the NHS think UK nurses are a joke (admittedly, not Gloria's exact words). They come with prescribing, phlebotomy and intravenous skills and find that the most advanced procedure a UK nurse at the point of registration can do is give an injection. Why there should be an association - and, as robust as it is, the effect seen by Germack et al. is just that: an association and not a cause and effect relationship - between the percentage of overseas nurses and low patient satisfaction is not clear. But I will speculate. Is it not possible that those areas of the NHS where there are higher percentages of overseas nurses are the areas where there are most problems - anyway? By dint of the fact that there are so many overseas nurses are these not the areas most hard-pressed financially, the worst managed and where the UK as well as the non-UK nurses provide the poorest care?
As my email signature says, 'the plural of anecdote is not data' but I must say, having trained as a nurse in London I trained alongside many nationalities and worked alongside them too. Some of them were shocking, and some of them were brilliant - just like my UK classmates and colleagues. Overseas registrants are over represented in Nursing and Midwifery Council disciplinary hearings, but so are men. Is there a call to have fewer men in nursing? No, quite the opposite. It cannot have escaped anyone's notice that we have increasing numbers of overseas patients; by whom do they prefer to be cared? I have just returned from the Middle East; where once expatriates stocked their health services, they are talking about 'Saudi-isation', 'Bahraini-isation', 'Qatari-isation' and 'Omani-isation' of their workforces. It is natural and right to want to educate and employ your own people. But these are, largely, mono-cultural societies. We are not.
Some of my best friends and colleagues in nursing are non-UK educated, I wonder how these reports make them feel? Inevitably, there will be some qualification by UK health ministers about aspects of the Stubbs report on overseas nurses, but I think we will lose a valuable contribution to our NHS workforce if we target overseas nurses. As for the Germack et al. article, if Jeremy Hunt can make use of one article on weekend working then he can make use and mis-use of this one.
You can listen to this as a podcast.
(c) Yould Publications Ltd
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