title: National Health Service

text: The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the "NHS" name (NHS England, NHS Scotland and NHS Wales). Health and Social Care in Northern Ireland was created separately and is often locally referred to as "the NHS". The four systems were established in 1948 as part of major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery—a health service based on clinical need, not ability to pay. Each service provides a comprehensive range of health services, free at the point of use for people ordinarily resident in the United Kingdom apart from dental treatment and optical care. In England, NHS patients have to pay prescription charges; some, such as those aged over 60 and certain state benefit recipients, are exempt.


title: National Health Service

text: Taken together, the four National Health Services in 2015–16 employed around 1.6 million people with a combined budget of £136.7 billion. In 2014, the total health sector workforce across the United Kingdom was 2,165,043. This broke down into 1,789,586 in England, 198,368 in Scotland, 110,292 in Wales and 66,797 in Northern Ireland. In 2017, there were 691,000 nurses registered in the United Kingdom, down 1,783 from the previous year. However, this is the first time nursing numbers have fallen since 2008. Every 24 hours it sees one million patients, and with 1.7 million staff it is the fifth biggest employer in the world, as well as the largest non-military public organisation in the world.


title: National Health Service

text: When purchasing drugs, the four healthcare services have significant market power that, based on their own assessment of the fair value of the drugs, influences the global price, typically keeping prices lower. A small number of products are procured jointly by two or more UK healthcare services. Several other countries either copy the United Kingdom’s model or directly rely on Britain’s assessments for their own decisions on state-financed drug reimbursements.


title: National Health Service

text: Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909.


title: National Health Service

text: Somerville Hastings, President of the Socialist Medical Association, successfully proposed a resolution at the 1934 Labour Party Conference that the party should be committed to the establishment of a State Health Service.


title: National Health Service

text: Following the 1942 Beveridge Report's recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease", cross-party consensus emerged on introducing a National Health Service of some description. Conservative MP and Health Minister, Henry Willink later advanced this notion of a National Health Service in 1944 with his consultative White Paper "A National Health Service" which was circulated in full and short versions to colleagues, as well as in newsreel.


title: National Health Service

text: When Clement Attlee's Labour Party won the 1945 election he appointed Aneurin Bevan as Health Minister. Bevan then embarked upon what the official historian of the NHS, Charles Webster, called an "audacious campaign" to take charge of the form the NHS finally took. Bevan's National Health Service was proposed in Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's Public Health Services Act 1947.


title: National Health Service

text: NHS Wales was split from NHS (England) in 1969 when control was passed to the Secretary of State for Wales. According to one history of the NHS, "In some respects the war had made things easier. In anticipation of massive air raid casualties, the Emergency Medical Service had brought the country’s municipal and voluntary hospitals into one umbrella organisation, showing that a national hospital service was possible." Webster wrote in 2002 that "the Luftwaffe achieved in months what had defeated politicians and planners for at least two decades."


title: National Health Service

text: The NHS was born out of the ideal that healthcare should be available to all, regardless of wealth. Although being freely accessible regardless of wealth maintained Henry Willink's principle of free healthcare for all, Conservative MPs were in favour of maintaining local administration of the NHS through existing arrangements with local authorities fearing that an NHS which owned hospitals on a national scale would lose the personal relationship between doctor and patient.


title: National Health Service

text: Conservative MPs voted in favour of their amendment to Bevan's Bill to maintain local control and ownership of hospitals and against Bevan's plan for national ownership of all hospitals. The Labour government defeated Conservative amendments and went ahead with the NHS as it remains today; a single large national organisation (with devolved equivalents) which forced the transfer of ownership of hospitals from local authorities and charities to the new NHS. Bevan's principle of ownership with no private sector involvement has since been diluted, with later Labour governments implementing large scale financing arrangements with private builders in private finance initiatives and joint ventures.


title: National Health Service

text: At its launch by Bevan on 5 July 1948 it had at its heart three core principles: That it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay.


title: National Health Service

text: Three years after the founding of the NHS, Bevan resigned from the Labour government in opposition to the introduction of charges for the provision of dentures, dentists, and glasses; resigning in support was fellow minister and future Prime Minister Harold Wilson. The following year, Winston Churchill's Conservative government introduced prescription fees. However, Wilson's government abolished them in 1965; they were later re-introduced but with exemptions for those on low income. These charges were the first of many controversies over changes to the NHS throughout its history.


title: National Health Service

text: From its earliest days, the cultural history of the NHS has shown its place in British society reflected and debated in film, TV, cartoons and literature. The NHS had a prominent slot during the directed by Danny Boyle, being described as "the institution which more than any other unites our nation".


title: National Health Service

text: Everyone living in the UK can use the NHS without being asked to pay the full cost of the service, though NHS dentistry and optometry do have standard charges in each of the four national health services in the UK. In addition, most patients in England have to pay charges for prescriptions though some patients are exempted.


title: National Health Service

text: Aneurin Bevan, in considering the provision of NHS services to overseas visitors wrote, in 1952, that it would be "unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody."


title: National Health Service

text: The provision of free treatment to non-UK-residents, formerly interpreted liberally, has been increasingly restricted, with new overseas visitor hospital charging regulations introduced in 2015.


title: National Health Service

text: Citizens of the EU holding a valid European Health Insurance Card and persons from certain other countries with which the UK has reciprocal arrangements concerning health care can get emergency treatment without charge.


title: National Health Service

text: The NHS is free at the point of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents. People with the right to medical care in European Economic Area (EEA) nations are also entitled to free treatment by using the European Health Insurance Card. Those from other countries with which the UK has reciprocal arrangements also qualify for free treatment. Since 6 April 2015, non-EEA nationals who are subject to immigration control must have the immigration status of indefinite leave to remain at the time of treatment and be properly settled, to be considered ordinarily resident. People not ordinarily resident in the UK are in general not entitled to free hospital treatment, with some exceptions such as refugees.


title: National Health Service

text: People not ordinarily resident may be subject to an interview to establish their eligibility, which must be resolved before non-emergency treatment can commence. Patients who do not qualify for free treatment are asked to pay in advance or to sign a written undertaking to pay, except for emergency treatment.


title: National Health Service

text: People from outside the EEA coming to the UK for a temporary stay of more than six months are required to pay an immigration health surcharge at the time of visa application, and will then be entitled to NHS treatment on the same basis as a resident. This includes overseas students with a visa to study at a recognised institution for 6 months or more, but not visitors on a tourist visa. In 2016 the surcharge was £200 per year, with exemptions and reductions in some cases. This was increased to £400 in 2018. The discounted rate for students and those on the Youth Mobility Scheme will increase from £150 to £300.


title: National Health Service

text: From 15 January 2007, anyone who is working outside the UK as a missionary for an organisation with its principal place of business in the UK is fully exempt from NHS charges for services that would normally be provided free of charge to those resident in the UK. This is regardless of whether they derive a salary or wage from the organisation, or receive any type of funding or assistance from the organisation for the purposes of working overseas. This is in recognition of the fact that most missionaries would be unable to afford private health care and those working in developing countries should not effectively be penalised for their contribution to development and other work.


title: National Health Service

text: Those who are not ordinarily resident (including British citizens who may have paid National Insurance contributions in the past) are liable to charges for services.


title: National Health Service

text: There are some other categories of people who are exempt from the residence requirements such as specific government workers and those in the armed forces stationed overseas.


title: National Health Service

text: The trade union, Unite, said back in early 2019 that the NHS had been under pressure as a result of economic austerity. A 2018 public survey reported that public satisfaction with the NHS has fallen from 70% in 2010 to 53% in 2018. The NHS is consistently ranked as the institution that makes people proudest to be British, beating the Royal family, Armed Forces and the BBC. One 2019 survey ranked nurses and doctors - not necessarily NHS staff - amongst the most trustworthy professions in the UK.


title: National Health Service

text: The systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services. About 10% of GDP is spent on health and most is spent in the public sector. The money to pay for the NHS comes directly from taxation. The 2008/09 budget roughly equates to a contribution of £1,980 per person in the UK.


title: National Health Service

text: When the NHS was launched in 1948 it had a budget of £437 million (equivalent to £ billion in ). In 2016–2017, the budget was £122.5 billion. In 1955/56 health spending was 11.2% of the public services budget. In 2015/16 it was 29.7%. This equates to an average rise in spending over the full 60-year period of about 4% a year once inflation has been taken into account. Under the Blair government spending levels increased by around 6% a year on average. Since 2010 spending growth has been constrained to just over 1% a year.


title: National Health Service

text: Some 60% of the NHS budget is used to pay staff. A further 20% pays for drugs and other supplies, with the remaining 20% split between buildings, equipment, training costs, medical equipment, catering and cleaning. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas. Since 2010, there has been a cap of 1% on pay rises for staff continuing in the same role. Unions representing doctors, dentists, nurses and other health professionals have called on the government to end the cap on health service pay, claiming the cap is damaging the health service and damaging patient care. The pay rise is likely to be below the level of inflation and to mean a real-terms pay cut. The House of Commons Library did research showing that real-terms NHS funding per head was to fall in 2018–19, and stay the same for two years afterwards.


title: National Health Service

text: There appears to be support for higher taxation to pay for extra spending on the NHS as an opinion poll in 2016 showed that 70% of people were willing to pay an extra penny in the pound in income tax if the money were ringfenced and guaranteed for the NHS. Two thirds of respondents to a King's Fund poll favour increased taxation to help finance the NHS.


title: National Health Service

text: "The Guardian" has said that GPs face excessive workloads throughout Britain and that this puts the GP's health and that of their patients at risk. The Royal College of Physicians surveyed doctors across the UK, with two-thirds maintaining patient safety had deteriorated during the year to 2018: 80% feared they would be unable to provide safe patient care in the coming year while 84% felt increased pressure on the NHS was demoralising the workforce. Jane Dacre said, "We simply cannot go through this [a winter when the NHS is badly overstretched] again. It is not as if the situation was either new or unexpected. As the NHS reaches 70, our patients deserve better. Somehow, we need to move faster towards a better resourced, adequately staffed NHS during 2018 or it will happen again." At a time when the NHS is short of doctors foreign doctors are forced to leave the UK due to visa restrictions. A study found that a fifth of doctors had faced bullying from seniors in the previous year due to pressure at work.


title: National Health Service

text: The NHS is under-resourced compared to health provisions in other developed nations. A King’s Fund study of OECD data from 21 nations, revealed that the NHS has among the lowest numbers of doctors, nurses and hospital beds per capita in the western world. Nurses within the NHS maintain that patient care is compromised by the shortage of nurses and the lack of experienced nurses with the necessary qualifications. According to a YouGov poll, 74% of the UK public believes there are too few nurses. The NHS performs below average in preventing deaths from cancer, strokes and heart disease. Staff shortages at histology departments are delaying diagnosis and start of treatment for cancer patients. In England and Scotland cancer wards and children's wards have to close because the hospital cannot attract sufficient qualified doctors and nurses to run the wards safely. Cancer patients and child patients are having to travel very long distances to get treatment and their relatives must travel far to visit the patients. In wards which have not closed staff sometimes work under stress due to staff shortages. Brexit is likely to aggravate these problems. Due to the shortage of nurses the NHS is relying on less qualified staff like healthcare assistants and nursing associates.


title: National Health Service

text: Cancer survival rates in the UK have been rising fast but probably still lag behind the best results internationally, mainly because of late diagnosis. However death rates from breast cancer are falling faster in Britain than in any other of the six largest countries in Europe, and are estimated now to have improved beyond the European average. According to Breast Cancer Care 72% of NHS trusts across the UK do not provide dedicated specialist nurses for patients with incurable breast cancer." Cancer Research UK maintains more NHS cancer personnel are needed to enable the UK to catch up The NHS in England is expanding early diagnosis services with the goal of increasing the proportion of cancers diagnosed early (at stages 1 and 2) from 53% to 75% in the decade to 2028. The NHS was the first health service in Europe to negotiate coverage for novel CAR-T cancer therapy, with agreement reached within 10 days of its European marketing authorisation.


title: National Health Service

text: In 2018, British Prime Minister Theresa May announced that NHS in England would receive a 3.4% increase in funding every year to 2024, which would allow it to receive an extra £20bn a year in real terms funding. There is concern that a high proportion of this money will go to service NHS debts rather than for improved patient care. There are calls for the government to write off the NHS debt. Saffron Cordery of NHS Providers said that hospitals needed help to do their work without being up in deficit, as two-thirds were in the year to 2018. Some expressed doubt over whether May could carry out this proposed increase in funding. The next day, Health Secretary Jeremy Hunt backed the extra £20bn annual increase in NHS funding and responded to criticism by stating that taxation would be used to carry out the funding and that details would be revealed when the next budget is unveiled in November.


title: National Health Service

text: The Institute for Fiscal Studies has stated a 5% real-terms increase was needed for real change. Paul Johnson of the IFS said the 3.4% was greater than recent increases, but less than the long-term average. Health experts maintain the money will "help stem further decline in the health service, but it's simply not enough to address the fundamental challenges facing the NHS, or fund essential improvements to services that are flagging." Inflation may erode the real value of this funding increase.


title: National Health Service

text: As part of the 2018 funding increase the UK Government asked the NHS in England to produce a 10-year plan as to how this funding would be used. On 7 January 2019, the NHS England published the NHS Long Term Plan.


title: National Health Service

text: In March 2022 Rishi Sunak doubled the annual efficiency target for the NHS in England. The 2.2 per cent target would deliver annual savings of saving of £4.75 billion. At the same time the additional covid funding is being removed in 2022-23. At the same time Sir Charles Bean, recently leader of the Office for Budget Responsibility pointed out that "the rising trend in health and social care spending and pensions will be adding something like another £75 billion spending over the next five years, £150 billion, potentially over the next decade" as if treatments are available to keep people alive longer, then people will want them.


title: National Health Service

text: The United Kingdom's exit from the European Union will affect physicians from EU countries, about 11% of the physician workforce. A survey suggested 60% of these physicians were considering leaving. Record numbers of EU nationals (17,197 EU staff working in the NHS which include nurses and doctors) left in 2016. The figures, put together by NHS Digital, led to calls to reassure European workers over their future in the UK.


title: National Health Service

text: In June 2018, the Royal College of Physicians calculated that medical training places need to be increased from 7,500 to 15,000 by 2030 to take account of part-time working among other factors. At that time there were 47,800 consultants working in the UK of which 15,700 were physicians. About 20% of consultants work less than full-time.


title: National Health Service

text: A study by the Centre for Progressive Policy called for NHS trusts to become “exemplar employers” by improving social mobility and pay especially for those "trusts in poorer places where they can play a particularly large role in determining the economic wellbeing of the local population.” They found the NHS to be " a middle ranking employer in comparison to other large organisations and falls short on social mobility and the real Living Wage", and ranked trusts using a ‘good employer index’. Ambulance trusts were ranked worst.


title: National Health Service

text: In September 2021 the Daily Telegraph carried a story saying that "nearly half of all NHS staff have no medical qualifications", being managers, administrators or unqualified assistants.


title: National Health Service

text: On 6 June 2022, the "Guardian" said that a survey of more than 20,000 frontline staff by the nurses' trade union and professional body, the Royal College of Nursing, said that only a quarter of shifts had the planned number of registered nurses on duty. The "Guardian" said that the union's general secretary, in her keynote speech at their annual congress in Glasgow, was expected to say that large numbers of nurses are leaving the profession because they are demoralised and overworked, and that they had concerns over patient safety.


title: National Health Service

text: The NHS is facing a shortage of general practitioners. From 2015 to 2022, the number of GPs has fallen by 1,622. Some family doctors have 2,500 patients each, forcing patients to attend A&E instead. Certain regions have fewer than 50 GPs per 100,000 people, while other regions have more than 70, presenting a challenge to the NHS's founding principle of equal treatment. A growing number of family doctors are reporting unsustainable workloads, and many have chosen to work part-time. A Health and Social Care spokesperson said that the department is making 4,000 training positions available for GPs every year, which help create an extra 50 million appointments annually.


title: National Health Service

text: There is concern that a disorderly Brexit may compromise patients' access to vital medicines. In February 2018 many medical organisations were planning for a worst-case Brexit scenario because "time is running out" for a transition deal to follow the UK’s formal exit, scheduled for March 2019. Pharmaceutical organisations working with the Civil Service to keep medicine supplies available in the case of a no-deal Brexit had to sign 26 Non-Disclosure Agreements (NDAs) to prevent them from giving the public information. The figures were given on 21 December 2018 after Rushanara Ali asked a parliamentary question. Ali said, "It is utterly unacceptable for the government to use non-disclosure agreements with pharmaceutical businesses and trade associations. By effectively ‘gagging’ these organisations, these secretive agreements are preventing essential information from being shared, are undermining transparency and are hampering businesses’ ability to speak out." As negotiations continue between the UK and the EU as of 1 January 2021, vulnerable people needing treatment when working, living or travelling to the UK may lose out by not having access to NHS Care.


title: National Health Service

text: Social care will cost more in future according to research by Liverpool University, University College London, and others and higher investment are needed. Professor Helen Stokes-Lampard of the Royal College of GPs said, “It’s a great testament to medical research, and the NHS, that we are living longer – but we need to ensure that our patients are living longer with a good quality of life. For this to happen we need a properly funded, properly staffed health and social care sector with general practice, hospitals and social care all working together – and all communicating well with each other, in the best interests of delivering safe care to all our patients.”


title: National Health Service

text: Some patients have to wait excessively long for mental health care. The Royal College of Psychiatrists found some must wait up to thirteen months for the right care. Wendy Burn of the Royal College of Psychiatrists said, “It is a scandal that patients are waiting so long for treatment. The failure to give people with mental illnesses the prompt help they need is ruining their lives.” Even patients who are suicidal or who have attempted suicide are sometimes denied treatment; patients are told they are not ill enough or waiting lists are too long. During very long waits for treatment, one in three patients deteriorate, and they may become unemployed or get divorced. One in four patients throughout the UK wait over three months to see an NHS mental health professional, with 6% waiting at least a year.


title: National Health Service

text: The National Audit Office found mental health provisions for children and young people will not meet growing demand, despite promises of increased funding. Even if promises to provide £1.4bn more for the sector are kept, there will be “significant unmet need” due to staff shortages, inadequate data and failure to control spending by NHS clinical commissioning groups. Currently one-quarter of young people needing mental health services can get NHS help. The Department of Health and Social Care hopes to raise the ratio to 35%. Efforts to improve mental health provisions could reveal previously unmet demand.


title: National Health Service

text: Meg Hillier of the select committee on public accounts said: "The government currently estimates that less than a third of children and young people with a diagnosable mental health condition are receiving treatment. But the government doesn’t understand how many children and young people are in need of treatment or how funding is being spent locally. The government urgently needs to set out how departments, and national and local bodies, are going to work together to achieve its long-term ambition.” Amyas Morse said, “Current targets to improve care are modest and even if met would still mean two-thirds of those who need help are not seen. Rising estimates of demand may indicate that the government is even further away than it thought."


title: National Health Service

text: In response, NHS England has embarked on a major programme to expand mental health services, whose budgets are now growing faster than the NHS overall. MIND the mental health charity responded saying: "We are pleased that the plan includes a commitment of £2.3bn a year towards mental health, to help redress the balance. The plan promises that this money will see around two million more people with anxiety, depression and other mental health problems receive help, including new parents, and 24 hour access to crisis care. The plan also includes a guarantee that investment in primary, community and mental health care will grow faster than the growing overall NHS budget so that different parts of the NHS come together to provide better, joined-up care in partnership with local government. Since the funding announcement in the summer, Mind has been working with the NHS, Government and voluntary sector to help shape the long term plan. This longer-term strategy was developed in consultation with people with mental health problems to ensure their views are reflected."


title: National Health Service

text: In November 2019 unprecedented shortages of medicines patients needed developed. Drugs to treat cancer, heart disease, Parkinson's disease, mental health conditions, some eye conditions, antibiotics for tuberculosis and drugs to control epilepsy are among those in short supply. Life saving drugs will have to be rationed and not all patients who need them will get them. Some patients can be switched onto other drugs, though this may increase the workload of hard-pressed medical staff; other patients cannot be switched to alternative drugs. Many problems can impact the supply chain, like IT failure, speculators stockpiling drugs, alterations in regulation and sudden disease outbreaks. Tony O’Sullivan of Keep Our NHS Public said: "The Health Department’s guidance includes an unprecedented list of drugs unavailable or in short supply. Patients and clinicians alike should be on high alert when the advice includes how to ‘share stocks’ to make them last, to ‘prioritise’ patients already on specific treatments including cancer rather than a new patient and effectively how to ration so many vital drugs. Drug companies’ behaviour must be controlled. We must urgently protect the NHS from further risks of loss of control of drug prices and supplies from trade deals with the US and that requires returning it to a wholly public service."


title: National Health Service

text: Performance of the NHS is generally assessed separately at the level of England, Wales, Scotland and Northern Ireland. Since 2004 the Commonwealth Fund has produced surveys, "Mirror, Mirror on the Wall", comparing the performance of health systems in 11 wealthy countries in which the UK generally ranks highly. In the 2021 survey the NHS dropped from first overall to fourth as it had fallen in key areas, including ‘access to care and equity.’ The Euro Health Consumer Index attempted to rank the NHS against other European health systems from 2014 to 2018. Civitas produced an International Health Care Outcomes Index in 2022 ranking the performance of the UK health care system against 18 similar, wealthy countries since 2000. It excluded the impact of the Covid-19 pandemic as data stopped in 2019. The UK was near the bottom of most tables except households who faced catastrophic health spending.


title: National Health Service

text: A comparative analysis of health care systems in 2010 put the NHS second in a study of seven rich countries. The report put the UK health systems above those of Germany, Canada and the US; the NHS was deemed the most efficient among those health systems studied.


title: National Health Service

text: A 2018 study by the King's Fund, Health Foundation, Nuffield Trust, and the Institute for Fiscal Studies to mark the NHS 70th anniversary concluded that the main weakness of the NHS was healthcare outcomes. Mortality for cancer, heart attacks and stroke, was higher than average among comparable countries. The NHS was doing well at protecting people from heavy financial costs when ill. Waiting times were about the same, and the management of longterm illness was better than in other comparable countries. Efficiency was good, with low administrative costs and high use of cheaper generic medicines. Twenty-nine hospital trusts and boards out of 157 had not met any waiting-time target in the year 2017–2018. The Office for National Statistics reported in January 2019 that productivity in the English NHS had been growing at 3%, considerably faster than across the rest of the UK economy.


title: National Health Service

text: In 2019, "The Times", commenting on a study in the "British Medical Journal", reported that "Britain spent the least on health, £3,000 per person, compared with an average of £4,400, and had the highest number of deaths that might have been prevented with prompt treatment". The "BMJ" study compared "the healthcare systems of other developed countries in spending, staff numbers and avoidable deaths".


title: National Health Service

text: Over 130,000 deaths since 2012 in the UK could have been prevented if progress in public health policy had not stopped due to austerity, analysis by the Institute for Public Policy Research found. Dean Hochlaf of the IPPR said: "We have seen progress in reducing preventable disease flatline since 2012."". The key NHS performance indicators (18 weeks (RTT), 4 hours (A&E) and cancer (2 week wait) have not been achieved since February 2016, July 2015 and December 2015 respectively.


title: National Health Service

text: Civitas published an International Health Care Outcomes Index in April 2022 comparing health care outcomes in global health systems across 19 comparable countries. It considered health spending, life expectancy, major disease outcomes and outcomes for treatable mortality and childbirth. Across 16 metrics with data to 2019 (or most recent available), the UK ranked at the bottom four times (stroke, heart attack and colon cancer survival), and in the bottom three eight times. No other comparable country had such a poor record. It was the best performer for one metric – the avoidance of diabetic limb amputations.


title: National Health Service

text: A ranking of individual hospitals around the world, published by Newsweek in March 2022, no NHS hospital was listed within the top 40. St Thomas' Hospital was ranked at 41, followed by University College Hospital at 54, and Addenbrooke's Hospital at 79.


title: National Health Service

text: Overall satisfaction with the NHS in 2021 fell, more sharply in Scotland than in England, 17 points to 36% – the lowest level since 1997 according to the British Social Attitudes Survey. Dissatisfaction with hospital and GP waiting times were the biggest cause of the fall.


title: National Health Service

text: The NHS Confederation polled 182 health leaders and 9 in 10 warned that inadequate capital funding harmed their “ability to meet safety requirements for patients” in health settings including hospitals, ambulance, community and mental health services and GP practices.


title: National Health Service

text: In 2020, the NHS issued medical advice in combating COVID-19 and partnered with tech companies to create computer dashboards to help combat the nation's coronavirus pandemic. During the pandemic, the NHS also established integrated COVID into its 1-1-1 service line as well. Following his discharge from the St. Thomas' Hospital in London on 13 April 2020 after being diagnosed with COVID-19, British Prime Minister Boris Johnson described NHS medical care as "astonishing" and said that the "NHS saved my life. No question." In this time, the NHS underwent major re-organisation to prepare for the COVID-19 pandemic.


title: National Health Service

text: On the 5 July 2021, Queen Elizabeth II awarded the NHS the George Cross. The George Cross, the highest award for gallantry available to civilians and is slightly lower in stature to the Victoria Cross, is bestowed for acts of the greatest heroism or most conspicuous courage. In a handwritten note the Queen said the award was being made to all NHS staff past and present for their “courage, compassion and dedication” throughout the pandemic.


title: National Health Service

text: In 2015, the UK had 2.6 hospital beds per 1,000 people. In September 2017, the King's Fund documented the number of NHS hospital beds in England as 142,000, describing this as less than 50% of the number 30 years previously. In 2019 one tenth of the beds in the UK were occupied by a patient who was alcohol-dependent.


title: National Health Service

text: NHS charity songs under various choir names have become a tradition (usually at Christmas time but not necessarily) and various formation carrying the name of NHS have released singles including:


title: Vitamin B12 deficiency

text: Vitamin B deficiency, also known as cobalamin deficiency, is the medical condition in which the blood and tissue have a lower than normal level of vitamin B. Symptoms can vary from none to severe. Mild deficiency may have few or absent symptoms. In moderate deficiency, feeling tired, anemia, soreness of the tongue, mouth ulcers, breathlessness, feeling faint, rapid heartbeat, low blood pressure, pallor, hair loss, decreased ability to think and severe joint pain and the beginning of neurological symptoms, including abnormal sensations such as "pins and needles", numbness and tinnitus may occur. Severe deficiency may include symptoms of reduced heart function as well as more severe neurological symptoms, including changes in reflexes, poor muscle function, memory problems, blurred vision, irritability, ataxia, decreased smell and taste, decreased level of consciousness, depression, anxiety, guilt and psychosis. If left untreated, some of these changes can become permanent. Temporary infertility reversible with treatment, may occur. In exclusively breastfed infants of vegan mothers, undetected and untreated deficiency can lead to poor growth, poor development, and difficulties with movement.


title: Vitamin B12 deficiency

text: Causes are usually related to conditions that give rise to malabsorption of vitamin B particularly autoimmune gastritis in pernicious anemia.


title: Vitamin B12 deficiency

text: Other conditions giving rise to malabsorption include surgical removal of the stomach, chronic inflammation of the pancreas, intestinal parasites, certain medications such as long-term use of proton pump inhibitors, H2-receptor blockers, and metformin, and some genetic disorders. Deficiency can also be caused by inadequate dietary intake such as with the diets of vegetarians, and vegans, and in the malnourished. Deficiency may be caused by increased needs of the body for example in those with HIV/AIDS, and shortened red blood cell lifespan. Diagnosis is typically based on blood levels of vitamin B below 150–180 pmol/L (200 to 250 pg/mL) in adults. A false high or normal assay may be observed. Elevated methylmalonic acid levels may also indicate a deficiency. A type of anemia known as megaloblastic anemia is often but not always present. Individuals with low or marginal values of vitamin B in the range of 148–221 pmol/L (200–300 pg/mL) may not have classic neurological or hematological signs or symptoms.


title: Vitamin B12 deficiency

text: Treatment is by vitamin B supplementation, either by mouth or by injection. Initially in high daily doses, followed by less frequent lower doses, as the condition improves. If a reversible cause is found, that cause should be corrected if possible. If no reversible cause is found, or when found it cannot be eliminated, lifelong vitamin B administration is usually recommended. A nasal spray is also available. Vitamin B deficiency is preventable with supplements, which are recommended for pregnant vegetarians and vegans, and not harmful in others. Risk of toxicity due to vitamin B is low.


title: Vitamin B12 deficiency

text: Vitamin B deficiency in the US and the UK is estimated to occur in about 6 percent of those under the age of 60, and 20 percent of those over the age of 60. In Latin America, about 40 percent are estimated to be affected, and this may be as high as 80 percent in parts of Africa and Asia. Marginal deficiency is much more common and may occur in up to 40% of Western populations.


title: Vitamin B12 deficiency

text: Vitamin B deficiency appears slowly and worsens over time, and can often be confused with other conditions. It may often go unrecognized, as the body becomes used to feeling unwell.


title: Vitamin B12 deficiency

text: Vitamin B deficiency can lead to anemia, neurological and digestive disorders. A mild deficiency may not cause any discernible symptoms, but at levels moderately lower than normal, a range of symptoms such as feeling tired, weak, lightheadedness, headaches, dizziness, rapid breathing, rapid heartbeat, cold hands and feet, low-grade fevers, tremor, cold intolerance, easy bruising and bleeding, pale skin, low blood pressure, sore tongue, upset stomach, loss of appetite, weight loss, constipation, diarrhea, severe joint pain, feeling abnormal sensations including numbness or tingling (pins and needles) to the fingers and toes, and tinnitus, may be experienced. A wide range of associated symptoms may include angular cheilitis, mouth ulcers, bleeding gums, hair loss and thinning, premature greying, a look of exhaustion and dark circles around the eyes, as well as brittle nails.


title: Vitamin B12 deficiency

text: Severe vitamin B deficiency can damage nerve cells. If this happens, vitamin B deficiency may result in sense loss, loss of sensation in the feet, difficulty walking, poor balance, blurred vision, changes in reflexes, muscle weakness, decreased smell and taste, decreased level of consciousness, mood changes, memory loss, depression, irritability, anxiety, clumsiness, confusion, psychosis and, in severe cases, dementia. Tissue deficiencies may negatively affect nerve cells, bone marrow, and the skin.


title: Vitamin B12 deficiency

text: A further complication of severe deficiency is the neurological complex known as subacute combined degeneration of spinal cord. also "myelosis funicularis", or "funicular myelosis". This complex consists of the following symptoms:


title: Vitamin B12 deficiency

text: The presence of peripheral sensory-motor symptoms or subacute combined degeneration of spinal cord strongly suggests the presence of a B deficiency instead of folate deficiency. Methylmalonic acid, if not properly handled by B, remains in the myelin sheath, causing fragility. Dementia and depression have been associated with this deficiency as well, possibly from the under-production of methionine because of the inability to convert homocysteine into this product. Methionine is a necessary cofactor in the production of several neurotransmitters. Each of those symptoms can occur either alone or with others. Vitamin B is essential for the development of the brain. Its deficiency can cause neurodevelopmental problems which can be partly reversible with early treatment. Only a small subset of dementia cases have been found to be reversible with vitamin B therapy. Tinnitus may be associated with vitamin B deficiency.


title: Vitamin B12 deficiency

text: Pernicious anemia is a disease caused by an autoimmune response that produces antibodies that attack the parietal cells in the stomach lining, preventing them from creating intrinsic factor needed for the absorption of vitamin B. It is the main and most common cause of vitamin B deficiency anemia in developed countries, and is characterized by a triad of symptoms:


title: Vitamin B12 deficiency

text: In babies, neurological symptoms can occur from malnutrition or pernicious anemia in the mother. These include poor growth, apathy, having no desire for food, and developmental regression. While most symptoms resolve with supplementation, some developmental and cognitive problems may persist.


title: Vitamin B12 deficiency

text: Vitamin B is a critical micronutrient essential for supporting the increasing metabolic demands of the foetus during pregnancy. B deficiency in pregnant women is increasingly common and has been shown to be associated with major maternal health implications, including increased obesity, higher body mass index (BMI), insulin resistance, gestational diabetes, and type 2 diabetes (T2D) in later life. A study in a pregnant white non-diabetic population in England, found that for every 1% increase in BMI, there was 0.6% decrease in circulating B. Furthermore, an animal study in ewes demonstrated that a B, folate and methionine restricted diet around conception, resulted in offspring with higher adiposity, blood pressure and insulin resistance which could be accounted for altered DNA methylation patterns.


title: Vitamin B12 deficiency

text: Both vitamin B and folate are involved in the one-carbon metabolism cycle. In this cycle, vitamin B is a necessary cofactor for methionine synthase, an enzyme involved in the methylation of homocysteine to methionine. DNA methylation is involved in the functioning of genes and is an essential epigenetic control mechanism in mammals. This methylation is dependent on methyl donors such as vitamin B from the diet. Vitamin B deficiency has the potential to influence methylation patterns in DNA, besides other epigenetic modulators such as micro (RNAs), leading to the altered expression of genes. Consequently, an altered gene expression can possibly mediate impaired foetal growth and the programming of non-communicable diseases.


title: Vitamin B12 deficiency

text: Vitamin B and folate status during pregnancy is associated with the increasing risk of low birth weight, preterm birth, insulin resistance and obesity in the offspring. In addition it has been associated with adverse foetal and neonatal outcomes including neural tube defects (NTDs) and delayed myelination or demyelination. The mother's B status can be important in determining the later health of the child, as shown in the Pune maternal Nutrition Study, conducted in India. In this study, children born to mothers with high folate concentrations and low vitamin B concentrations were found to have higher adiposity and insulin resistance at age 6. In the same study, over 60% of pregnant women were deficient in vitamin B, which was considered to increase the risk of gestational and later diabetes in the mothers. Increased longitudinal cohort studies or randomised controlled trials are required to understand the mechanisms between vitamin B and metabolic outcomes, and to potentially offer interventions to improve maternal and offspring health.


title: Vitamin B12 deficiency

text: Multiple studies have explored the association between vitamin B and metabolic disease outcomes, such as obesity, insulin resistance and the development of cardiovascular disease. A long-term study where vitamin B was supplemented across a period of 10 years, led to lower levels of weight gain in overweight or obese individuals (p < 0.05).


title: Vitamin B12 deficiency

text: There are several mechanisms which may explain the relationship between obesity and decreased vitamin B status. Vitamin B is a major dietary methyl donor, involved in the one-carbon cycle of metabolism and a recent genome-wide association (GWA) analysis showed that increased DNA methylation is associated with increased BMI in adults, consequently a deficiency of vitamin B may disrupt DNA methylation and increase non- communicable disease risk. Vitamin B is also a co-enzyme which converts methylmalonyl- CoA to succinyl-CoA in the one carbon cycle. If this reaction cannot occur, methylmalonyl- CoA levels elevate, inhibiting the rate-limiting enzyme of fatty acid oxidation (CPT1 – carnitine palmitoyl transferase), leading to lipogenesis and insulin resistance. Further to this, reduced vitamin B concentrations in the obese population is thought to result from repetitive short-term restrictive diets and increased vitamin B requirements secondary to increased growth and body surface area. It has also been hypothesised that low vitamin B concentrations in obese individuals are a result of wrong feeding habits, where individuals consume a diet low in micronutrient density. Finally, vitamin B is involved in the production of red blood cells, and vitamin B deficiency can result in anemia, which causes fatigue and the lack of motivation to exercise.


title: Vitamin B12 deficiency

text: The investigation into the relationship between cardiovascular disease (CVD) and vitamin B has been limited, and there is still controversy as to whether primary intervention with vitamin B will lower cardiovascular disease. Deficiency of vitamin B can impair the remethylation of homocysteine in the methionine cycle, and result in raised homocysteine levels. There is much evidence linking elevated homocysteine concentrations with an increased risk of cardiovascular disease, and homocysteine lowering treatments have led to improvements in cardiovascular reactivity and coagulation factors. In adults with metabolic syndrome, individuals with low levels of vitamin B had higher levels of homocysteine compared to healthy subjects. It is thus possible that vitamin B deficiency enhances the risk of developing cardiovascular disease in individuals who are obese. Alternatively, low levels of vitamin B may increase the levels of proinflammatory proteins which may induce ischaemic stroke.


title: Vitamin B12 deficiency

text: It is important to screen vitamin B deficiency in obese individuals, due to its importance in energy metabolism, and relationship with homocysteine and its potential to modulate weight gain. More studies are needed to test for the causality of vitamin B and obesity using genetic markers. A few studies have also reported no deficiency of vitamin B in obese individuals. Finally, a recent literature review conducted over 19 studies, found no evidence of an inverse association between BMI and circulating vitamin B.


title: Vitamin B12 deficiency

text: Previous clinical and population-based studies have indicated that vitamin B deficiency is prevalent amongst adults with type 2 diabetes. Kaya et al., conducted a study in women with polycystic ovary syndrome, and found that obese women with insulin resistance had lower vitamin B concentrations compared to those without insulin resistance. Similarly, in a study conducted in European adolescents, there was an association between high adiposity and higher insulin sensitivity with vitamin B concentrations. Individuals with a higher fat mass index and higher insulin sensitivity (high Homeostatic Model Assessment [HOMA] index) had lower plasma vitamin B concentrations. Furthermore, a recent study conducted in India reported that mean levels of vitamin B decreased with increasing levels of glucose tolerance e.g. individuals with type 2 diabetes had the lowest values of vitamin B, followed by individuals with pre-diabetes and normal glucose tolerance, respectively. However, B levels of middle aged-women with and without metabolic syndrome showed no difference in vitamin B levels between those with insulin resistance (IR) and those without. It is believed that malabsorption of vitamin B in diabetic patients, is due to individuals taking metformin therapy (an insulin sensitizer used for treating type 2 diabetes). Furthermore, obese individuals with type 2 diabetes are likely to develop gastroesophageal reflux disease, and take proton pump inhibitors, which further increased the risk of vitamin B deficiency.


title: Vitamin B12 deficiency

text: A recent literature review conducted over seven studies, found that there was limited evidence to show that low vitamin B status increased the risk of cardiovascular disease and diabetes. However, the review did not identify any associations between vitamin B and cardiovascular disease in the remaining four studies. Currently, no data supports vitamin B supplementation on reducing the risk of cardiovascular disease. In a dose-response meta-analysis of five prospective cohort studies, it was reported that the risk of coronary heart disease (CHD) did not change substantially with increasing dietary vitamin B intake. Of these five studies, three of the studies stated a non-significant positive association and two of the studies demonstrated an inverse association between vitamin B supplementation and coronary heart disease (only one of the studies was significant).


title: Vitamin B12 deficiency

text: Vitamin B deficiency is one of the main causes of anemia. In countries where B deficiency is common, it is generally assumed that there is a greater risk of developing anemia. However, the overall contribution of vitamin B deficiency to the global incidence of anemia may not be significant, except in elderly individuals, vegetarians, cases of malabsorption and some genetic disorders. Anemia is defined as a condition in which there are not enough red blood cells, as the tissues and organs of the body do not get enough oxygen. Megaloblastic anemia caused by vitamin B deficiency is characterized by red blood cells that are larger than normal and are unable to deliver oxygen to the body's organs. The clinical case indicates an altered synthesis of DNA, in which vitamin B is essential for the production and maturation of red blood cells in the bone marrow. Adult patients often report to medical attention symptoms related to anemia, such as feeling tired and weak, breathlessness, exercise intolerance, feeling faint, headaches, paleness, dry lips and a disturbance of taste.


title: Vitamin B12 deficiency

text: Pernicious anemia is the most common cause of vitamin B deficiency anemia in adults, which results from malabsorption of vitamin B due to a lack or loss of intrinsic factor. There are relatively few studies which have assessed the impact of haematological measures in response to B supplementation. One study in 184 premature infants, reported that individuals given monthly vitamin B injections (100 µg) or taking supplements of vitamin B and folic acid (100 µg/day), had higher haemoglobin concentrations after 10–12 weeks, compared to those only taking folic acid or those taking no vitamin B injections. In deficient Mexican adult women and pre-schoolers, it was found that vitamin B supplementation did not affect any haematologic parameters.


title: Vitamin B12 deficiency

text: In the elderly, vitamin B deficiency has been associated with the development of macular degeneration, and the risk of frailty. Macular degeneration is the leading cause of severe, irreversible vision loss in older adults. Several risk factors have been linked to macular degeneration, including family history, genetics, hypercholesterolemia, hypertension, sunlight exposure and lifestyle (smoking and diet). It has been shown that daily supplementation of vitamin B, B and folate over a period of seven years can reduce the risk of age-related macular degeneration by 34% in women with increased risk of vascular disease (n=5,204). However, another study failed to find an association between age-related macular degeneration and vitamin B status in a sample of 3,828 individuals representative of the non-institutionalized US population.


title: Vitamin B12 deficiency

text: Frailty is a geriatric condition which is characterized by diminished endurance, strength, and reduced physiological function that increases an individual's risk of mortality and impairs an individual from fulfilling an independent lifestyle. Frailty is associated with an increased vulnerability to fractures, falls from heights, reduced cognitive function and more frequent hospitalisation. The worldwide prevalence of frailty within the geriatric population is 13.9%, therefore there is an urgent need to eliminate any risk factors associated with frailty. Poor vitamin B status has been shown to be associated with an increased risk of frailty. Two cross sectional studies have reported that deficiencies of vitamin B were associated with the length of hospital stay, as observed by serum vitamin B concentrations and methylmalonic acid (MMA) concentrations [139, 140]. Furthermore, another study looking at elderly women (n=326), found that certain genetic variants associated with vitamin B status (Transcobalamin 2) may contribute to reduced energy metabolism, consequently contributing to frailty. In contrast, a recent study by Dokuzlar et al., found that there was no association between vitamin B levels and frailty in the geriatric population (n=335). Given that there are limited studies, which have assessed the relationship between vitamin B and frailty status, more longitudinal studies are needed to clarify the relationship.


title: Vitamin B12 deficiency

text: Severe vitamin B deficiency is associated with subacute combined degeneration of the spinal cord, which involves demyelination of the posterior and lateral columns of the spinal cord. Symptoms include memory and cognitive impairment, sensory loss, motor disturbances, loss of posterior column functions and disturbances in proprioception. In advanced stages of vitamin B deficiency, cases of psychosis, paranoia and severe depression have been observed, which may lead to permanent disability if left untreated. Studies have shown the rapid reversal of the neurological symptoms of vitamin B deficiency, after treatment with high-dose of vitamin B supplementation; suggesting the importance of prompt treatment in reversing neurological manifestations.


title: Vitamin B12 deficiency

text: Elderly individuals are currently assessed on vitamin B status during the screening process for dementia. Studies investigating the association between vitamin B concentrations and cognitive status have produced inconclusive results. It has been shown that elevated MMA concentrations are associated with decreased cognitive decline and Alzheimer's Disease. In addition, low vitamin B and folate intakes have shown associations with hyperhomocysteinemia, which is associated with cerebrovascular disease, cognitive decline and an increased risk of dementia in prospective studies.


title: Vitamin B12 deficiency

text: There are limited intervention studies which have investigated the effect of supplementation of vitamin B and cognitive function. A Cochrane review, analysing two studies, found no effect of vitamin B supplementation on the cognitive scores of older adults. A recent longitudinal study in elderly individuals, found that individuals had a higher risk of brain volume loss over a 5-year period, if they had lower vitamin B and holoTC levels and higher plasma and MMA levels. More intervention studies are needed to determine the modifiable effects of vitamin B supplementation on cognition.


title: Vitamin B12 deficiency

text: There has been growing interest on the effect of low serum vitamin B concentrations on bone health. Studies have found a connection between elevated plasma and an increased risk of bone fractures, but is unknown whether this is related to the increased levels of or to vitamin B levels (which are involved in homocysteine metabolism). Results from the third NHANES conducted in the United States, found that individuals had significantly lower bone mass density (BMD) and higher osteoporosis rates with each higher quartile of serum MMA (n= 737 men and 813 women). Given that poor bone mineralization has been found in individuals with pernicious anemia, and that the content of vitamin B within bone cells in culture has shown to affect the functioning of bone forming cells (osteoblasts); it is possible that vitamin B deficiency is causally related to poor bone health.


title: Vitamin B12 deficiency

text: Randomized intervention trials investigating the association of vitamin B supplementation and bone health have yielded mixed results. Two studies conducted in osteoporotic risk patients with hyperhomocysteinemia and individuals who had undergone a stroke, found positive effects between supplementation of B vitamins on BMD. However, no improvement in BMD was observed in a group of healthy older people. Further, controlled trials are needed to confirm the impact and mechanisms vitamin B deficiency has on bone mineralization.


title: Vitamin B12 deficiency

text: Vitamin B deficiency can be caused by impaired absorption, inadequate dietary intake, or increased requirements. Impaired absorption explains most cases of vitamin B deficiency, but it can also result from other factors.


title: Vitamin B12 deficiency

text: Vitamin B cannot be produced by the human body, and must be obtained from the diet. The body normally gets enough vitamin B from the consumption of foods with animal sources. Inadequate dietary intake of animal products such as eggs, meat, milk, fish, fowl (and some type of edible algae) can result in a deficiency state. Vegans, and to a lesser degree vegetarians, are at risk for B deficiency if they do not consume either a dietary supplement or vitamin-fortified foods. Children are at a higher risk for B deficiency due to inadequate dietary intake, as they have fewer vitamin stores and a relatively larger vitamin need per calorie of food intake.


title: Vitamin B12 deficiency

text: Increased needs by the body can occur due to AIDS and hemolysis (the breakdown of red blood cells), which stimulates increased red cell production.


title: Vitamin B12 deficiency

text: The total amount of vitamin B stored in the body is between two and five milligrams in adults. Approximately 50% is stored in the liver, but approximately 0.1% is lost each day, due to secretions into the gutnot all of the vitamin in the gut is reabsorbed. While bile is the main vehicle for B excretion, most of this is recycled via enterohepatic circulation. Due to the extreme efficiency of this mechanism, the liver can store three to five years worth of vitamin B under normal conditions and functioning. However, the rate at which B levels may change when dietary intake is low depends on the balance between several variables.


title: Vitamin B12 deficiency

text: The human physiology of active vitamin B absorption from food is complex. When foods containing B are eaten, the vitamin is usually bound to protein and is released by proteases released by the pancreas in the small intestine. Following its release, most B is absorbed in the ileum, the last part of the small intestine, after binding to a protein known as intrinsic factor.


title: Vitamin B12 deficiency

text: Vitamin B deficiency causes particular changes to the metabolism of two clinically relevant substances in humans:


title: Vitamin B12 deficiency

text: Methionine is activated to "S"-adenosyl methionine, which aids in purine and thymidine synthesis, myelin production, protein/neurotransmitters/fatty acid/phospholipid production and DNA methylation. 5-methyl tetrahydrofolate provides a methyl group, which is released to the reaction with homocysteine, resulting in methionine. This reaction requires cobalamin as a cofactor. The creation of 5-methyl tetrahydrofolate is an irreversible reaction. If B is absent, the forward reaction of homocysteine to methionine does not occur, homocysteine concentrations increase, and the replenishment of tetrahydrofolate stops. Because B and folate are involved in the metabolism of homocysteine, hyperhomocysteinuria is a non-specific marker of deficiency. Methylmalonic acid is used as a more specific test of B deficiency.


title: Vitamin B12 deficiency

text: Early changes include a spongiform state of neural tissue, along with edema of fibers and deficiency of tissue. The myelin decays, along with axial fiber. In later phases, fibric sclerosis of nervous tissues occurs. Those changes occur in dorsal parts of the spinal cord and to pyramidal tracts in lateral cords and are called subacute combined degeneration of spinal cord. Pathological changes can be noticed as well in the posterior roots of the cord and, to lesser extent, in peripheral nerves.


title: Vitamin B12 deficiency

text: In the brain itself, changes are less severe: They occur as small sources of nervous fibers decay and accumulation of astrocytes, usually subcortically located, and also round hemorrhages with a torus of glial cells.


title: Vitamin B12 deficiency

text: MRI of the brain may show periventricular white matter abnormalities. MRI of the spinal cord may show linear hyperintensity in the posterior portion of the cervical tract of the spinal cord, with selective involvement of the posterior columns.


title: Vitamin B12 deficiency

text: A diagnosis of vitamin B deficiency requires further investigation into its cause. There is no gold standard assay to confirm a vitamin B deficiency. Serum levels of B are often low in vitamin B deficiency, but if there are clinical signs that conflict with normal levels of vitamin B; additional investigations are justified. Deficiency is often suspected first, as diagnosis usually requires several tests. Diagnosis requires serum levels of vitamin B in the blood, levels of methylmalonic acid and/or homocysteine, and a complete blood count. Occasionally, the blood may be tested for antibodies against intrinsic factor and the parietal cells of the stomach.


title: Vitamin B12 deficiency

text: Blood tests may show low levels of vitamin B, elevated levels of methylmalonic acid and/or homocysteine, and a routine complete blood counts may shows anemia with an elevated mean cell volume. The presence of antibodies to gastric parietal cells and IF may be indicative of pernicious anemia (PA). These antibody tests can distinguish between PA and food-B malabsorption.


title: Vitamin B12 deficiency

text: Deficiency can develop without anemia or within normal vitamin B levels, methylmalonic acid and/or homocysteine assay is required. Higher levels indicate a deficiency, indicators are usually more reliable. In some cases, a peripheral blood smear may be used; which may allow to show macrocytes and hypersegmented polymorphonuclear leukocytes. Neuropsychiatric symptoms can precede hematologic signs and are often the presenting manifestation of B deficiency.


title: Vitamin B12 deficiency

text: However, elevated methylmalonic acid levels may also be related to metabolic disorders such as methylmalonic acidemia. If elevated methylmalonic acid levels are further accompanied by elevated malonic acid levels, this may be indicative of combined malonic and methylmalonic aciduria (CMAMMA).


title: Vitamin B12 deficiency

text: If nervous system damage is present and blood testing is inconclusive, a lumbar puncture to measure cerebrospinal fluid B- levels may be done. On bone marrow aspiration or biopsy, megaloblasts are seen.


title: Vitamin B12 deficiency

text: A blood test shows vitamin B levels in the blood. Vitamin B deficiency can be determined, but not always. This means it measures forms of vitamin B that are "active" and can be used by the body, as well as the "inactive" forms, which cannot. Vitamin B deficiency can be found within normal levels, so clinical symptoms should be taken into account when a diagnosis is made.


title: Vitamin B12 deficiency

text: The normal serum levels are considered to be between (200–1000 pg/mL) in adults. Vitamin B levels in humans that are 400 pg/mL or higher considered as "normal"; less than 400 pg/mL considered as "marginal deficiency"; 200 pg/ml or less considered as "deficiency". Some researchers have suggested that current standards for vitamin B levels are too low. a Japanese study showed that the normal limits should be between (500–1300 pg/mL).


title: Vitamin B12 deficiency

text: Treatment should take into account the cause and severity of the condition. The duration and course of treatment may vary. Depending on the cause, treatment may need to be lifelong. Treatment is done by vitamin B supplementation, either by mouth or by injection. Initially in high daily doses, followed by less frequent lower doses, as the condition improves. More serious vitamin B deficiency requires injections initially. When supplements given orally in high doses (1 or 2 mg), absorption is not dependent on intrinsic factor or intact ileum; instead, 1% to 5% may be absorbed along the entire intestine by passive diffusion.


title: Vitamin B12 deficiency

text: If vitamin B deficiency exists with folate deficiency, vitamin B should be replaced first to prevent subacute combined degeneration of the spinal cord which, if left untreated, can cause lasting serious side effects that affect the nervous system and brain.


title: Vitamin B12 deficiency

text: Vitamin B deficiency is common and occurs worldwide. In the US and UK, around 6 percent of the general population have the deficiency; in those over the age of sixty, around 20 percent are deficient. In under-developed countries, the rates are even higher: across Latin America 40 percent are deficient; in some parts of Africa, 70 percent; and in some parts of India, 70 to 80 percent.


title: Vitamin B12 deficiency

text: According to the World Health Organization (WHO), vitamin B deficiency may be considered a global public health problem affecting millions of individuals. However, the incidence and prevalence of vitamin B deficiency worldwide is unknown due to the limited population-based data available (see table below).


title: Vitamin B12 deficiency

text: Developed countries such as the United States, Germany and the United Kingdom have relatively constant mean vitamin B concentrations. The data from the National Health and Nutrition Examination Survey (NHANES) reported the prevalence of serum vitamin B concentrations in the United States population between 1999 and 2002. Serum vitamin B concentrations of < 148 pmol/L was present in < 1% of children and adolescents. In adults aged 20–39 years, concentrations were below this cut-off in ≤ 3% of individuals. In the elderly (70 years and older), ≈ 6% of persons had a vitamin B concentration below the cut-off.


title: Vitamin B12 deficiency

text: Furthermore, ≈ 14–16% of adults and > 20% of elderly individuals showed evidence of marginal vitamin B depletion (serum vitamin B: 148–221 pmol/L). In the United Kingdom, a National Diet and Nutrition Survey (NDNS) was conducted in adults aged between 19 and 64 years in 2000–2001 and in elderly individuals (≥ 65 years) in 1994–95. Six percent of men ("n" = 632) and 10% of women ("n" = 667) had low serum vitamin B concentrations, defined as < 150 pmol/L. In a subgroup of women of reproductive age (19 to 49 years), 11% had low serum B concentrations < 150 pmol/L ("n" = 476). The prevalence of vitamin B deficiency increased substantially in the elderly, where 31% of the elderly had vitamin B levels below 130 pmol/L. In the most recent NDNS survey conducted between 2008 and 2011, serum vitamin B was measured in 549 adults. The mean serum vitamin B concentration for men (19–64 years) was 308 pmol/L, of which 0.9% of men had low serum B concentrations < 150 pmol/L. In women aged between 19 and 64 years, the mean serum vitamin B concentration was slightly lower than men (298 pmol/L), with 3.3% having low vitamin B concentrations < 150 pmol/L. In Germany, a national survey in 1998 was conducted in 1,266 women of childbearing age. Approximately, 14.7% of these women had mean serum vitamin B concentrations of < 148 pmol/L.


title: Vitamin B12 deficiency

text: Few studies have reported vitamin B status on a national level in non-Western countries. Of these reported studies, vitamin B deficiency was prevalent among school- aged children in Venezuela (11.4%), children aged 1–6 years in Mexico (7.7%), women of reproductive age in Vietnam (11.7%), pregnant women in Venezuela (61.34%) and in the elderly population (> 65 years) in New Zealand (12%). Currently, there are no nationally representative surveys for any African or South Asian countries. However, the very few surveys which have investigated vitamin B deficiency in these countries have been based on local or district level data. These surveys have reported a high prevalence of vitamin B deficiency (< 150 pmol/L), among 36% of breastfed and 9% of non-breastfed children ("n" = 2482) in New Delhi and 47% of adults ("n" = 204) in Pune, Maharashtra, India. Furthermore, in Kenya a local district survey in Embu ("n" = 512) revealed that 40% of school-aged children in Kenya had vitamin B deficiency.


title: Vitamin B12 deficiency

text: Between 1849 and 1887, Thomas Addison described a case of pernicious anemia, William Osler and William Gardner first described a case of neuropathy, Hayem described large red cells in the peripheral blood in this condition, which he called "giant blood corpuscles" (now called macrocytes), Paul Ehrlich identified megaloblasts in the bone marrow, and Ludwig Lichtheim described a case of myelopathy. During the 1920s, George Whipple discovered that ingesting large amounts of liver seemed to most rapidly cure the anemia of blood loss in dogs, and hypothesized that eating liver might treat pernicious anemia. Edwin Cohn prepared a liver extract that was 50 to 100 times more potent in treating pernicious anemia than the natural liver products. William Castle demonstrated that gastric juice contained an "intrinsic factor" which when combined with meat ingestion resulted in absorption of the vitamin in this condition. In 1934, George Whipple shared the 1934 Nobel Prize in Physiology or Medicine with William P. Murphy and George Minot for discovery of an effective treatment for pernicious anemia using liver concentrate, later found to contain a large amount of vitamin B.


title: Vitamin B12 deficiency

text: Ruminants, such as cattle and sheep, absorb B synthesized by their gut bacteria. Sufficient amounts of cobalt and copper need to be consumed for this B synthesis to occur.


title: Vitamin B12 deficiency

text: In the early 20th century, during the development for farming of the North Island Volcanic Plateau of New Zealand, cattle had what was termed "bush sickness". It was discovered in 1934 that the volcanic soils lacked the cobalt salts essential for synthesis of vitamin B by their gut bacteria. The "coast disease" of sheep in the coastal sand dunes of South Australia in the 1930s was found to originate in nutritional deficiencies of the trace elements, cobalt and copper. The cobalt deficiency was overcome by the development of "cobalt bullets", dense pellets of cobalt oxide mixed with clay given orally, which then was retained in the animal's rumen.


title: The Last of the Mohicans

text: The Last of the Mohicans: A Narrative of 1757 is a historical romance written by James Fenimore Cooper in 1826.


title: The Last of the Mohicans

text: It is the second book of the "Leatherstocking Tales" pentalogy and the best known to contemporary audiences. "The Pathfinder", published 14 years later in 1840, is its sequel. "The Last of the Mohicans" is set in 1757, during the French and Indian War (the North American theater of the Seven Years' War), when France and Great Britain battled for control of North America. During this war, both the French and the British used Native American allies, but the French were particularly dependent, as they were outnumbered in the Northeast frontier areas by the British. Specifically, the events of the novel are set immediately before, during, and after the Siege of Fort William Henry.


title: The Last of the Mohicans

text: The novel is set primarily in the area of Lake George, New York, detailing the transport of the two daughters of Colonel Munro, Alice and Cora, to a safe destination at Fort William Henry. Among the caravan guarding the women are the frontiersman Natty Bumppo, Major Duncan Heyward, singing teacher David Gamut, and the Indians Chingachgook and Uncas, the latter two being the novel's title characters. These characters are sometimes seen as a microcosm of the budding American society, particularly with regard to their racial composition.


title: The Last of the Mohicans

text: The novel has been one of the most popular English-language novels since its publication and is frequently assigned reading in American literature courses. It has been adapted numerous times and in many languages for films, TV movies, and cartoons.


title: The Last of the Mohicans

text: At the time of Cooper's writing, many U.S. settlers believed and perpetuated the myth that Native Americans were disappearing, believing they would ultimately be assimilated or killed off entirely due to the genocidal structure of settler colonialism. Especially in the East, as Native Peoples' land was stolen and settled on in the name of U.S. expansion and Jeffersonian agrarianism, the narrative that many Native Peoples were "vanishing" was prevalent in both novels like Cooper's and local newspapers. This allowed settlers to view themselves as the original people of the land and reinforced their belief in European ethnic and racial superiority through, among other beliefs, the tenets of scientific racism. In this way, Cooper was interested in the American progress narrative when more colonists were increasing pressure on Native Americans, which they, and Cooper, would then view as "natural".


title: The Last of the Mohicans

text: Cooper grew up in Cooperstown, New York, which his father had established on what was then a western frontier settlement, which had developed after the Revolutionary War.


title: The Last of the Mohicans

text: Cooper set this novel during the Seven Years' War, an international conflict between Great Britain and France, which had a front in North America known by the Anglo-American colonists as the French and Indian War. The conflict arrayed American settlers and minimal regular forces against royal French forces, with both sides also relying on Native American allies. The war was fought primarily along the frontiers of the British colonies from Virginia to Nova Scotia.


title: The Last of the Mohicans

text: In the spring of 1757, Lieutenant Colonel George Monro became garrison commander of Fort William Henry, located on Lake George in the Province of New York. In early August, Major General Louis-Joseph de Montcalm and 7,000 troops besieged the fort. On 2 August General Webb, who commanded the area from his base at Fort Edward south of the lake, sent 200 regulars and 800 Massachusetts militia to reinforce the garrison at William Henry. In the novel, this is the relief column with which Monro's daughters travel.


title: The Last of the Mohicans

text: Monro sent messengers south to Fort Edward on 3 August requesting reinforcements, but Webb refused to send any of his estimated 1,600 men north because they were all that stood between the French and Albany. He wrote to Munro on 4 August that he should negotiate the best terms possible; this communication was intercepted and delivered to Montcalm. In Cooper's version, the missive was being carried by Bumppo when he, and it, fell into French hands.


title: The Last of the Mohicans

text: On 7 August Montcalm sent men to the fort under a truce flag to deliver Webb's dispatch. By then the fort's walls had been breached, many of its guns were useless, and the garrison had taken significant casualties. After another day of bombardment by the French, Monro raised the white flag and agreed to withdraw under parole.


title: The Last of the Mohicans

text: When the withdrawal began, some of Montcalm's Indian allies, angered at the lost opportunity for loot, attacked the British column. Cooper's account of the attack and aftermath is lurid and somewhat inaccurate. A detailed reconstruction of the action and its aftermath indicates that the final tally of British missing and dead ranges from 70 to 184; more than 500 British were taken captive.


title: The Last of the Mohicans

text: Cora and Alice Munro, daughters of Lieutenant Colonel Munro, are traveling with Major Duncan Heyward from Fort Edward to Fort William Henry, where Munro is in command, and acquire another companion in David Gamut, a singing teacher. They are guided through the forest by a native named Magua, who leads them through a shortcut unaccompanied by the British militia. Heyward is dissatisfied with Magua's shortcut, and the party roams unguided and finally join Natty Bumppo (known as Hawk-eye), a scout for the British, and his two Mohican friends, Chingachgook and his son Uncas. Heyward becomes suspicious of Magua, and Hawk-eye and the Mohicans agree with his suspicion, that Magua is a Huron scout secretly allied with the French. Upon discovery as such, Magua escapes, and in the (correct) belief that Magua will return with Huron reinforcements, Hawk-eye and the Mohicans lead their new companions to a hidden cave on an island in a river. They are attacked there by the Hurons, and their ammunition is soon exhausted. Knowing they will be killed instantly but that the English party will make valuable captives, Hawk-eye and the Mohicans escape, with a promise to return for their companions.


title: The Last of the Mohicans

text: Magua and the Hurons capture Heyward, Gamut, and the Munro sisters. Magua admits that he is seeking revenge against Cora's father, Colonel Munro, for turning him into an alcoholic with whiskey (causing him to be temporarily cast out of the Hurons) and then whipping him at a post for drunken behavior. He offers to spare the party if Cora becomes his wife, but she refuses. Upon a second refusal, he sentences the prisoners to death. Hawk-eye and the Mohicans rescue all four and lead them to a dilapidated building that was involved in a battle between the Huron and the British some years ago. They are nearly attacked again, but the Hurons leave the area, rather than disturb the graves of their tribesmen.


title: The Last of the Mohicans

text: The next day, Hawk-eye leads the party to Fort Henry, past a siege by the French army. Munro sends Hawk-eye to Fort Edward for reinforcements, but he is captured by the French, who deliver him to Fort Henry without the letter. Heyward returns to Colonel Munro and announces his love for Alice, and Munro gives his permission for Heyward's courtship. The French general, Montcalm, invites Munro to a parley and shows him General Webb's letter, in which the British general has refused reinforcements. At this, Munro agrees to Montcalm's terms: that the British soldiers, together with their women and children, must leave the fort and withdraw from the war for eighteen months. Outside the fort, the column of British evacuees is betrayed and ambushed by 2,000 Huron warriors; in the ensuing massacre, Magua kidnaps Cora and Alice, and he leads them toward the Huron village, with David Gamut in pursuit.


title: The Last of the Mohicans

text: Hawk-eye, the Mohicans, Heyward, and Colonel Munro survive the massacre and set out to follow Magua, and cross a lake to intercept his trail. They encounter a band of Hurons by the lakeshore, who spot the travelers. A canoe chase ensues, in which the rescuers reach land before the Hurons can kill them, and eventually follow Magua to the Huron village. Here, they find Gamut (earlier spared by the Hurons as a harmless madman), who says that Alice is held in this village and Cora in one belonging to the Lenape (Delaware).


title: The Last of the Mohicans

text: Disguised as a French medicine man, Heyward enters the Huron village with Gamut to rescue Alice; Hawk-eye and Uncas set out to rescue Cora, and Munro and Chingachgook remain in safety. Uncas is taken prisoner by the Hurons and left to starve when he withstands torture, and Heyward fails to find Alice. A Huron warrior asks Heyward to heal his lunatic wife, and both are stalked by Hawk-eye in the guise of a bear. They enter a cave where the madwoman is kept, and the warrior leaves. Soon after the revelation of his identity to Heyward, Hawk-eye accompanies him, and they find Alice. They are discovered by Magua, but Hawk-eye overpowers him, and they leave him tied to a wall. Thereafter Heyward escapes with Alice, while Hawk-eye remains to save Uncas. Gamut convinces a Huron to allow him and his magical bear (Hawk-eye in disguise) to approach Uncas, and they untie him. Uncas dons the bear disguise, Hawk-eye wears Gamut's clothes, and Gamut stays in a corner mimicking Uncas. Uncas and Hawk-eye escape by traveling to the Delaware village where Cora is being held, just as the Hurons suspect something is amiss and find Magua tied up in the cave. Magua tells his tribe the full story behind Heyward and Hawk-eye's deceit before assuming leadership of the Hurons, who vow revenge.


title: The Last of the Mohicans

text: Uncas and Hawk-eye are being held prisoner with Alice, Cora, and Heyward by the Delawares. Magua enters the Delaware village and demands the return of his prisoners. During the ensuing council meeting, Uncas is revealed to be a Mohican, a once-dominant tribe closely related to the Delawares. Tamenund, the sage of the Delawares, sides with Uncas and frees the prisoners, except Cora, whom he awards to Magua according to tribal custom. This makes a showdown between the Hurons and Delawares inevitable, but to satisfy laws of hospitality, Tamenund gives Magua a three-hour head start before pursuit. While the Delawares are preparing for battle, David Gamut escapes the Huron village and tells his companions that Magua has positioned his men in the woods between the Huron and Delaware villages. Undeterred, Uncas, Hawk-eye, Heyward, Gamut, and the Delawares march into the woods to fight the Hurons.


title: The Last of the Mohicans

text: In the ensuing battle, the Delawares are joined by Chingachgook and Munro, and ultimately vanquish the Hurons and capture their village, but Magua escapes with Cora and two other Hurons; Uncas, Hawk-eye, Heyward, and Gamut pursue them up to a high mountain. In a fight at the edge of a cliff, one of the Hurons kills Cora, Gamut kills one of the Hurons, Magua kills Uncas, and Hawk-eye kills Magua. The novel concludes with a lengthy account of the funerals of Uncas and Cora at the Delaware village, and Hawk-eye reaffirms his friendship with Chingachgook. Tamenund prophesies: "The pale-faces are masters of the earth, and the time of the red-men has not yet come again..."


title: The Last of the Mohicans

text: According to Susan Fenimore Cooper, the author's eldest daughter, Cooper first conceived the idea for the book while visiting the Adirondack Mountains in 1825 with a party of English gentlemen. The party passed through the Catskills, an area with which Cooper was already familiar, and about which he had written in his first novel featuring Natty Bumppo: "The Pioneers." They passed on to Lake George and Glens falls.


title: The Last of the Mohicans

text: Impressed with the caves behind the falls, one member of the party suggested that "here was the very scene for a romance." Susan Cooper says that Edward Smith-Stanley, 14th Earl of Derby, made this remark. Cooper promised Stanley "that a book should be written, in which these caves should have a place; the idea of a romance essentially Indian in character then first suggesting itself to his mind."


title: The Last of the Mohicans

text: Cooper began work on the novel immediately. He and his family stayed for the summer in a cottage belonging to a friend, situated on the Long Island shore of the Sound, opposite Blackwell's Island, not far from Hallett's Cove (the area is now part of Astoria). He wrote quickly and completed the novel in the space of three or four months. He suffered a serious illness thought to have been brought on by sunstroke and, at one point, he dictated the outline of the fight between Magua and Chingachgook (12th chapter), to his wife, who thought that he was delirious.


title: The Last of the Mohicans

text: In the novel, Hawkeye refers to Lake George as the "Horican". Cooper felt that Lake George was too plain, while the French name, "Le Lac du St. Sacrement", was "too complicated". Horican he found on an old map of the area; it was a French transliteration of a native group who had once lived in the area.


title: The Last of the Mohicans

text: Cooper grew up in Cooperstown, New York, the frontier town founded by his father. His daughter said that as a young man he had few opportunities to meet and talk with Native Americans: "occasionally some small party of the Oneidas, or other representatives of the Five Nations, had crossed his path in the valley of the Susquehanna River, or on the shores of Lake Ontario, where he served when a midshipman in the navy." He read what sources were available at the time—Heckewelder, Charlevoix, William Penn, Smith, Elliot, Colden, Lang, Lewis and Clark, and Mackenzie.


title: The Last of the Mohicans

text: By using the name Uncas for one of his characters, he seemed to confuse the two regional tribes: the Mohegan of Connecticut, of which Uncas had been a well-known sachem, and the Mohican of upstate New York. The popularity of Cooper's book helped spread the confusion.


title: The Last of the Mohicans

text: In the period when Cooper was writing, deputations from the Western tribes frequently traveled through the region along the Mohawk River, on their way to New York or Washington, D.C. He made a point of visiting these parties as they passed through Albany and New York. On several occasions, he followed them to Washington to observe them for longer. He also talked to the military officers and interpreters who accompanied them.


title: The Last of the Mohicans

text: The novel was first published in 1826 by Carey & Lea, of Philadelphia. According to Susan Cooper, its success was "greater than that of any previous book from the same pen" and "in Europe, the book produced quite a startling effect."


title: The Last of the Mohicans

text: Over time the book grew to be regarded by some as the first Great American Novel. It was not always the case. Cooper's novels were popular in their day, but contemporary and subsequent 19th-century reviewers were often critical, or dismissive. For example, the reviewer of the "London Magazine" (May 1826) described the novel as "clearly by much the worst of Mr. Cooper's performances." Mark Twain notably derided the author in his essay "Fenimore Cooper's Literary Offenses", published in "North American Review" (July 1895). Twain complained that Cooper lacked a variety of styles and was overly wordy. In the early 1940s, Twain scholar Bernard DeVoto found that there was more to the essay, and pieced together a second one from the extra writing, titled "Fenimore Cooper's Further Literary Offenses," in which Twain re-writes a small section of "The Last of the Mohicans", claiming that Cooper, "the generous spendthrift", used 100 "extra and unnecessary words" in the original version.


title: The Last of the Mohicans

text: Re-reading the book in his later years, Cooper noted some inconsistencies of plot and characterization, particularly the character of Munro. But, he wrote that in general, "the book must needs have some interest for the reader since it could amuse even the writer, who had in a great measure forgotten the details of his work."


title: The Last of the Mohicans

text: "The Last of the Mohicans" has been James Fenimore Cooper's most popular work. It has influenced popular opinion about American Indians and the frontier period of eastern American history. The romanticized images of the strong, fearless, and ever-resourceful frontiersman (i.e., Natty Bumppo), as well as the stoic, wise, and noble "red man" (i.e., Chingachgook), were notions derived from Cooper's characterizations more than from anywhere else. The phrase, "the last of the Mohicans", has come to represent the sole survivor of a noble race or type. Critic Evan Lang Pandya calls "The Last of the Mohicans" "the premier crystallization of the Frontier myth in American letters—the great-great-grandfather, twice removed, of the Western."


title: The Last of the Mohicans

text: In the "M*A*S*H" book, film and television franchise, the character Hawkeye Pierce is given his nickname by his father, after Hawk-eye from "The Last of the Mohicans". A main character in the original and subsequent film adaptation, Hawkeye, as portrayed by Alan Alda, is the central character in the long-running TV series.


title: The Last of the Mohicans

text: A number of films have been based on the lengthy book, making various cuts, compressions, and changes. The American adaptations include:


title: The Last of the Mohicans

text: The 1920 film has been deemed "culturally significant" by the Library of Congress and selected for preservation in the United States National Film Registry. According to the director Michael Mann, his 1992 version was based more on the 1936 film version. Mann believes Cooper's novel is "not a very good book", taking issue with Cooper's sympathy for the Euro-Americans and their seizure of the American Indians' domain.


title: The Last of the Mohicans

text: In Germany, , with Béla Lugosi as Chingachgook, was the second part of the two-part film released in 1920. "The Last Tomahawk" directed by Harald Reinl was a 1965 West German/Italian/Spanish co-production setting elements of the story in the era after the American Civil War. Based on the same series of the novels, ("Chingachgook the Great Serpent"), starring Gojko Mitić as Chingachgook, appeared in East Germany in 1967, and became popular throughout the Eastern Bloc.


title: The Last of the Mohicans

text: Marvel Comics has published two versions of the story: in 1976 a one-issue version as part of their "Marvel Classics Comics" series (issue #13). In 2007, they published a six-issue mini-series to start the new "Marvel Illustrated" series.


title: The Last of the Mohicans

text: Famed manga artist Shigeru Sugiura wrote and illustrated a very loose manga adaptation of the story in 1952-3 (remade in 1973–4). This adaptation is heavily influenced by American movies and western comics and is filled with absurd humor and anachronistic jokes. An English translation of Sugiura's 1973-4 version including a lengthy essay on Sugiura's artistic influences was published in the United States in 2013.


title: Bad Teacher

text: Bad Teacher is a 2011 American comedy-drama film directed by Jake Kasdan from a screenplay by Lee Eisenberg and Gene Stupnitsky. Starring Cameron Diaz, Justin Timberlake, Lucy Punch, John Michael Higgins and Jason Segel, the film tells the story of a lazy middle school teacher who hates her job, her students, and her co-workers who is forced to return to teaching to make enough money for breast implants after her wealthy fiancé dumps her. "Bad Teacher" was released in the United States on June 24, 2011 by Columbia Pictures. It grossed $216.2 million against a $20 million budget.


title: Bad Teacher

text: Elizabeth Halsey is a lazy, immoral, manipulative, gold-digging Chicago teacher at John Adams Middle School who curses at her students, drinks heavily, smokes marijuana and lets her kids watch movies so she can sleep through class. She plans to quit teaching and marry her wealthy fiancé, but he dumps her when his mother shows him that Elizabeth is only after his money, so she resumes her job. She tries to win over wealthy substitute teacher Scott Delacorte. Her dedicated and enthusiastic colleague Amy Squirrel also pursues him while Elizabeth rejects advances from the school's gym teacher, Russell Gettis.


title: Bad Teacher

text: Elizabeth plans to have her breasts enlarged and becomes more motivated to do so upon learning Scott's ex-girlfriend had large breasts. However, she cannot afford the $9,300 procedure. Elizabeth attempts to raise money for the surgery through the 7th grade car wash, wearing provocative clothing and manipulating parents to give her money for more school supplies and tutoring, but her efforts are not enough. Amy informs the principal about Elizabeth's embezzlement, but he dismisses her claims when no evidence is provided. Scott also admits that he is attracted to Amy and only likes Elizabeth as a friend.


title: Bad Teacher

text: Discovering that the teacher of the class with the highest state test scores will receive a $5,700 bonus, Elizabeth decides to change her style of teaching, forcing the class to intensely study "To Kill a Mockingbird" for the test. However, since it is late in the school year, combined with her unorthodox teaching methods, the students score low on the book quizzes, further frustrating her. Meanwhile, she befriends Russell, as Amy and Scott start dating.


title: Bad Teacher

text: Elizabeth plans to steal the state test answers by impersonating a journalist and seducing Carl Halabi, a state professor in charge of creating and distributing the exams. She convinces Carl to go into his office to have sex, but drugs him and steals the answer key. A month later Elizabeth wins the bonus, completing her needed funds, and books her breast enlargement.


title: Bad Teacher

text: When Elizabeth learns that Amy and Scott are chaperoning an upcoming field trip, she smears an apple with poison ivy and leaves it for Amy, who ends up with blisters covering her face and cannot go. On the trip, Elizabeth seduces Scott. They dry hump and Elizabeth secretly leaves Amy a message through Scott's phone, recording all the action. However, Scott's ever-changing ideals disappoint Elizabeth. After her student Garrett is taunted by his classmates for confessing to an unrequited attraction to a superficial girl in the class named Chase, Elizabeth consoles him and helps make him popular, which prompts her to begin reflecting on her own superficial ways.


title: Bad Teacher

text: Back at the school, Amy switches Elizabeth's desk with her own to trick the janitor into unlocking Elizabeth's sealed drawer. The evidence Amy finds leads her to suspect Elizabeth cheated on the state exam. Amy informs the principal and gets Carl to testify against her. However, Elizabeth took embarrassing photos of Carl while he was drugged and uses them to blackmail him to say she is innocent. Having been informed that her desk was switched, Elizabeth states that teachers in the school use drugs. When the police bring a sniffer dog to search the school, they find Elizabeth's mini liquor bottles, marijuana and OxyContin pills in Amy's classroom, in Elizabeth's desk, leading to Amy getting arrested and transferred to another school by the superintendent. Scott asks Elizabeth to start over, but she rejects him in favor of Russell, having learned they have a lot in common.


title: Bad Teacher

text: When the new school year starts, Elizabeth reformed. She is kinder to her co-workers, and has started a relationship with Russell, and did not get her breasts enlarged because she feels that it is unnecessary. Elizabeth also has a new position as the new guidance counselor.


title: Bad Teacher

text: "Bad Teacher" is directed by Jake Kasdan based on a screenplay by Lee Eisenberg and Gene Stupnitsky. Columbia Pictures purchased Eisenberg and Stupnitsky's spec script in August 2008. In May 2009, Kasdan was hired to direct "Bad Teacher". The following December, Cameron Diaz was cast in the film's lead role. Justin Timberlake was cast opposite Diaz in March 2010, and filming began later in the month.


title: Bad Teacher

text: The film grossed $100.3 million in the U.S. and Canada, while its worldwide total stands at $216.2 million. Documents from the Sony Pictures hack revealed the film turned a profit of $64 million.


title: Bad Teacher

text: The film was released in North America on June 20, 2011, in 3,049 theaters. It took in $12,243,987—$4,016 per theater—in its opening day, and grossed a total of $31,603,106 in its opening weekend, finishing second at the box office, behind "Cars 2". In Germany, the film reached No. 1 on the country's Cinema Charts in its opening week after 496,000 people saw the film. This caused "Kung Fu Panda 2", which reached No. 1 the week before, to fall to No. 2.


title: Bad Teacher

text: On "Rotten Tomatoes", the film has an approval rating of 45% based on 192 reviews and a rating average of 5.3/10. The site's critical consensus reads, "In spite of a promising concept and a charmingly brazen performance from Cameron Diaz, "Bad Teacher" is never as funny as it should be." "Metacritic" gave the film a score of 47 out of 100 based on 38 critics, indicating "mixed or average reviews". "CinemaScore" polls reported that moviegoers gave the film an average grade of "B+" on an A+ to F scale.