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NHS under fire over closure plans

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NHS England is facing growing criticism over its stewardship of the 44 sustainability and transformation plans (STPs) that are proposing service closures and other changes to health and social care services across the country.

Local representatives from the NHS and local authorities have been drawing up plans since December 2015, when NHS England set them a deadline of 21 October 2016 to submit draft proposals to meet the triple aim of improving health, improving care, and saving money.

Friction has emerged since this deadline after four local councils opted to publish their local plans in draft form before they had been approved by NHS England and the regulator NHS Improvement, as they were concerned about the lack of transparency in the process.

The heat on NHS England intensified after a survey of clinical commissioning groups by the Health Service Journal showed that almost half of STP areas planned to reduce the number of hospital beds and a third planned to close or downgrade a local emergency department.

Tajek Hassan, president of the Royal College of Emergency Medicine, said the mooted closures would be “potentially

catastrophic and will put lives at risk.” He said, “The hospital bed base is already one of the lowest per head in the Western world, and to reduce bed numbers and close more emergency departments will not only add to the pressure but undoubtedly compromise safety in those that remain open.”

So far four local councils have published their STPs in draft form: Hartlepool (Durham, Darlington, Tees, Hambleton, Richmondshire and Whitby STP), Sutton (South West London STP), Birmingham City (Birmingham and Solihull STP), and Camden (North Central London STP).

Christopher Akers-Belcher, leader of Hartlepool Borough Council, said that he had written to NHS England expressing “serious concerns” about the lack of transparency in the process.

Sarah Hayward, leader of Camden Council, said, “There has been no political oversight and minimal public and patient engagement.”

An NHS England spokesperson said, “It is hardly a secret that the NHS is looking to make major efficiencies, and the best way of doing so is for local doctors, hospitals, and councils to work together.” Gareth Iacobucci, The BMJCite this as: BMJ 2016;355:i5898

More bed closures would compromise safety further, said Tajek Hassan, president of the Royal College of Emergency Medicine

the bmj | 5 November 2016 211

C O N S E N T page 212 • W O L B A C H I A page 213 • F O R M U L A M O N E Y page 214

SEVEN DAYS IN

Cancer Cancer strategy ambitions are unlikely to be met A shortage of skilled staff and adequate resources means that the ambitions of England’s five year cancer strategy are unlikely to be met, the Royal College of Radiologists warned. When the strategy was published last July the college highlighted the “dire state of radiology services,” and its position statement on progress to date concluded, “Fifteen months on and radiology services are in no better state at all. In fact, all the indicators of vacancy rates, the vast spend on outsourcing, and increasing workloads point to services under even more stress.”

Safety Anaesthetists are concerned about safe care A third of anaesthetists in UK hospitals find it hard to deliver safe and effective patient care because of a wide ranging lack of resources, showed a study by the Royal College of Anaesthetists. They blamed a demoralised, fatigued workforce, inadequate facilities, disengagement, and lack of cooperation by

management, saying that the lack of qualified staff restricts delivery of safe and effective patient care.

Research news Industry studies rarely link sugary drinks to obesity Research studies funded by sugar sweetened drink makers are significantly less likely to link sugary drinks to obesity or diabetes related outcomes than independently funded studies,

a review in Annals of Internal Medicine found. All 26 studies that found no link had funding ties to industry. But only one of the 34 studies (2.9%) to find a link

between sugar sweetened drinks and obesity or diabetes was supported by industry. (doi: 10.1136/bmj.i5852 )

Brexit UK researchers are not yet affected by Brexit A dedicated government inbox for reports of discrimination against UK researchers caused by the country’s decision to leave the EU has not received any concrete examples, MPs heard. Jo Johnson, minister for universities, science, research, and innovation, told the science

and technology committee that he had had 132 emails, two thirds relating to funding issues that had been dealt with. “The remaining third were questions related to mobility. We are still listening and looking for evidence of concrete discrimination,” he said. (doi: 10.1136/bmj.i5811 )

Dementia Few know dementia risk factors More than a quarter (28%) of the British public cannot correctly identify any potentially modifiable risk factor for developing dementia (depicted below in the film Iris, about Iris Murdoch), showed findings from the British Social Attitudes survey. It studied whether people could identify heavy drinking, smoking, high blood pressure, depression, or diabetes as risk factors, as well as the protective factor of taking regular exercise, and just 2% identified all of them.

NHS trusts risk a dramatic rise in litigation payouts unless they change the way they obtain patients’ consent to operations, the Royal College of Surgeons has warned, a� er a landmark case in the UK Supreme Court.

The judgment last year in Montgomery v Lanarkshire Health Board requires doctors to explore the risks of proposed treatments and alternatives much more thoroughly with patients. But the college fears that this message may not have � ltered through, and it has issued new guidance to help surgeons adapt their processes.

The judgment came in the case of Nadine Montgomery, whose baby was le� with cerebral palsy as a result of shoulder dystocia during delivery. Montgomery (le� , with son Sam) was just over 1.5m tall and had diabetes, putting her at risk of having a large baby, but her obstetrician said that she did not warn women with diabetes of the risk of shoulder dystocia because they would opt for caesarean sections.

Leslie Hamilton, a cardiac surgeon and college council member, said: “Hospitals and medical sta� are leaving themselves very vulnerable to expensive litigation and increased payouts by being slow to change the way the consent process happens.”

Trusts risk litigation without full consent

Clare Dyer, The BMJ Cite this as: BMJ 2016;355:i5840

212 5 November 2016 | the bmj

Down’s syndrome Safer, non-invasive prenatal test launched A new prenatal blood test for Down’s, Edwards, and Patau syndromes will be rolled out from 2018, the Department of Health announced. Each year around 10 000 pregnant women considered at raised risk of carrying a baby with one of these syndromes are currently offered amniocentesis, which carries a small risk of miscarriage. Introducing the blood test could cut the number of women undergoing amniocentesis from 7900 to 1400 a year and reduce the number of test related miscarriages from 46 to around 3.

Doctor morale GMC warns of doctors’

“state of unease” A state of unease

exists in the medical profession, as well

as a dangerous level of alienation among junior

doctors, the General Medical Council warned in its sixth annual report on UK medical education and practice. Terence Stephenson, GMC chair, said that the situation may affect

Clock changes Daylight saving time is linked to depression Putting the clocks back in autumn is linked to an 11% higher rate of unipolar depressive episodes, research in Epidemiology found. But the research found no change in incidence of unipolar depressive episodes when clocks were put forward to summertime, and clock changes had no effect on incidence of bipolar disorder. (doi: 10.1136/bmj.i5857 )

Stroke care Music making can aid stroke recovery A pilot programme by the Royal Philharmonic Orchestra and Hull Integrated Community Stroke Service (Strokestra) showed that music making can benefit stroke survivors and carers. Some 86% of patients reported improvements in cognition, emotional wellbeing, and symptom relief, and 71% of patients reported physical benefits.

Cite this as: BMJ 2016;355:i5871

WOL-WHAT-IA? Wolbachia is a genus of bacteria that occurs in 60% of insects worldwide. The reason it’s of particular interest at the moment is that Wolbachia species signi� cantly reduce the ability of mosquitoes to replicate viruses such as Zika and dengue that they pass on to humans.

THAT’S ZIKA SORTED, THEN Unfortunately not. Wolbachia doesn’t occur naturally in Aedes aegypti , the species of mosquito that transmits Zika as well as dengue and chikungunya viruses to humans.

THEN WHY WAFFLE ON ABOUT WOLBACHIA ? Researchers have pioneered a way to transfer Wolbachia into Aedes mosquitoes. Field trials that released squadrons of Wolbachia carrying mosquitoes into areas of Australia, Brazil, Colombia, Indonesia, and Vietnam stopped local transmission of mosquito-borne viral diseases. Because the viruses could no longer replicate, the primed mosquitoes could not pass them on.

ALL VERY WELL, BUT WHAT HAPPENS WHEN THE WOLBACHIA CARRIERS DIE? The Wolbachia carrying mosquitoes breed with local mosquitoes and pass the bacteria to the resulting o� spring. Within a few months most mosquitoes in an area carry Wolbachia . So the e� ect is self sustaining, with no need for further release of infected mosquitoes.

BUT COULD WOLBACHIA POSE A NEW HEALTH THREAT? Laboratory research shows that Wolbachia bacteria are too big to travel down mosquitoes’ salivary ducts and into the human bloodstream during biting. And experiments with hardy volunteers found no antibodies to Wolbachia in their blood even a� er three years of giving themselves up to bites at regular intervals.

WHAT NEXT FOR THESE VACCINATED BLOODSUCKERS? Researchers are planning trials in large urban areas of Brazil and Colombia over the next two to three years to measure the e� ectiveness of using mosquitoes to � ght the diseases they can pass on, including Zika, dengue, and chikungunya.

Susan Mayor, The BMJ Cite this as: BMJ 2016;355:i5847

SIXTY SECONDS ON . . . WOLBACHIA

SPEND ON HEALTHThe UK spent £179bn on healthcare in 2014,

or 9.9% of GDP, and ranked 6th of the G7 countries for healthcare expenditure, show figures from the Office for National Statistics


MEDICINEThe study examined the incidence of hospital appointments for unipolar and bipolar disorder episodes in Denmark when the clocks changed

patients as well as doctors. “The signals of distress are unmistakeable. There appears to be a general acceptance that the system cannot simply go on as before,” he said. (doi: 10.1136/bmj.i5804 )

Budget cuts increase strain on emergency departments The government must urgently tackle underfunding in adult social care to relieve pressure on emergency departments, said the Commons Health Committee in its winter planning report. Unless the shortfall in social care provision is dealt with, it said, people will continue to face avoidable admission and delayed discharge from hospital.

Death rates Performance ratings do not show poor surgeons Publishing patient death rates of individual surgeons in England is unlikely to highlight those whose mortality rates are above average because case loads vary so much, an analysis in BMJ Open found. Performance within the “expected” range is too crude a measure to detect doctors whose practice may be a cause for concern and therefore creates a false sense of security, said the researchers.

The Royal College of Paediatrics and Child Health (RCPCH) has rejected calls from its membership to stop accepting funding from formula milk companies.

Instead, it will continue to allow funding under clearly pre-specified conditions with a rigorous and robust set of safeguards in place, which it said the majority of its members had supported in a consultation. The council of the college announced the decision along with the results of the consultation, which had a 16% response rate (2522).

In the consultation 650 paediatricians voted that the RCPCH should not accept any funding from companies that market or manufacture specialist milk formula, but 698 said that it should accept such funding after due diligence. Another 1083 said that it should accept funding with due diligence and further safeguards.

The college said in a statement, “RCPCH consulted its members on its relationships with formula milk companies (FMCs). The majority of those that responded felt that the college should accept funding from FMCs and allow them to advertise at conferences and events, but only with a robust set of safeguards in place. This decision was subsequently ratified by RCPCH council.

“RCPCH has a due diligence document with a series of policies that will inform decisions on whether or not to accept FMC funding. These policies are publicly available and contain robust criteria to ensure that the RCPCH retains its reputation as an unbiased, independent educator and advocate for child health.”

Neena Modi, president of the college, told The BMJ that the decision would mean that the college’s annual conference would no longer have a “headline” sponsor by a baby milk manufacturer. Instead, a new “Children’s Fund” will allow industry to support the college’s work without having a conflict of interest. And policies on

funding for education and research projects will allow funding from FMCs as long as strict conditions are met.

In April, 66 delegates at the RCPCH’s annual general meeting voted in favour of a motion that urged it to decline any commercial transactions or other funding from all companies that market breast milk substitutes.

Patti Rundall, policy director of the campaign group Baby Milk Action, said that the results of the survey were “really disappointing” but emphasised that hundreds

of paediatricians had voted in the consultation to reject any funding by FMCs.

“We really hope that this decision will not set the clock

back and that the effectiveness of the new rules will be regularly reviewed,” said Rundall.

Charlotte Wright, who had proposed the April motion, said that she was very unhappy, as she and others believed that the college was misleading members about the probity of its actions.

She criticised the members’ survey, saying, “It was a very confusing and badly designed survey, the wording of which was not consulted on and which gave the very biased impression that ‘due diligence’ would avoid the possibility of accepting inappropriate funding.

“The recent World Health Assembly resolution (see box) very clearly stated that professional organisations should not accept any funding from formula milk firms—not that it was fine after ‘due diligence.’ This was the chance for the RCPCH to take an ethical lead, and they have opted instead for more income at the price of children’s health.”Jacqui Thornton, London Cite this as: BMJ 2016;355:i5827


Paediatricians vote for college to continue accepting funds from infant formula companies

This was the chance for the RCPCH to take an ethical lead, and they have opted instead for more income at the price of children’s health

General practices in England achieved 95% of their available Quality and Outcomes Framework (QOF) points last year, figures from NHS Digital have shown:

PRACTICES achieved an average score of 532.9 QOF points out of 559 in 2015-16. This was a slight increase from the average of 529.6 points out of 559 in 2014-15.

OBESITY and chronic kidney disease were last year’s biggest achievers earning 99.9% of available points. The lowest level of achievement was for osteoporosis, at 87.5%.

MAXIMUM of 559 points was achieved by 640 practices in 2015-16. In 2014-15 448 practices achieved the maximum.

General practices achieved 95% of QOF points last year

Neena Modi, RCPCH president: New fund will allow industry to support the college’s work without conflicts of interest

Patti Rundall, from Baby Milk Action: We hope the new rules are regularly reviewed

CONDITIONS with the highest prevalence were again hypertension (13.8%), obesity (9.5%), and depression (8.3%).

HYPERTENSION (7.9 million people), obesity (4.3 million), and depression (3.8 million) had the highest patient numbers last year. In 2014-15 hypertension (7.8 million), obesity (4.2 million), and asthma (3.4 million) were commonest.

DEPRESSION (up by 470 168) and obesity (up by 132 222) saw the largest increases in patient numbers.

Gavin Jamie, a GP in Swindon who runs the QOF Database website, said that GPs had achieved “a very steady set of figures.”

He said, “There have been consistent high levels of achievement by practices. Prevalence

has remained stable, although obesity recording has risen by a little over 5% over the year.”

QOF was introduced as part of the new general medical services contract for GPs in 2004 to reward practices for the quality of care, but it is to be phased out and replaced with a new scheme over the next 18 months.Gareth Iacobucci, The BMJCite this as: BMJ 2016;355:i5834

A senior surgeon jailed for manslaughter after a delay in operating on a patient with a perforated bowel should not have been convicted of causing or significantly contributing to the

patient’s death, three judges at the Court of Appeal were told this week.

The patient, James Hughes, was taking an anticoagulant that could have caused him to bleed to death if David Sellu had operated on him earlier, Mark Ellison QC, for Sellu, told the court in the surgeon’s appeal against his conviction.

Sellu, a senior consultant colorectal surgeon, was sentenced to two and a half years in prison in November 2013 for contributing to Hughes’s death in February 2010 at the Clementine Churchill Hospital in Harrow, north London. The conviction and sentence, of which Sellu served half in prison and half on licence, has caused widespread alarm among doctors.

Hughes had knee replacement surgery at the hospital, run by BMI Healthcare, on 5 February 2010. Sellu, 69, who did private operations at the hospital alongside his NHS job at Ealing Hospital NHS Trust, was asked to step in when Hughes fell unexpectedly ill with abdominal pains six days later.

Hughes was first seen by Sellu just after 9 pm on 11 February and was taken to theatre just after 10 pm on 12 February. He died on 14 February 2010, nine days after his knee operation.

Ellison said that it had been overlooked at Sellu’s trial that Hughes was taking the anticoagulant dabigatran, which at the time had no antidote. If Hughes had been operated on during the period when Sellu was accused of being grossly negligent for not operating, the presence of dabigatran created a high risk of surgical haemorrhage, carrying a significant risk of death, the QC added.

The new evidence is crucial because, for a manslaughter conviction, the prosecution must prove not only that the doctor was grossly negligent but that this negligence caused or significantly contributed to the patient’s death. The judgment will be given at a later date.

Judges hear senior surgeon’s appeal against manslaughter conviction

The conviction has caused widespread alarm among doctors

WHO has tightened its code on marketing breast milk substitutes, and in May the World Health Assembly recommended that health professional associations should not allow such companies to sponsor meetings of health professionals and scientific meetings.

WHO’s new code aimed to end inappropriate promotion of foods for infants and young children and to promote, protect, and support breast feeding; prevent obesity and non-communicable diseases;

promote healthy diets; and ensure that caregivers receive clear and accurate information on feeding.

The World Health Assembly said that the new guidance clarified that, to protect, promote, and support breast feeding, the marketing of “follow-up formula” and “growing-up milks”—targeted for consumption by babies aged 6 months to 3 years—should be regulated in the same way as infant formula for babies aged 0-6 months.

WORLD HEALTH ORGANIZATION CODE ON INFANT FORMULA

Companies that made huge increases in the prices the NHS pays for out-of-patent medicines are facing an inquiry by the Competition and Markets Authority (CMA).

The CMA announced the investigation into “suspected unfair pricing by way of charging excessive prices in the supply of certain pharmaceutical products” without naming any of the companies being investigated.

But the Times newspaper, which has run a series of investigative stories about generic drug pricing, reported that Concordia

International, one of the companies featured in the stories, had confirmed that it was under investigation.

Concordia, formerly known as AMCo, was formed by the private equity company Cinven in a merger of two existing companies. One of them had been selling the thyroid drug carbimazole to the NHS at a constant price since 2004. After the formation of AMCo the price of a pack of 20 mg tablets rose from £25.12 in October 2012 to £261.92 in March 2016. Nigel Hawkes, LondonCite this as: BMJ 2016;355:i5849

Probe into drug price hikes


Clare Dyer, The BMJCite this as: BMJ 2016; 355:i5812


Having spent seven years at the General Medical Council, Niall Dickson has been in the post longer than

he planned. “I originally thought I would do six years here, because that’s the same time I did at the King’s Fund,” he says, “and now it’s been seven so I think I’ve done my stint.”

After a brief spell as a history teacher, Dickson spent his early career as a journalist, and is described by colleagues from that time as both ambitious and highly respected. A true specialist in the field of health and social affairs, Dickson’s move to the King’s Fund in 2004 was not a surprise to those who knew him.

“Good fit” at GMCIn 2010 Dickson moved to the GMC and, although this was a further step away from journalism, former colleagues say that it was a good fit for someone who cared deeply about transparency and accountability in the NHS. For now, however, he is taking a break from the world of healthcare, though he hasn’t yet decided what shape the next chapter of his working life will take.

During his time at the GMC Dickson oversaw shifts in the regulator’s role; the introduction of revalidation; and an increase in the organisation’s responsibility for postgraduate medical training.

More recently the GMC has faced calls for it to be funded by taxpayers rather than doctors. Dickson is clear that the current funding system is key to preserving the regulator’s independence.

State funding would, he says, mean state control over the GMC. “I think our independence is one of those precious British compromises,” he says.

The regulator’s independence from government may occasionally be questioned by the profession, Dickson says, but in his experience it has never wavered. “Would I say that government ministers, from all parts of the UK, have tried to influence us in one form or another? Of course they have. But have they ever told us what to do and have we ever done it? The answer is no.”

Successor and controversyWhen it was announced in July that Charlie Massey, a director general at the Department of Health in England, would be replacing Dickson as chief executive, the regulator’s independence was once again called into question (see p 231). However, Dickson says that it would be wrong to confuse Massey’s previous roles with a professional affiliation to a political party or government.

“Charlie Massey has advised Labour ministers, Liberal Democrat ministers, and Conservative ministers. He cannot be held responsible for all of their decisions because actually they made different decisions,” Dickson says. “Charlie Massey needs to be judged on his record at the GMC, his record as a civil servant is what it is—as a civil servant. He has not been responsible, as a civil servant, for government policy, nor is he responsible for the ministers who make that policy.”

Dickson says that it was unfortunate timing for Massey to be

appointed while tensions were still high between junior doctors and the government.

Like many other organisations, the GMC faced criticism from doctors over its behaviour during the contract dispute. The regulator issued guidance for junior doctors taking part in industrial action—something that the BMA said was inappropriate. The GMC also wrote to the BMA following the announcement of escalation of industrial action to five days, asking it not to go ahead with the action.

“I think there’s no doubt that we’ve taken a hit from the industrial dispute. There are a lot of doctors who are angry and frustrated about that,” Dickson says.

Next steps for the GMCOne of the GMC’s key future roles will be to ensure standards for the education and training of junior doctors. “The new educational guidance is tougher on employers,” Dickson says. “The proof of the pudding will be if the GMC enforces the new guidance.”

GMC independence is a Great British compromiseNiall Dickson, outgoing chief executive and registrar of the General Medical Council, talks to Abi Rimmer about maintaining the GMC’s independence, his successor, and rebuilding the trust of doctors

I hope that doctors in training will come to see the GMC as an ally


Reena AggarwalSpecialty trainee year 6 in obstetrics and gynaecology at Queens Hospital, London, Aggarwal is working under the terms and conditions of the new contract but as a higher trainee remains on the old pay scale and has not yet signed a new contract.

“It’s been fairly painless so far but I think that’s because no one really knows what’s happening,” she says. “In terms of exception reporting and things like that, I’ve spoken to a couple of my consultants and they’ve been looking at the BMA

advice and the amount of workload there is for educational supervisors seems to have increased quite a lot. I think everyone is unsure how that is going to work out.

“The rotas haven’t changed dramatically: it’s still pretty much the same rota. They have made some stipulations that you have to have 48 hours’ rest after three night shifts so that’s changed; previously we had 47 hours so we now have the appropriate amount of rest.”

Natalie CrawfordCrawford, a specialty trainee year 3 in obstetrics and gynaecology in Southampton, has signed her new contract. “I think we’ve been really well looked after in Southampton by the trust,” she says. “Our guardian has been fantastic, she’s been really visible, and she holds a meeting every week that we’re welcome to go to. We also have one of our junior consultants, who was a trainee not that long ago, overseeing the rota and making sure that it works as well as it can for our department.

“In terms of take home pay, my overall extra is less than £200 a month under the new contract and that’s not going to change for the next however many years.

“In terms of patient safety, it’s really difficult because the contract is a blanket contract for all specialties. Departments for different specialties all work so differently but if there can be some flexibility and common sense then potentially it will be a good thing.

“I was trying to reassure my partner. He works in cardiothoracic surgery, which is a lifestyle, not just a job. If we do take this new contract seriously perhaps it will be acceptable to come to work, enjoy it, be good at it, and give your patients the best care—but not have it be your entire life.”

Edward MullinsA specialty trainee year 6 in obstetrics and gynaecology at Queen Charlotte’s and Chelsea Hospital, London, Mullins has signed a new contract but as a higher trainee remains on the old pay scales.

“The new contract is a compromise and, as with the previous contract, has mechanisms to produce results which are likely to have unforeseen consequences,” he says. “We will see immediately those who will be paid less, but we don’t yet know

how measures such as exception reporting will work in practice. I have taken the view that this is the best we will get, that there will be no further negotiation, and that the BMA has little additional influence to exert at the present time.

“Our predecessors negotiated their contracts to reduce the deleterious impact on staff and patients of excessive working hours. With our contract, the desired outcomes for doctors were never clearly identified, whereas our employers had clear objectives to achieve a more flexible workforce for no extra money.”Abi Rimmer, BMJ Careers [email protected] this as: BMJ 2016;355:i5906

In terms of tackling services that are struggling under rising demand, Dickson says that progress has been made in North Middlesex, where the GMC intervened after concerns were raised about its emergency department. But he says that there are still hundreds of other hospitals that could potentially have problems that need investigating. “There’s a limit to what a regulator can do if the service is coming under more and more pressure. That’s the question for the whole system, as well as the GMC—how do you manage this?”

Protecting and supporting doctors in training is, Dickson says, a key part of the GMC’s role, because ultimately it means protecting patients. But, he says, providing that protection and support is more difficult now than it has been in the past. “I hope that doctors in training, despite the soreness that they currently feel, will come to see the GMC as an ally, in the sense that our job is to protect their education and training environment.”Abi Rimmer, BMJ Careers [email protected] this as: BMJ 2016;355:i5905

How is the new junior doctor contract working in practice?Since October, obstetrics trainees have been working under the new junior doctors’ contract. Abi Rimmer talks to some about how it has been going

NIALL DICKSON CV1976-78 Broughton High School, Edinburgh, teacher of history1978 National Corporation of the Care of Old People, publicity officer1979-80 Age Concern England, press office1980-81 Age Concern England, head of publishing1981-83 Macmillan Publishers, editor, Therapy Weekly1983-88 Macmillan Publishers, editor, Nursing Times1988-89 BBC, health correspondent, radio news1989-95 BBC, chief social affairs correspondent1995-2003 BBC, social affairs editor2004-09 King’s Fund, chief executive2010-16 General Medical Council, chief executive and registrar

Last Saturday Mexico City held a huge parade for the Day of the Dead, inspired by a scene in last year’s James Bond film Spectre.

Does the increasing commercialisation of ways to honour the dead, and to celebrate life’s finiteness, help us to discuss our own certain end? A recent British survey on death and dying found that although more than two thirds of respondents said that they would be comfortable talking about their death, more than two fifths had not discussed their wishes.

About two thirds of respondents to the British Social Attitudes survey said that they would prefer to die at home, but the most recent data from the Office for National Statistics show that only about a fifth of us achieve this.Richard Hurley, features and debates editor, The BMJCite this as: BMJ 2016;355:i5897

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THE BIG PICTURE

Celebrating death


EDITORIAL

Assessing flow limitation in stable anginaHas simple coronary angiography had its day?

Appropriate use of revascularisation in stable angina depends on cardiologists being able to discriminate

flow limiting coronary atherosclerotic lesions from those that are merely bystanders. Studies over the past decade have shown that flow limitation can be accurately assessed by using a pressure wire to measure fractional flow reserve (FFR)—the ratio of distal to proximal pressures during maximal hyperaemia induced by adenosine infusion.

When validated against non-invasive stress testing, a threshold FFR of 0.75 was found to discriminate ischaemic from non-ischaemic flow limitation, although to maximise sensitivity a value of 0.8 is usually used in practice.2 In the Defer study, published in 2007, risk of death or myocardial infarction was less than 1% a year (over five years) among patients with a single lesion and an FFR >0.75. Stenting did not decrease this risk.3

In the FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) 2 trial, FFR was measured across all stenoses in 1220 patients with stable angina. Patients with any lesions defined as flow limiting (FFR ≤0.80) were randomised to percutaneous coronary intervention and drug treatment or drugs alone. The trial was stopped early in response to a higher rate of urgent revascularisation in those randomised to drug treatment alone. This trial was unblinded so findings should be interpreted with caution, but at two years, there was still a lower rate of urgent revascularisation in the percutaneous coronary intervention group.4 The UK RIPCORD study and a French registry study found that pressure wire assessment of patients with stable angina changed the management plan in one quarter of cases in the UK and nearly one half in France.5 6

These data have already led to a European class 1a recommendation for the use of FFR in guiding treatment decisions.7 They also raise important questions about how patients with stable coronary artery disease should be investigated.

Combined assessmentIt seems clear that initial angiographic assessment of patients with stable angina should be combined with pressure wire assessment when possible, but adoption of such a policy would require major reorganisation of cardiology services in most healthcare systems. Pressure wire evaluation of coronary lesions carries a higher risk of complications than simple angiography and requires the availability of immediate “bailout” stenting. The combined evaluation therefore has to be done by trained interventional cardiologists. However, in the UK, for example, the roughly 740 interventional cardiologists could not cope with the estimated 247 000 coronary angiograms done annually.

Initial non-invasive ischaemia testing could ensure that angiography and revascularisation

are targeted appropriately without the need for large numbers of pressure wire studies. This might also allow patients with high burdens of ischaemia (most likely to require revascularisation) to be directed to interventional cardiologists for possible pressure wire evaluation while those with lower risk results could be investigated by cardiologists trained in angiography alone.

But even when ischaemia testing and angiography are available, it can be difficult to decide which lesions are flow limiting. FFR is currently the only tool that can be used to assess multiple lesions in multiple vessels. Computed tomographic coronary angiography also looks promising, but further clinical validation is required.8

Best optionPerhaps the best option is to make pressure wire evaluation available at the time of initial diagnostic angiography for all patients being assessed by angiographers who are able to do it. This would require that patients consent to a small extra risk and that funding is available to cover the costs. When angiography is performed by non-interventional cardiologists, further assessment by pressure wire will often be required before percutaneous intervention is planned.

Concerns remain about the many lesions currently left untreated because angiography suggests that it is not needed. An unknown proportion would prove flow limiting if FFR was measured, and these patient are being denied effective treatment. For now, however, we do not have the staff to offer pressure wire evaluation of coronary lesions to all those who might benefit, and coronary angiography alone will remain the mainstay of initial treatment allocation in patients with stable coronary artery disease.Cite this as: BMJ 2016;355:i5534Find this at: http://dx.doi.org/10.1136/bmj.i5534SP

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Jonathan N Townend professor [email protected] F Ludman consultantSagar N Doshi consultantHamid Khan clinical fellow, Department of Cardiology, Queen Elizabeth Hospital, BirminghamPatrick A Calvert consultant, Department of Cardiology, Papworth Hospital, Cambridge, UK

Perhaps the best option is to make pressure wire evaluation available at the time of initial diagnostic angiography


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EDITORIAL

General practice is making a leap in the dark New models of working risk throwing the baby out with the bathwater

A strong case is being made in many countries that the traditional model of general practice

needs to change. Critics claim that practices are too small and too isolated, that they are increasingly unable to meet their patients’ needs and expectations, and are unfit to lead the necessary redesign of health systems.1 2 As general practice in the UK in particular struggles with a demoralised workforce and inadequate resources,3 these criticisms are being taken on board. Quietly but rapidly, and in a largely ad hoc fashion, general practice is changing; small practices are closing or merging with other practices, practice networks are forming, the primary care workforce is becoming increasingly multidisciplinary, and new integrated models of care that bring together community and hospital based services are being developed.

Possible consequencesMany of these changes may be good for patients and for the health system, but insufficient attention is being paid to the possible unintended consequences. One substantial risk should be exercising policy makers but is not doing so: that the emerging new models may not deliver the same benefits to patients and the health system as the traditional model.

We know that health systems with a strong focus on general practice deliver better outcomes at lower cost than those that are more specialist oriented. Starfield and others have shown that effective general practice is associated with better outcomes (including life expectancy, early

detection of cancer, and reduced deaths from cardiovascular disease), better system performance (including fewer hospital admissions, lower cost, and reduced health inequalities), and better patient experience (including high rates of satisfaction and trust).4 5 The evidence, although observational, seems consistent over time and across different health systems.

What are the likely mechanisms by which general practice achieves such important outcomes?6 7 Firstly, it provides accessible care to all communities, including those with the greatest need and the greatest scope for improvement. Secondly, given that a large proportion of health is socially determined,8 the “whole person” orientation of general practice care is more likely to be effective than the disease orientation of most medical specialties. Thirdly, in dealing with uncertainty and managing risk, general practice reduces the likelihood, consequences, and the costs of overmedicalisation. Fourthly, while specialists are generally better at adhering to single disease guidelines, generalists are more effective at dealing with the growing epidemic of multimorbidity. Finally, general practice care is more likely to focus on prevention and on enabling patients to look after their own health. A commitment to continuity of care and general practitioners’ sense of responsibility for individual patients underpins these mechanisms.9

Unanswered questionPolicy makers and health system leaders should be asking whether changes to the structure, governance, and working processes of general practice will enable it to continue

to deliver these benefits. The jury is not just out on this question; it has not even been convened. We simply do not know whether clinicians who have not had an opportunity to build a personal trusting relationship with their patients because they work in large organisations will be as effective at preventing unnecessary investigations or referrals. We do not know what effect moving experienced medical generalists back from the front line of care will have on the effective use of resources. We do not know whether working as an employee in larger organisations will engender the same level of good will (a poorly valued asset) as does working independently in a small practice. And we do not know whether better access to diagnostic facilities and to medical specialists in community settings will result in over use and higher costs.

These are fundamental questions that researchers need to answer. To do this we must ensure that published evidence about how to organise and deliver health services is mobilised in a way that is useful to decision makers.10

We also need strong commitment to evaluating the new models, building on early research into the nature and impact of scale recently published by the Nuffield Trust.12 When there is uncertainty about the best way forward, action can be based on past experience and good theory. But rigorous evaluation using the full range of available theories and methods is essential. In the absence of this commitment, the NHS is at serious risk of throwing the baby of general practice out with the bathwater of health service reform.Cite this as: BMJ 2016;355:i5698Find this at: http://dx.doi.org/10.1136/bmj.i5698

Martin Marshall, professor of healthcare improvement, Department of Primary Care and Population Health, UCL Sir Ludwig Guttman Centre, London E20 1AS, UK [email protected] Pereira Gray emeritus professor, University of Exeter, Exeter, UK

Critics claim that practices are too small and too isolated

Small: no longer beautiful?


BMJ CONFIDENTIAL

Paul MarksLast doctor-only coroner

Paul Marks is a neurosurgeon who was a consultant at Leeds General Infirmary for 20 years until, in 2012, he switched careers to become coroner for the East Riding of Yorkshire and Hull. He was the last coroner to be appointed before new rules required a legal qualification. As a surgeon he specialised in spinal surgery, vascular problems, and pituitary disease and was elected Hunterian professor by the Royal College of Surgeons in 1994 for his research on pituitary tumours. His long interest in medicolegal issues led him to work in the coronial service.

What was your earliest ambition?At school I wanted to be a cathedral organist, but I realised that I’d have to perform pieces by composers whose works I couldn’t stand—Britten, Walton, Tippett, Berkeley. At university I wanted to be a neurosurgeon or a forensic pathologist.Who has been your biggest inspiration?Tom King at the London Hospital, for capturing my interest in neurosurgery; Roger Whittaker, coroner for West Yorkshire, for appointing me to coronial office and training me; and Chris Lavy, for introducing me to international surgical work.What was the worst mistake in your career?Seeing a retractor slip during anterior cervical surgery and perforate the common carotid artery. Fortunately, I repaired it by direct suture.What was your best career move?Reading law at Cardiff Law School, as it allowed me to pursue a second career and motivated me to set up courses to teach elements of law to doctors.Bevan or Hunt? Who has been the best and the worst health secretary?In 1989 I was at a prestigious US clinic where I witnessed a 30 year old pregnant woman with high cord compression due to a meningioma, who was anaesthetised and about to have surgery, being woken up because she didn’t have insurance. I realised how fortunate we are to have the NHS, so for me Bevan was the best.Who is the person you would most like to thank, and why?My father, for impressing on me the importance of study but balancing it with other interests and hobbies.If you were given £1m what would you spend it on?I’d buy an operating microscope for the neurosurgical department of the Queen Elizabeth Central Hospital in Blantyre, Malawi, where I’m honorary professor, and I’d put the remainder in trust to sponsor surgeons to visit the unit.Where are or were you happiest?Sitting on the veranda at the family villa in Kefalonia, with a cold beer, looking out at the Ionian Sea.What single unheralded change has made the most difference in your field?The enactment of the Coroners and Justice Act which said that all coroners would have to be legally qualified as well, which I believe was a serious mistake.What is your most treasured possession?My 1957 Leica M3, which I use for black and white photography.What personal ambition do you still have?To set up an NHS facility to produce generic surgical instruments. Where does alcohol fit into your life?I adhere to the old adage that a person doesn’t have a problem with alcohol if he drinks less than his doctor.What is your pet hate?Colleagues whose confidence is inversely proportional to their ability.What would be on the menu for your last supper?Tuscan sausage pasta, followed by fillet steak with a Roquefort sauce, washed down with copious quantities of Primitivo.Cite this as: BMJ 2016;355:i5824

ILLUSTRATION: DUNCAN SMITH


Since the NHS was created, the patients it treats have become increasingly diverse. But some patients, perhaps because of their

age, sex, or ethnicity, have worse experiences than others—for example, in unequal access to care, variation in health outcomes, or care that is not tailored to their needs.

The NHS is one of the most multicultural employers in England, but lack of diversity in its leadership is a barrier to it achieving its full potential.

Elitist leadershipNHS leadership, often criticised for being elitist, does not reflect and therefore cannot truly represent the diversity of its patient population or its workforce. Although non-white people make up about 14% of the general population,1 in 2013 only 5.8% of NHS board members in England had a black, Asian, or other minority ethnic (BAME) background.2

Women are also hugely under-represented among senior NHS leadership: only 36% of chief executives and 24% of medical directors are women—but women account for 77% of NHS staff overall.3

The late American entrepreneur Malcolm Forbes described diversity as “the art of thinking independently together.” Imagine the potential for more ideas that greater diversity in NHS leadership could bring.

THE NHS IF . . .

What if NHS leaders were more diverse? Having senior levels representative of patients would enable more innovation, writes Vijaya Nath

Better performanceMore diversity could bring more understanding of the needs and opinions of users and staff, encouraging more creativity in problem solving and greater innovation. Evidence from sectors outside healthcare indicates that diverse leadership may even improve institutional performance. The management consultant McKinsey found that companies with more female board members, or more ethnically diverse boards, tended to outperform their peers financially.4 This moves us beyond moral arguments for diversity in top leadership.

There are no quick fixes; indeed, in London, the proportion of BAME board members actually fell between 2006 and 2014.2 Individual organisations need to alter attitudes that act as barriers to more inclusive leadership, including challenging unconscious bias and identifying the diversity that already exists among the leadership to work out “who’s missing.” This can then inform recruitment strategies, which might, for example, ban all-male shortlists.

Of course, diversity is not just about sex and ethnicity. For the NHS to keep up with future demands, including an ageing patient population, representatives of different age groups should inform leadership.

Local youth forumWhat if each NHS organisation had a community led board, informed by a council of elders as well as a local youth forum? What if the board and executive team truly represented the patient population they serve in terms of sex, ethnicity, and age? How might this affect the quality of care, equity of access, and the appropriateness of patient centred care for local needs?

In the current NHS, individual egos loom large, but more diversity could lead to a more inclusive and tolerant culture in general. The current composition of NHS leadership cannot propel it to achieve the successes that the future demands. We need current leaders to commit to change.Vijaya Nath, director of leadership development, Leadership Foundation for Higher Education, London WC1X 8LZ [email protected] this as: BMJ 2016;355:i5828

COMPETITION: WRITE YOUR OWN “THE NHS IF . . .” ESSAYThis extract by Vijaya Nath is from one of a series of essays published by the King’s Fund under the title “The NHS if . . .” to explore hypothetical future scenarios for the health service and their impact.

The King’s Fund is holding a competition for people to write their own “The NHS if . . .” essay. An expert panel of judges, including The BMJ’s editor in chief, Fiona Godlee, and NHS England’s chief executive, Simon Stevens, will select the winning essay, which will be published by the King’s Fund and for publication in The BMJ. Find out more at www.kingsfund.org.uk/reports/thenhsif/competition

14% Non-white people in the general population

5.8%Of NHS board members in England with a black, Asian, or other minority ethnic background

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In 1876, George Eliot wrote, “Attempts at description are stupid: who can all at once describe a human being? Even when he is presented to us we

only begin that knowledge of his appearance which must be completed by innumerable impressions under differing circumstances. We recognise the alphabet; we are not sure of the language.”1

In just such a way, evidence based medicine tempts us to try to describe people in terms of data from biomedical science: these are not, and will never be, enough. Such evidence is essential but always insufficient for the care of patients. It gives us an alphabet—but, as clinicians, we remain unsure of the language.

Most clinicians are not scientists; they have a different responsibility—to attempt to relieve distress and

ESSAY Iona Heath

Medicine needs an injection of humanityClinical consultations need to be rebalanced, with more emphasis on the aspects for which evidence based medicine has no answers

suffering and, to this end, to enable sick people to benefit from biomedical science while protecting them from its harms.

Each patient has unique values, aspirations, and context. More fundamentally, history and experience alter how each body works through many mechanisms, and socioeconomic inequality and the directly consequent unequal distribution of hope and opportunity often play out in premature disease and death.

Clinicians must see and hear each patient in the fullness of his or her humanity in order to minimise fear, to locate hope (however limited), to explain symptoms and diagnoses in language that makes sense to the particular patient, to witness courage and endurance, and to accompany suffering.

No biomedical evidence helps with any of this, so a rift runs through every consultation. On one side, evidence has a huge part to play, assuming it is free of bias; on the other side is the substantive role for humanity. Clinicians must constantly bridge the rift because, as Kleinman writes: “Physicians are poised at the interface between scientific and lay cultures.”2

To make sense of the world the human mind simplifies experience and denies much of its complexity. The reductive nature of biomedical science and our relatively crude disease taxonomy is part of this process. It has led to enormous progress in clinical medicine but devalues individual experience.

The disjunction is also between the body as an object and the body lived as a subject. The rift tempts us to offer easy technical solutions to

Iona Heath was a GP for 35 years in an inner London practice in Kentish Town and president of the Royal College of General Practitioners from 2009 to 2012. She wrote a regular column for The BMJ until 2013.

The reductive nature of biomedical science has led to enormous progress in clinical medicine but devalues individual experience


the insoluble existential challenges of ageing, death, and loss.3 Valerie Miké, of Cornell University, has proposed an ethics of evidence with two clear imperatives: the creation, dissemination, and use of the best possible scientific evidence as a basis for every phase of medical decision making and the need to increase awareness of, and come to terms with, the extent, and ultimately irreducible nature, of uncertainty.4

Uncertainty is inevitable whenever we apply evidence from studies of populations to individuals. This evidence can only inform us about probabilities; it can never predict what will happen to an individual because “trials . . . are deliberately aimed at showing average efficacy in a diseased group rather than optimum management for individual patients.”5

Yet these trials are used to construct clinical guidelines that, despite all the well meaning caveats, are too often used to coerce behaviour at the level of individual patient care through, for example, the financial incentives of payment for performance.

And worse, the evidence based medicine movement has never taken proper account of the warning of one of its pioneers, Dave Sackett: “The two disciplines [preventive and curative medicine] are absolutely and fundamentally different in their obligations and implied promises to the individuals whose lives they modify.”6

Curative medicine is uncertain enough, but preventive medicine has become almost ludicrously so. The populations of the richest countries in the world are healthier by objective standards now than ever before, yet they report relatively more illness than those living in poorer countries.7 People live longer than ever before but feeling fearful and ill, labelled as subject to ever more risk factors and exposed to endless health scares. And the effectiveness of most preventive interventions is hugely overestimated. How much have doctors colluded with that misplaced optimism? How much have doctors created it?

Health service policy in general, and particularly evidence based medicine, is founded on the values

of utilitarianism—seeking to achieve the greatest benefit for the greatest number—or those of egalitarianism—recognising equal rights to healthcare throughout society—or, most often, a rather confused mixture of the two.

However, the task of clinicians is to engage with the needs and values of each patient and their moral obligation is to do the best for that particular patient, and so the values of clinicians inevitably become primarily deontological. This commitment is poorly understood and little appreciated by policy makers,

whose priorities relate to population or societal levels. Yet, without this foundation in deontology, patients would find themselves unable to trust clinicians, with less efficiency at societal level.

This leads to another rift—between society and the individual. At the societal level our notions of health and disease are crude, reductive, and normative, while at the level of the sick individual, the clinician needs to pay attention to detail and description.

A profound problem is that the map of biomedical science only roughly matches the territory of human suffering. The American physician Eric Cassell, writes: “We all recognise certain injuries that almost invariably cause suffering: the death or suffering of loved ones, powerlessness, helplessness, hopelessness, torture, the loss of a life’s work, deep betrayal, physical agony, isolation, homelessness, memory failure, and unremitting fear. Each touches features common to us all, yet each contains features that must be defined in terms of a specific person at a specific time.”8

Yet these potent sources of suffering are largely absent from the map of biomedical science. We can bridge this aspect of the rift only with the help of different arenas of knowledge and understanding. Arthur Kleinman recommends ethnography, biography, history, and psychotherapy to “enable us to grasp, behind the simple sounds of bodily pain and psychiatric symptoms, the complex inner language of hurt, desperation, and moral pain (and also triumph) of living with an illness.”2

At its starkest, the rift is between numbers and words. Numbers have seductive beauty and purity that suggest solidity and certainty. Words are infinitely malleable and adaptable but can communicate much more. We try to define disease using numbers, but this has separated the map from the territory even further. Words are essential to help patients

People live longer than ever before but feeling fearful and ill, labelled as subject to ever more risk factors and exposed to endless health scares

We try to define disease using numbers, but words are essential to help patients to understand what is happening to them and what might help

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to understand what is happening to them and what might help. Only with words can we forge trust, relieve fear, and find meaning. Yet as Alvan Feinstein reminds: “Most of the research devoted to patient care has been more mathematical than clinical.”5

We need words to acknowledge and respond to emotions, which are just as important in the care of patients. And this is why clinicians will always need the insights of qualitative research alongside the quantitative, and why clinical journals should publish both.9

Reason does not hold a monopoly on truth, as George Eliot explained in Daniel Deronda: “Suppose he had introduced himself as one of the strictest reasoners: do they form a body of men hitherto free from false conclusions and illusory speculations? The driest argument has its hallucinations, too hastily concluding that its net will now at last be large enough to hold the universe.”1 She could have been writing about some of the excessive claims for evidence based medicine.

Yvor Winters, American poet and critic, proposes poetry as the necessary link between reason and emotion: “The artistic process is one of moral evaluation of human experience, by means of a technique which renders possible an evaluation more precise than any other. The poet tries to understand his experience in rational terms, to state his understanding, and simultaneously to state, by means of the feelings we attach to words, the kind and degree of emotion that should properly be motivated by this understanding.10

Clinicians need to be just this—experts in the feelings we attach to words—otherwise our efforts to communicate with our patients will oscillate between the tedious and the cruel. The American poet Robert Frost described poetry as “the shortest emotional distance between two points: the writer and the reader.” And this is so often the intensity of connection that doctors need to help people experiencing suffering and loss.

W H Auden wrote, famously, “Poetry is not concerned with telling people what to do, but with

extending our knowledge of good and evil, perhaps making

the necessity for action more urgent and its nature more clear, but only leading us to the point where it is possible for us to make a rational moral choice.”11

He provides another bridge across our rift and a much needed defence against the many people who want to tell patients and professionals what to do. Poems ask us to think, and most of us, when ill, want a doctor who is prepared to think.

I long for a day, when instead of guidelines, doctors are simply given summaries of evidence, with clear indications of the limitations and extent

of uncertainty, and always acknowledging possible harm. This would encourage clinicians to think instead of telling them what to do.

So, in the end, my rift comes down to one between scientific evidence and literary humanism. And as long as we are spared evidence based poetry, music, or art of any sort, these aspects of human understanding will remain dependent on genius.

As the poet Seamus Heaney has pointed out: “The world is different after it has been read by a Shakespeare or an Emily Dickinson or a Samuel Beckett because it has been augmented by their reading of it.”12

Literary humanism allows us to find new sense and meaning in the world. And all too often, clinicians

try to help their patients to see a terrible world differently and to find meaning in it.

I am not arguing for just one side of this multifaceted rift, but for a rebalancing. Medicine needs to approach each patient in the fullness of their humanity and so must draw on knowledge and wisdom from across the full range of human understanding.

It seems that we may have exploited rationality at the expense of humanity. The Dutch philosopher Annemarie Mol proposes a way forward: “Instead of either pushing professionals back into their cage, or allowing them to do whatever they like, it is better to open up and share the crucial substantive questions publicly. How to live well, what to die from, and how, thus, to shape good care?”13

Let me end with a different Eliot. In his 1944 essay on Virgil, T S Eliot wrote, “In our age, when men seem more than ever prone to confuse wisdom with knowledge, and knowledge with information, and to try to solve problems of life in terms of engineering, there is coming into existence a new kind of provincialism which perhaps deserves a new name.

“It is a provincialism, not of space, but of time; one for which history is merely the chronicle of human devices which have served their turn and been scrapped, one for which the world is the property solely of the living, a property in which the dead hold no shares.”14

Today, evidence based medicine is used to drive definitions of clinical quality that involve insufficient doubt, and this has become difficult to question because the aim is so worthy. Nonetheless, such unidimensional means are damaging because they propagate an intensely normative and objectifying view of what it means to be healthy and of what human life and healthcare should be.

We need more breadth, more balance, and more doubt, and only then will our consultations cohere.Iona Heath is a former general practitioner, London, UK [email protected] this as: BMJ 2016;355:i5705Find this at: http://dx.doi.org/10.1136/bmj.i5705

Ж See BLOG OF THE WEEK, p 235

Medicine has to approach each patient in the fullness of their humanity and so must draw on wisdom from across the full range of human understanding

• thebmj.comIS IT EASIER TO OFFER COMPASSION THAN EMPATHY? “I take it as axiomatic that it is not possible to achieve true empathy. Because one cannot fully understand another’s perspective or circumstances, it is not possible to feel exactly how that other person feels,” writes Jeffrey Aronson.

“Compassion does not require one to achieve complete understanding of the other’s perspective and circumstances, engendering exactly the same feelings, it merely calls on one to imagine what it might be like to suffer in the way that the other is suffering, which, if achieved, will engender the corresponding emotion, which can then be conveyed.”

• Read his blog in full at bmj.com/blogs

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