2001 Uk Foot and Mouth Disease Outbreak Review

April 16, 2022 Post a Comment

Abstract

The 2001 pes and mouth illness outbreak in the UK was widespread and devastating. Some areas (e.k. Cumbria) were very badly hit, merely all farmers were affected to some degree. Huge numbers of animals, infected and healthy, were slaughtered. Tourism was badly affected. Data from iii systematic studies found elevated levels of psychological morbidity among farmers and other rural workers, peculiarly those directly affected. Almost farmers turned to family unit and friends (and veterinary surgeons) for back up; relatively few approached health or social services, mainly because they did not run across their reactions every bit affliction. Many farmers and other rural workers prefer to use supports within their own community, or anonymous supports such as self-help materials or computer-based treatments. Mental wellness services should take account of these preferences past adopting an educational and consultative role in any like outbreak.

The outbreak of foot and mouth disease in 2001 affected many parts of the United kingdom. Information technology began in Essex and apace spread. Cumbria, Devon, and Dumfries and Galloway were the worst afflicted counties; the merely large rural areas to exist gratuitous of the affliction were key and northern Scotland. The speed and breadth of the spread were notable, caused in office by the mutual practice of transporting animals over long distances to afar farms, auctions and abattoirs.

The epidemic started in February and reached a peak in March and Apr. The last new case was reported in Oct, and 'disease-free' status for the Uk was regained in January 2002. Over 2000 farms straight experienced the disease. Farms without directly experience were too badly affected; within a few days of the outbreak, severe restrictions on the movement of all farm animals (infected and healthy) were imposed. Farmers were obliged to leave their livestock in fields or indoors under increasingly unhealthy atmospheric condition, it was oftentimes difficult to obtain feed deliveries and there were numerous livestock deaths as a issue.

Dealing with the outbreak

The official authorities response to the outbreak was to order the slaughter of all infected animals. In mid-March this slaughter policy was extended to neighbouring unaffected farms ('face-to-face alternative') and to situations of 'dangerous contacts' involving all animals that might accept been in any kind of contact with the infection. According to official figures 4 000 000 animals were slaughtered, but other estimates put the figure as loftier as x 000 000. They were importantly cattle and sheep, but pigs, goats and deer were besides killed. The furnishings of the slaughter were highly visible, with expressionless animals lying in fields and huge funeral pyres across the countryside. Animals were slaughtered at nearly x 000 farms. Travel to and from farms was also restricted, isolating farmers and their families, preventing children from attending school, and interfering with the constructive delivery of health and other services (e.g. Reference Walsh and HowkinsWalsh & Howkins, 2002). The rapid spread of the affliction reduced the effectiveness of these measures.

Veterinary surgeons were employed in big numbers during the outbreak. Many private practitioners were enrolled as temporary workers for the State Veterinary Service and others were recruited from abroad. Their main function was to test suspect cases, and they were therefore involved in making decisions that would result in the deaths of large numbers of animals, some of which were healthy only had to be slaughtered every bit function of the preventive culling policy. Many veterinarian surgeons participated in, or were witness to, big-scale slaughter, in marked contrast to their normal professional role of safeguarding animal welfare.

Economic consequences

The restrictions on movement had major economic consequences. Many farmers (almost one-third: Reference Peck, Grant and McArthurPeck et al, 2002) supplement their livelihoods through other income-generating activities such as tourism and haulage; this additional income rapidly ceased. Many parts of the British countryside were about closed past these and other official restrictions, discouraging walkers, cyclists and other holidaymakers. At that place were unavoidable and obtrusive signs of the culling throughout the countryside, which besides deterred visitors. Thus, many rural communities of a sudden lost income from their two main sources, agriculture and tourism, with knock-on effects for public transport, agronomical suppliers, catering and other local industries. Some urban areas besides suffered, with the closure of zoos and nearby country parks. The economic costs of the outbreak were loftier. Reference Thompson, Muriel and RussellThompson et al (2002) estimated that the losses for agronomics and the nutrient manufacture were over £iii 000 000 000, with like levels of loss for the tourist industry. It has been argued that tourism was economically more adversely afflicted than agriculture: farming received compensation for losses, but tourism did not.

Farming hardships before the outbreak

Before the 2001 outbreak of foot and rima oris disease, British farming, specially livestock farming, was in a parlous state (Box i). Previous diseases that had damaged the industry included bovine spongiform encephalopathy (BSE) and swine fever. Moreover, the prices of agricultural products, especially meat and dairy, had dropped markedly in contempo years. Incomes were therefore very depression, especially in upland sheep-farming areas, where the average annual bacon in 2001 was about £6000. Nearly a tertiary of upland farmers had net incomes of less than zero. Many farmers also had large debts, on boilerplate £50 000. Bureaucratic procedures, especially the requirement to complete numerous official forms, were major additional stressors. Not surprisingly, farmers began to go out the industry: about five% of the workforce had left in 1999/2000 alone. Many farmers regard farming as a way of life rather than simply a job, and for them giving upwardly farming would be particularly deleterious to mental health. Moreover, in farming, houses are ofttimes 'tied' to the task; therefore leaving farming could be highly confusing to daily life.

Box 1 The state of agronomics before the outbreak

• Diseases that had affected farming in the contempo by included BSE and swine fever
• Incomes were very low, especially for upland livestock farmers
• Debts were common and high
• Many farmers were leaving the job
• Suicide rates for farmers and for veterinary surgeons were high

Mental health of agronomical workers

The mental wellness of farmers had been investigated before the outbreak of human foot and oral fissure illness past Reference Thomas, Lewis and ThomasThomas et al (2003). At that fourth dimension, but half-dozen% of farmers reported clinically important psychological morbidity, less than in the general population. Like low figures for overall psychological morbidity in rural areas earlier the outbreak had been reported by Reference Paykel, Abbott and JenkinsPaykel et al (2000). Paradoxically, however, Thomas et al did annotation that farmers were more probable to feel that life was non worth living. This is consistent with the high rate of suicide amid farmers; interestingly, veterinary surgeons also have loftier suicide rates (Reference Hawton, Simkin and AslogHawton et al, 1998).

In summary, the foot and mouth disease outbreak had devastating economic and social consequences on rural communities; farmers suffered the nigh, just there were besides major consequences for related agricultural industries, other rural professions and tourism (Box two).

Box 2 The foot and mouth outbreak

• Infections occurred in most areas of the Great britain, autonomously from central and northern Scotland
• The outbreak spread very rapidly, before preventive measures could fully take effect
• All farms, infected or non, were subject area to strict restrictions on movement of animals and people
• At to the lowest degree four million animals were slaughtered, many of them salubrious but killed in a preventive choose
• The countryside was well-nigh 'closed' for many months
• The outbreak cost farming at least £three billion, with similar losses for tourism

The psychological sequelae of the outbreak

Several reports published in the firsthand backwash of the outbreak commented on its adverse psychological bear upon (Reference Deaville and JonesDeaville & Jones, 2001; Regal Society of Edinburgh, 2002), only the data were mainly anecdotal. A survey in ane rural and i semi-rural area in England investigated the full general public's views on the adverse effects of the illness outbreak; the stress and anxiety in rural communities were rated as of import as the affect on animal welfare or on the future of rural communities (Reference Poortinga, Bickerstaff and LangfordPoortinga et al, 2004).

Information technology appears that only three systematic studies of the effects of the outbreak on farmers and other rural workers accept been conducted (Reference Peck, Grant and McArthurPeck et al, 2002; Reference Hannay and JonesHannay & Jones, 2002; Constitute for Health Enquiry, 2004), although statistical data are available from national databases. Box three summarises results from these sources, which are described in more than detail below.

Box 3 The psychological furnishings of the outbreak

• Loftier rates of psychological morbidity were constitute in affected areas (73% caseness in Cumbria)
• These rates were college than in unaffected areas (east.g. caseness in the Scottish Highlands was 33%), and were higher than before the outbreak
• Farmers were more desperately affected than tourism workers
• The level of psychological morbidity in farmers was correlated with the degree of culling and restrictions
• The number of farmers who were because leaving the job increased
• Little is known about the effects on other groups
• There was no increment in demand for mental health services in afflicted areas
• There was no detectable increment in the suicide rates for farmers or for veterinary surgeons
• Typically, farmers turned to family, friends and veterinarian surgeons for support
• Few farmers or veterinary surgeons construed their emotional response to the outbreak as an 'illness', and most would exist reluctant to seek support through health or social services in any future outbreak
• The about acceptable sources of support would be from within the agricultural community itself, or from more than anonymous sources such equally printed or internet communication

Systematic studies

Comparing farmers in infected and non-infected areas

My colleagues and I conducted a postal survey comparing the psychological morbidity of farmers in Cumbria (many cases of human foot and mouth disease) with farmers in the Highlands of Scotland (no cases) (Reference Peck, Grant and McArthurPeck et al, 2002). Questionnaires were posted in January and February 2002, within a few months of the end of the outbreak: 400 were sent in Cumbria, of which 118 were returned; 285 were sent in the Highlands, of which 80 were returned. Comparing the ii areas was intended to command, at least in part, for the pre-outbreak levels of psychological morbidity experienced in the full general farming customs, as discussed above. Morbidity was measured by the 12-item General Health Questionnaire (GHQ–12), using a cut-off score of 4. In brief, high morbidity was institute in both areas (73% in Cumbria and 33% in the Highlands), levels well above the x% or less plant in pre-outbreak studies (Reference Paykel, Abbott and JenkinsPaykel et al, 2000; Reference Thomas, Lewis and ThomasThomas et al, 2003). Differences between pre- and post-outbreak studies must be interpreted charily considering different example detection instruments were used. All the same, it would appear that outbreak of the affliction produced essentially college levels of morbidity among farmers, compared with levels earlier the affliction, and that more than twice as many farmers in areas with many cases suffered psychological morbidity, compared with farmers in areas with no cases.

Farmers were also asked to land, on a particularly devised questionnaire, to whom they had turned for personal support during the foot and mouth crisis. Not surprisingly, most (well-nigh two-thirds) turned to family unit, friends and other farmers. Of particular involvement, the next virtually-cited group who were approached to provide personal (emotional) support was veterinary surgeons (40%). This probably reflects the friendships that develop between farmers and veterinary surgeons over the years, only may as well be because they were one of the few groups allowed to travel around the farms during the outbreak. The National Farmers' Wedlock and other farming organisations were cited past about 20%. General practitioners (xi%), ministers of religion (xiii%) and the Samaritans (1%) were less ofttimes cited. Of particular importance, but 1.5% of the farmers sought support from a mental health specialist (psychiatrist, psychologist, social worker or community psychiatric nurse). I-quarter of farmers considered that visits from health or social piece of work authorities would have been 'not helpful' or 'harmful'; only 13% said that they would have welcomed such visits. More would accept been willing to attend farmers' self-assistance groups (38%), read printed advice sent to all farmers (45%), or use telephone and internet helplines (25%).

Unfortunately, the response rate in our study was low (29%) in both areas, and this may cast doubt on the validity of the findings. However, nosotros compared the subcontract characteristics (number and kinds of livestock, acreage and percentage infected) of responding and non-responding farmers, and no significant differences were revealed. It is probable, therefore, that the obtained sample was representative of farmers in general in the 2 areas studied.

Comparing farmers and tourism workers in an affected area

Reference Hannay and JonesHannay & Jones (2002) conducted a similar postal survey in Dumfries and Galloway, the just surface area in Scotland badly afflicted by the disease. The tourist industry besides every bit farmers were targeted; the response rates were 30% for tourism and 40% for farmers, producing a total sample of near 1200 respondents. They used the COOP/WONCA functional wellness condition charts. These charts contain a pictorial and verbal representation of six scales (feelings, daily activities, overall wellness, social activities, social support and quality of life) and respondents are asked to rate these items on a 5-bespeak calibration. The charts exercise not use cutting-off scores. The charts were completed in June and September 2001. Respondents were asked to relate their responses to the first 2 weeks after their animals had been culled; those who had not directly experienced a cull (and the tourism respondents) were asked to relate them to the 2 weeks preceding chart completion.

The main findings were that, on all six sub-scales, both farmers and tourism workers had scores indicating that they were badly afflicted by the outbreak. In add-on, farmers experienced significantly more than adverse furnishings than tourism workers, and the scores of both samples were high in relation to international comparative information.

The authors also asked respondents from whom they had received support during the crunch. The responses paralleled those that my colleagues and I received (Reference Peck, Grant and McArthurPeck et al, 2002), in that family and friends were near often cited (about 14%) and few (4%) cited their general practitioners. The scores on the charts were correlated with the caste of culling and animal restrictions experienced. Nonetheless, in contrast to our report, very few cited veterinarian surgeons as providing support (1%), and the overall level of receiving support from family and friends was considerably lower (67% v. 14%). The reasons for these differences are non clear, just they may reverberate the wording of the questions, or the time span over which emotional land was assessed. Moreover, Hannay & Jones did not present the information on back up-seeking for tourism and for farming separately; accordingly, the support-seeking rates for farming may take been diluted past combining them with data from tourism, which was not as badly affected in Dumfries and Galloway equally in other regions of the United kingdom of great britain and northern ireland.

A qualitative full general population report in an affected area

This pocket-size written report by the Constitute for Health Enquiry (2004) used a purposive sample comprising a panel of 54 residents of Cumbria; of these, 9 were farmers, 4 were veterinarian workers and the remainder worked in tourism, ship and a variety of other jobs. Each participant kept a weekly diary, and virtually (52) also agreed to an in-depth interview; group meetings were as well held. The console'due south participation began in Dec 2001 and connected for 18 months. Sixteen participants reported wellness, financial or social problems direct attributable to the outbreak, 24 had feelings of anxiety and stress that were non being addressed, 11 reported signs of post-traumatic experience and 6 were receiving medical treatment for low or anxiety. The Institute for Health Research also highlighted the theme of 'collective trauma', or a shared sense of shock, hardship and endurance among the participants; this sense of sharing may have functioned equally a supportive mechanism in the affected communities. Most participants did not construe their adverse emotional reactions to the outbreak as an illness that required specialist input.

Finally, the authors noted that participants oftentimes commented on the highly useful office played past local radio during the crunch, in terms of local knowledge, trustworthiness, up-to-date information and rendering official advice more understandable. My colleagues and I noted similar laudatory comments about local radio from their Cumbrian respondents (Reference Peck, Grant and McArthurPeck et al, 2002).

Lack of research on other groups

Not surprisingly, the higher up studies focused mainly on the effects of the foot and mouth disease outbreak on farming and/or on tourism. Several other groups were potentially affected to a like degree, but picayune is known about its effects in these groups. Veterinary surgeons in particular probably suffered greatly during and after the crisis. Not only were they directly involved in the slaughter, but many as well experienced the burden of providing emotional support for distressed farmers, a role for which they accept piddling or no training. Unfortunately, no inquiry studies take direct addressed the consequences of the outbreak for veterinary surgeons.

Statistical information from other sources

Public health departments

The Public Health Department of N Cumbria Primary Care Trusts collated information on changes in the need for services in response to the human foot and oral cavity outbreak. No noticeable increase was observed in the need for mental health services during, or in the backwash of, the outbreak (C. Gregson, personal communication, 2005). This is consequent with the finding of my team (Reference Peck, Grant and McArthurPeck et al, 2002) and of the Constitute for Health Research (2004) that virtually farmers did not come across the emotional stresses arising from the foot and oral fissure disease outbreak every bit being a health problem; they were therefore unlikely to approach their general practitioner or other health workers to seek personal support, at least in the outset instance. This is also consistent with Reference Boulanger, Deaville and Randall-SmithBoulanger et al's (1999) report of evidence supporting the stereotype that farmers practise not desire to exist seen as 'weak' past seeking psychological back up.

Function for National Statistics

The Office for National Statistics (ONS) gathers data on the overall number of deaths (and of these, how many were due to suicide and decease 'of undetermined intent') for occupations related to 'farming action' and veterinary piece of work. In the 3 years preceding the foot and rima oris outbreak (1998, 1999 and 2000) the mean number of suicides and deaths of undetermined intent per chiliad deaths for agricultural workers (including veterinary workers) was 28.7. In the years during and after the outbreak (2001, 2002 and 2003) the mean was 26.4. This slight decrease remained after the information-sets for farm workers and veterinary workers were examined separately (F. Van Galen, Health & Care Division of the Part for National Statistics, personal communication, 2005).

There was therefore a slight reduction in such deaths during and after the outbreak. Moreover, in 2002 in that location was a sudden dip to a mean of 21.1. This is surprising, in that the adverse effects of exposure to traumatic events might have been expected to reach a peak in the year after the outbreak because of the well-documented latency period of up to several months between exposure to trauma and the development of post-traumatic stress reactions (Reference Freeman, Johnstone, Freeman and ZealleyFreeman, 1998). The decrease might reflect the effects of mutual support in rural communities in the face of the collective trauma described by the Establish for Health Research (2004). Whatever the explanation, the ONS information are consequent with those of the Public Health Department of N Cumbria Primary Intendance Trust (C. Gregson, personal communication, 2005), which institute no increment in demand for services every bit a result of the foot and oral fissure illness outbreak. Still, it is important to continue to monitor the state of affairs in all affected areas, in case of substantial delays in the appearance of wellness consequences.

Department for Environment, Food and Rural Affairs

The Section for Environment, Food and Rural Affairs (2002) conducted a survey of the effects of the outbreak in England. They were chiefly concerned with what changes in farming practice were likely to occur in the years afterwards the outbreak. Mental health issues were not directly addressed, merely some indirect indications of related stresses may be discerned in that about 13% of farmers on pocket-sized-to-medium premises were definitely or perhaps planning to move out of farming; however, those on large farms were just half as likely to be considering a move out (6%). It is interesting to compare these figures with the 5% of the workforce who left farming in 1999/ 2000. Many other farmers were planning to stay on their premises, but to diversify into non-farming ventures such as holiday lets and sporting activities.

British Veterinarian Association's Vet Helpline

The British Veterinary Association runs a phone helpline for veterinary surgeons and their families. Vet Helpline does non offer formal counselling or therapy, only information technology provides a sympathetic listener and encouragement in problem-solving. Records are kept of the number of contacts received each month. These information are very variable and it is difficult to arrive at unequivocal conclusions. Nevertheless, in November and December 2000 (pre-outbreak) the numbers of contacts were 20 and 27, respectively; contacts rose to a mean of 29 during the first 3 months of the outbreak (February to Apr 2001), increasing to a height mean of forty for the period Baronial to Oct 2001, by which time the preventive culling policy had been in operation for several months. By mid-2002 numbers had decreased to pre-outbreak levels, with occasional subsequent monthly rises that are hard to explain (Vet Helpline, personal communication, 2005.) Despite the variability in these data (and the wide confidence intervals because of the small numbers), one tin can conclude that they are consequent with the view that veterinarian surgeons tended to seek help from their ain profession, rather than from health or social work agencies.

Implications for mental wellness services

Despite the loftier levels of psychological morbidity during and after the 2001 outbreak of foot and oral cavity disease, distressed individuals (specially the farmers) did not see their emotional reactions as a sign of illness, and did non therefore seek personal support through the channels of health or social services. This is entirely advisable, in that most emotional reactions to the outbreak should be seen as normal responses to a series of very deplorable events, rather than as a medical disorder requiring specialist treatment. Nevertheless, it should be pointed out that two of the systematic studies from which I have taken data (Reference Hannay and JonesHannay & Jones, 2002; Reference Peck, Grant and McArthurPeck et al, 2002) used simply measures of symptoms, and neglected to address the upshot of functional harm. Consequently, i cannot establish whether whatsoever of the participants reached the threshold for adjustment disorder.

Near farmers sought assist from family, friends and others working in the agricultural industry, especially veterinary surgeons. At that place was also an expressed willingness to use anonymised sources of support such as telephone or internet helplines; this is consistent with the documented reluctance of farmers to admit to, and seek help for, an emotional problem. In whatsoever futurity outbreak information technology is likely that like patterns of assistance-seeking volition occur.

Developing local support networks

Information technology may exist most fruitful to concentrate scarce specialist resources on maximising the effectiveness of the supports that farmers and others are known to be more than likely to apply. For case, mental health specialists might adopt an educational and consultative function for veterinary surgeons, farming organisations, self-aid groups (at least in the early stages of their establishment) and local radio. Conspicuously, links betwixt these agencies and mental wellness services should be initiated at present, and non left until a crisis is underway. The consultation project might best be achieved under the aegis of local emergency planning, but the links may need to be developed separately. Veterinary surgeons will undoubtedly play an of import personal support role in whatsoever similar futurity outbreak. Just every bit noted, the education of counselling skills does not feature in their initial grooming nor in their CPD. Such teaching could profitably be introduced into the veterinary curriculum. In the meantime, mental health specialists should make contact with local veterinarian surgeons and establish relevant training, which should be brief and simple.

Treating postal service-traumatic experiences

Technically, the reactions to the foot and mouth disease outbreak cannot exist classified as postal service-traumatic stress disorder (PTSD), since there was no extreme trauma involving actual or threatened death or serious injury, and no single traumatic event. Yet, the Plant for Wellness Inquiry (2004) recorded 'mail-traumatic experiences' such as flashbacks in 11 of their 54 participants. Information technology is likely that methods known to be effective in relieving PTSD would also be useful in a future similar outbreak. Fortunately, these methods are straightforward (although the show base of operations is limited). Reference Mollica, Cardozo and OsofskyMollica et al (2004) listing them every bit 'psychological beginning aid, which consists of listening (non forcing talk), conveying compassion, ensuring basic needs, mobilising support from family unit members and significant others' (pp. 2060–2061); they comment that psychotropic drugs can be effective, and that 'group meetings and shared activities' may exist more helpful than 'individual therapeutic provision' (p. 2062). They also advise confronting the use of stress debriefing. It would appear that these approaches were 'naturally' employed in the agronomical communities affected by the foot and mouth outbreak, and with a remarkable caste of success when one considers that there was no apparent increment in suicide or in mental health service utilisation during or after the outbreak. This may be seen as a heartening case of how communities can successfully develop their own ways of coping with horrendous events, without recourse to specialist services.

Specialist support

Although simply a minority of farmers approached their general practitioners for back up, a reasonable proportion (about 10%) still did so, and the organisation of services in any similar crisis should reflect this. On the other mitt, how willing farmers would be to have a traditional referral to a specialist service is unclear. For the few farmers who would accept more specialist support, computerised cognitive–behavioural therapy (CCBT) may be worth because. At that place is now compelling evidence of its effectiveness for anxiety and depression (Reference Kaltenthaler, Parry and BeverleyKaltenthaler et al, 2004), and mental health authorities should consider making CCBT available throughout their surface area. Of item relevance to events such as the foot and mouth disease outbreak, CCBT tin be used even if people are restricted to their farms and if they live in remote areas; furthermore, the method is bearding and would therefore be more acceptable to many farmers.

Conclusions

Assay of the psychological aftermath of the 2001 foot and mouth outbreak in the UK reveals a number of implications for mental health services (Box four). Perhaps the near important lesson that we tin can larn from these is that mental health professionals can best reply to such disasters not past treatment after the event, only past pre-emptive community education and consultative support.

Box 4 Implications for mental health services

• About people psychologically affected past the outbreak did not seek help from general practitioners or from specialist services
• Many farmers do not openly admit to emotional distress
• In whatsoever future similar crisis, loftier need for specialist services should non be expected
• Specialists could make a greater contribution by working with and training those who are more likely to be asked for support, especially local veterinary surgeons
• Working closely with farming organisations and local radio would be helpful
• Printed, phone and internet self-aid advice should be available
• Computerised cognitive–behavioural therapy might help the minority who would take more specialist support
• Reaction to the outbreak exemplifies how communities successfully develop their own ways of coping with a crisis

MCQs

1 The 2001 foot and oral cavity disease outbreak:
1. a afflicted just a few areas in the United kingdom
2. b led to restrictions on the movements of people every bit well as animals
3. c had minimal effects on tourism
4. d cost billions of pounds to farming and to tourism
5. eastward lasted about 9 months.
two Before the outbreak:
1. a farming had no major crises
2. b livestock farmers were financially well off
3. c about 1 in 20 farmers were leaving farming per year
4. d suicide rates among farmers were high
5. e suicide rates among veterinary surgeons were high.
3 The effects of the outbreak included:
1. a high levels of psychological morbidity amid farmers
2. b higher levels of morbidity among tourism workers than farmers
3. c increased suicide rate amidst farmers
4. d increased suicide rate amid veterinary surgeons
5. e no apparent increase in need for mental health services.
4 Many farmers turned to the following for support during the outbreak:
1. a general practitioners
2. b mental health services
3. c veterinary surgeons
4. d farming organisations
5. east ministers of religion.
5 In any similar crisis, mental wellness professionals should:
1. a piece of work in a consultative and educative way
2. b visit farms to come across if help is required
3. c liaise with community organisations such as local radio
4. d exist involved in writing self-help materials for the farming community
5. e prepare for a massive increase in referrals from GPs.

MCQ answers

1		ii		3		4		five
a	F	a	F	a	T	a	F	a	T
b	T	b	F	b	F	b	F	b	F
c	F	c	T	c	F	c	T	c	T
d	T	d	T	d	F	d	T	d	T
eastward	T	eastward	T	east	T	e	F	e	F

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