Health policies lack transparency - BMJ 2018-03-19 · this week LATEST ONLINE • Plans for improving care are being derailed by acute care deficits, GP leader warns • Government

this week

LATEST ONLINE

• Plans for improving care are being derailed by acute care deficits, GP leader warns

• Government must not shy away from bold action on public health, says MP

• EU to launch new antimicrobial resistance action plan

Health policies lack transparencyThe UK government must do more to “show its workings” when presenting the case for new policies such as seven day services in the NHS, says a major review of government transparency.

The review, the first assessment of transparency across UK government, identified wide variation across and within departments that made it difficult for policy proposals to be scrutinised.

The charity Sense about Science, which co-produced the report, said that departments seem often to have assembled an evidence base to inform decisions but don’t share it. This made it hard for the public or parliament to scrutinise their thinking or follow the reasoning for policies, it concluded.

The report examined 593 government policy proposals from 13 departments published between May 2015 and May 2016, including 15 from the Department of Health for England. The review cited the health department’s assessment of the case for a seven day NHS as an example of a policy that required greater transparency.

“The DH’s seven day NHS [plans] arose from means focused manifesto commitments and gave limited information about the source of the policy,” it said.

But the report gave the department more positive feedback on alcohol guidelines and death certification reforms, which were praised respectively for being frank about the strengths and weaknesses of the evidence and for linking implementation to lessons from pilot programmes.

The authors said their sample indicated that policies announced in the budget and autumn statement were less transparent about the underlying evidence than other policies. The organisations intend to score and rank individual government departments on their evidence transparency next year, saying that their report highlighted key areas for improvement.

Tracey Brown, director of Sense about Science and the report’s main author, said, “We found cases of very good practice, such as discussion of gaps in the evidence base. But there were many areas where departments need to be more open about the evidence they are using to justify and shape policies. Without transparency, the public cannot understand or question proposals, and researchers can’t evaluate the evidence the government is using or improve on it.”Gareth Iacobucci, The BMJ Cite this as: BMJ 2016;355:i6308

The government needs to be more open about the evidence base for policies, such as the NHS seven day services proposal

the bmj | 26 November 2016 337

CRYONICS page 339 • TELEMEDICINE page 340 • EVERINGTON PROFILE page 341

SEVEN DAYS IN

Footprint areasMap shows plans for England’s NHS servicesAll sustainability and transformation plans (STPs) for cutting costs in 44 “footprint” areas in England will be published by Christmas and implementation will begin in the New Year, NHS England said. Health activists and local councillors have widely criticised the plans, concerned that hospital services will be cut to deliver the £22bn in savings by 2020-21 demanded by health chiefs. The BMJ interactive map with a summary of the plan is at http://bmj.co/stpMap.

ScienceBrexit could prompt science “brain drain”The government must prevent a “brain drain” of scientists from the UK by exempting them from any tightening of immigration rules, MPs urged. Evidence submitted to the House of Commons Science and Technology Committee’s inquiry into the effect on science and research of the UK’s decision to leave the EU said that many researchers were “seriously considering” leaving the UK. Ottoline Leyser, of the Royal Society, said that the 31 000 scientists and researchers from

the rest of the EU working in the UK were “feeling very anxious and alone.” (doi:10.1136/bmj.i6193)

Scientific research gets £2bn a year boostThe government will invest £2bn a year by 2020 In research and development, the prime minister told business leaders on Monday in her first speech to the Confederation of British Industry’s annual conference. Theresa May also announced a review of current research and development tax incentives to ensure the UK’s global competitiveness as a home for scientists, innovators, and tech investors, as well as a new Industrial Strategy Challenge Fund to back technologies such as robotics and biotechnology.

Flu vaccineHigh vaccine uptake by healthcare workersSome 372 339 (40.4%) front line health workers in England had been vaccinated against influenza by 31 October 2016, NHS England figures showed—higher

than at the same stage during previous winters, including 312 203 (32.4%) last winter. NHS Employers hopes that the final end-of-winter tally will exceed last year’s 502 033 (50.6%).

ScotlandAbortions may be offered to Northern Irish womenNicola Sturgeon (below), first minister, told the Scottish parliament

that her government would consider giving women from Northern Ireland access to

terminations in Scotland’s health service free of charge. The Supreme Court is considering

an application from a Northern Irish teenager challenging

the refusal by the NHS in England to fund the procedure for women from

Northern Ireland. Sturgeon said, “When a woman opts to have an abortion—I

stress that that is never, ever an easy decision for

any woman—the procedure should be available in a safe

and legal way.”

Final appeal against minimum alcohol priceThe Scotch Whisky Association announced that it will make a final legal challenge to Scotland’s minimum price on a unit of alcohol. It will appeal to the

UK Supreme Court, since the Court of Session last month rejected its claim

that minimum pricing was incompatible with EU law. Scotland’s health secretary,

Shona Robison, said that minimum pricing had the overwhelming support of the Scottish parliament, had been tested in Europe, and had been approved twice in the Scottish courts. (doi:10.1136/bmj.i6202)

Foreign patientsID for NHS care?The Department of Health is examining if patients should show identification to get some NHS care, an idea being tested at some hospitals. Chris Wormald, the department’s permanent secretary, told the Public Accounts Committee that the NHS has a “lot further to go” in reclaiming money from foreign visitors. Figures from 2014-15 show £674m was charged to the UK government for care of Britons abroad but just £49m was charged for EEA nationals’ care.

All GP clinics must appoint a “freedom to speak up” guardian to make it easier for staff to raise concerns, under whistleblowing guidance drawn up by NHS England.

The guidance comes after Robert Francis QC (left) recommended that the principles outlined in his Freedom to Speak Up report be adapted for primary care. A national whistleblowing policy is already in place for secondary care.

NHS England said that all NHS staff working in primary care should be encouraged to raise any concern at the earliest opportunity. Primary care providers should be proactive in preventing any inappropriate behaviour, such as bullying, towards staff members who raise a concern. All general practices should review and update their policies and procedures by September 2017, in line with the new guidance. This includes naming one person, who is independent of the line management chain and is not the direct employer, as a “freedom to speak up guardian.” This person should raise awareness of how staff can share concerns and support anyone who does so.

In large GP clinics or federations, the guardian could be internal but others could come from another practice, clinical commissioning group, or hospital trust.

Practices must appoint whistleblowers’ guardian

Jacqui Wise Cite this as: BMJ 2016;355:i6266

338 26 November 2016 | the bmj

NicotineE-cigarettes raise teens’ risk of cough and wheezeTeenagers who use e-cigarettes have twice the risk of respiratory symptoms such as persistent cough, bronchitis, and wheeze, a study in the American Journal of Respiratory and Critical Care Medicine found. The results were based on a survey of 2086 teenagers aged 16-18 about their use of e-cigarettes and chronic cough, phlegm, bronchitis, and wheeze in the previous 12 months. (doi:10.1136/bmj.i6203)

NICE approves 75% of cancer fund drugsSeven of nine treatments that NICE has looked at in the Cancer Drugs Fund have been approved, and the rest are being reappraised. Andrew Dillon, NICE chief executive, said, “Sensible pricing, and in some cases better data, is helping to secure access to important cancer medicines as they move out of the old Cancer Drugs Fund.” Money in the CDF can be used for newer, innovative cancer treatments, he said.

Public healthMinimal effects of school sex educationLittle evidence shows that school sex and reproductive health classes affect the number of young people infected with HIV or other STIs, or the number of adolescent pregnancies, a Cochrane review concluded. Giving cash or free uniforms to encourage pupils to stay in school also has little effect on infection rates, although better school attendance may reduce teenage pregnancies, said researchers.

Research newsMeniere’s disease eased by steroid injectionsInjections of the steroid methylprednisolone through the eardrum are as effective as the current standard treatment of gentamicin in reducing dizziness in patients with Meniere’s disease but without the associated risk of hearing loss, showed a double blind trial of 60 patients reported in the Lancet. Patients treated with methylprednisolone showed a 90% reduction in the mean number of attacks from 16.4 to 1.6, and those treated with gentamicin showed an 87% reduction in attacks from 19.9 to 2.5. (doi:10.1136/bmj.i6185)

Thiazide diuretic may protect against fractureThe thiazide diuretic chlorthalidone was associated with a 21% lower risk of hip and pelvic fracture than amlodipine or lisinopril, a randomised trial with over 22 000 participants found. The authors concluded, “The present results of short term and long term fracture protection with thiazide antihypertensive therapy compared with other antihypertensive drugs strongly recommends use of a thiazide for hypertension treatment in addition to its long track record of cardiovascular protection.” (doi:10.1136/bmj.i6263)Cite this as: BMJ 2016;355:i6291

I THOUGHT THIS WAS SCI-FI FANTASYSo did we. But a legal ruling last week propelled cryogenics into the limelight after a 14 year old girl became the first British child to have her body frozen after dying from cancer.

SO WHAT’S INVOLVED?After a person is pronounced dead they are cooled rapidly with iced water. The Cryonics Institute near Detroit (www.cryonics.org), one of three organisations (two in the US and one in Russia) offering the process, recommends cardiopulmonary support, such as CPR compressions, to keep blood circulating and heparin to prevent clotting. The body is then packed in ice and sent to the cryogenics facility where the blood is drained and replaced with substances to prevent ice forming. Finally, the body is cooled gradually to −120°C and stored in liquid nitrogen.

SOUNDS GRIM, BUT IS IT POPULAR?Since 1967 more than 300 people are thought to have had their body or just their head (in the belief a body could be cloned or regenerated) cryonically preserved. Cryonics UK (www.cryonics-uk.org), a non-profit organisation that helps people who want to be cryopreserved, said that it has helped 10 people in the UK so far.

ARE THERE ETHICAL CONCERNS?The hospital trust involved in the teenager’s case shared “real misgivings” with the judge about events on the day of her death. It reported that her mother was preoccupied with the postmortem arrangements at the expense of being there for her daughter.

WHAT IS THE EVIDENCE BASE?There is none, says Clive Coen, a professor of neuroscience at King’s College London. Cryopreservation of the whole body is “just ridiculous and the whole brain is only slightly less ridiculous,” he said. And the £37 000 price tag with no established outcomes makes it difficult for NICE to assess.

WHAT ABOUT REGULATION?No, that’s lacking too. The UK’s Human Tissue Authority did say last week that it would look at the risks to individuals and to public confidence more broadly.

Susan Mayor Cite this as: BMJ 2016;355:i6280

SIXTY SECONDS ON . . . CRYONICS

DRUGSThe NHS in England spent

£16.8bn on drugs in 2015-16, up from

£15.5bn in 2014-15. Adalimumab, the TNF inhibitor, absorbed

£417m —the most of any NICE approved drug last year

MEDICINE


Government auditors have joined the growing chorus of organisations warning of the precarious state of finances of the NHS in England ahead of the chancellor’s autumn statement this week.

In an analysis published on Tuesday 22 November, the National Audit Office (NAO) said that the financial performance of NHS bodies worsened considerably in 2015-16 and warned that the current situation was endemic and unsustainable.

Trusts’ deficits grew by 185% to £2.45bn, up from £859m in 2014-15, and 32 clinical commissioning groups reported cumulative deficits in 2015-16, up

from 19 in both 2014-15 and 2013-14. The NAO also expressed doubt about the NHS’s ability to close the estimated £22bn funding gap by 2020-21.

Amyas Morse (below), NAO’s head, said that although the Department of Health for England and NHS leaders had put considerable effort and funding towards stabilising the system, they had not yet shown that this had successfully balanced resources and achieved stability.“It is fair to say that aggressive

efficiency targets have helped to swell the ranks of trusts in deficit over the past few years,” he said.

The warning came as many organisations urged the chancellor to commit extra funding for health and social care in the autumn statement due on 23 November.

NHS Providers, which represents acute care, ambulance, and community and mental health services, called for additional funding to be “rigorously targeted at the areas of greatest challenge” and said that general practice and social care should be the top priorities.

In its submission to the Treasury, the Royal College of Physicians said the NHS budget had not kept pace with rising demand and urged the government to provide

a new settlement that included realistic targets for efficiency savings and protected funds for transformation projects.

In a joint briefing paper, the Nuffield Trust, the King’s Fund, and the Health

Foundation argued that plugging the social care gap was “the most urgent

priority” for the chancellor.

Ailing NHS finances are not sustainable, auditors warn

Gareth Iacobucci, The BMJ Cite this as: BMJ 2016;355:i6283

A telemedicine service run by a Yorkshire NHS trust has reduced care home referrals to GPs by 40% and ambulance calls by almost 30%.

Staff in more than 200 care homes across England are linked to a digital hub at Airedale NHS Foundation Trust in Keighley and can seek advice 24 hours a day about the health of any resident. The service is run by a team of senior nurses who have online access to GP patient records and can consult trust doctors if they need to.

From the north to the Isle of WightThe aim is to improve care and to make best use of GP and emergency facilities by reducing needless referrals. “We started off with the local population, and then on the back of evidence that it worked, we went national,” said Justin Tuggey, consultant in respiratory and general medicine and clinical director of digital care and telemedicine at Airedale. “We now look after care homes from northern England to the Isle of Wight.”

The hospital has run a telemedicine service for prison inmates for 10 years, gaining experience on which it built its care home initiative,

recently described by the Care Quality Commission as outstanding and selected by NHS England as a vanguard site for new care models.

The service now covers 217 care homes and around 7500 residents. Between April and August this year it dealt with 3754 calls. Had it not been there, two thirds of the homes said that they would have called the patient’s GP, in or out of hours, and 8% would have called an ambulance. The advice provided eliminated 40% of the calls to GPs and 29% of the calls to the ambulance service.

Tuggey told The BMJ that telemedicine adds incremental value to existing efforts to reduce referrals in conventional ways. A formal audit of local care homes showed referrals falling generally, but falling faster

in those covered by the service, generating an 8% reduction in costs of emergency admissions over a 20 month period and a 14% faster decline in emergency department attendances.

A typical case might be an elderly woman who falls out of bed. “A member of staff would normally have to accompany her to the emergency department and wait four hours while she was seen,” Tuggey said. “Now she can be assessed by a senior nurse with access to her record, and guidance can be given to staff on what to do. She can be called back an hour later to see how she is getting on.

“Lots of care home residents with diarrhoea and vomiting are admitted to hospital, which is the worst place for them. Now a nurse can talk to them, make sure they have a glass of water at their bedside, and say, ‘I want you to drink half of that by the time I ring you back.’ The eye to eye contact is vital.”

Unexpected benefitsThe service has found uses that weren’t originally intended. Christine Dennis, who cared for her husband, Stuart, until he was admitted to a hospice, was distraught when she herself was admitted to Airedale Hospital with pneumonia and could no longer visit him. With the aid of an iPad and the telemedicine system, an online meeting was arranged.

“I didn’t know what to expect but he was so clear on the screen and looked so well,” she said. “We had a chat and it was really lovely. That connection I had with Stuart was the most important one that I ever had. It was as near as it could have been to being with him in person, which was wonderful for us both.”Nigel Hawkes, LondonCite this as: BMJ 2016;355:i6287

Hub cuts care home referrals to GPs by more than a third

The service now covers around 7500 residents. It dealt with 3754 call in five months this year

TRUSTS’ DEFICITS. . . grew by

185% to £2.45bn, up from

£859m in 2014-15, and 32 clinical commissioning groups reported cumulative deficits in 2015-16, up from 19 in both 2014-15 and 2013-14


Sam Everington: the proud generalist

“It was a complete shock to me and a lot of other people too, dare I say it. I initially left the letter alone because I thought it was a tax demand.”

Sam Everington’s reaction to being awarded a knighthood in 2015 for his services to primary care refl ects an unpretentious yet determined demeanour that has helped propel him through a highly successful career.

His pioneering work at the Bromley by Bow health centre in Tower Hamlets, east London, is a shining beacon of holistic care in one of the country’s most deprived communities. In the centre, general practice coexists with more than 100 diff erent community projects, including art therapy, a café, and a park.

Over his 30 year career Everington has deft ly juggled his day job as a GP with other roles that include advising Labour and Conservative ministers who have come to observe his work.

Still working as a GP two days a

Whichever politician you talk to, primary care is seen as plan A, B, and C

T he pioneering east London GP tells Gareth Iacobucci the time for primary care is now

week, he divides the rest of his week between chairing Tower Hamlets Clinical Commissioning Group, overseeing NHS England’s national vanguard programme to test new models of care, and acting as the clinical lead for his local sustainability and transformation plan (STP).

Life has never been tougher for GPs His thirst for a new project perhaps explains the numerous roles he has held and his desire to prolong his career as a GP, despite his view that life has never been tougher for GPs as a result of rising demand, an ageing population with increasing comorbidity, and funding pressures.

“The message I give to GPs is, ‘I feel your pain.’ Monday is a 12 hour day for me normally, and I see up to 50 or 60 patients,” he says.

But he believes that the penny has fi nally dropped among policy makers that primary care, if properly

supported, can provide the solutions the NHS needs. “[NHS England’s] rescue plan and its General Practice Forward View is probably the fi rst time general practice has been recognised in all my years,” he says.

“It’s entirely understandable that GPs are sceptical, but whichever politician you talk to, primary care is seen as plan A, B, and C.”

It’s about delivering high quality care The plans being tested across the so called vanguard sites could see GPs working in traditional partnerships, as salaried doctors, together in larger federations, or alongside acute and community care, says Everington. “It’s not so much about the model: it’s about how you deliver high quality care and enable GPs to deliver that, whatever circumstances they fi nd themselves in,” he asserts.

Everington says medical schools need to rethink the way they train doctors to encourage multidisciplinary working and a focus on population health. Once doctors are trained, he also thinks they should be encouraged to look beyond the four walls of the institution they work in.

“If it was within my gift I would make the majority of every NHS trust board [medical] consultants,” he affi rms. “That would achieve the same sort of engagement as in primary care, a sense of that much wider responsibility to the health and wellbeing of the whole community.” He adds, “Being a clinician [in a leadership role] enables you to speak out in a way that actually is very tough for managers in the NHS.”

His enthusiasm still burns brightly, Everington can’t envisage retiring. “ I think: live for the moment and enjoy what you’re doing now. If something turns up and you want to do it, do it.” Cite this as: BMJ 2016;355:i6251

EVERINGTON ON . . .

• BEING A GP: “The real joy is the continuity of care. It’s a fantastic privilege to be a GP, an amazing job.”

• POLITICIANS: “The most important message I can give is: just treat politicians like human beings.”

• STPs: “The concept that you create a group of relationships to manage the whole population has to be a good one.”

• NEW TECHNOLOGY: “I often describe the iPad or the iPhone as the equivalent of a stethoscope.”

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Sam Everington has been a GP in Tower Hamlets for 30 years



Junior doctors working night shifts should be allowed to take regular short naps, says Jim Horne, a sleep neuroscientist and emeritus

professor of psychophysiology at Loughborough University.

Horne was speaking at a conference held at the Royal Society of Medicine in London on 16 November about the effects of sleep deprivation on workers. He told the conference that a lack of sleep could affect a person’s ability to work and deal with emergencies.

Speaking to BMJ Careers, Horne said that “there’s absolutely no doubt” that junior doctors should be allowed to take short naps. “It’s safer for everyone concerned; it makes the doctor safer to work, it improves patient safety, it reduces accidents, and doctors are happier because they

think the organisation cares for them more.”

He added, “It’s been proven many times in other organisations that naps, roughly every four hours, ideally for about 15 minutes maybe with a cup of coffee beforehand, can be very effective indeed and highly recommended.”

Risk taking while tiredSpeaking to the conference, Horne explained that although sleep deprivation didn’t affect a person’s ability to carry out routine tasks—“something that you are pre-programmed to dealing with”—it did affect a person’s ability to deal with an unexpected emergency situation.

“Risk taking is a serious issue, because [sleep deprived] people start taking more risks,” Horne said. He

added that sleep deprived people were also more easily distracted and struggled to focus. “Your language and communication skills become impaired . . . You’re more likely to talk in clichés than actually describe how the situation is changing,” he said.

He argued that organisations that employed shift workers needed to be aware of the potential effects of sleep deprivation and manage their staff accordingly. He said that staff who were sleep deprived should not be encouraged to say, “It’s my watch, I’ll carry on.” He said, “That’s very laudable but inadvisable, and really that person should be encouraged to seek help from others.”

Also at the conference, Derk-Jan Dijk, professor of sleep and physiology at the University of Surrey, said that people who worked nights

Doctors need to nap to protect patient safetyNeuroscientist says that working night shifts without any sleep can affect an individual’s ability to deal with emergencies, and mean they are more easily distracted and struggle to focus. Abi Rimmer reports

1SAVINGS FROM LOCUM CAP

NHS Improvement says that a cap on the hourly rates that hospital trusts pay agency staff saved more than £600m in the first year after it was introduced in November 2015.

2GP LOCUM CAP PROPOSED

Earlier this year, NHS England proposed that general practices should have to record annually the number of instances where they pay a locum doctor more than a maximum indicative rate.

3GPs REJECT LOCUM CAP

At the BMA’s conference of local medical committees in May, GPs rejected the proposed cap on fees charged by locum doctors, saying that terms and conditions should be agreed mutually.

4SPENDING ON LOCUM RECRUITMENT

An investigation by BMJ Careers found that NHS acute trusts in England were each spending nearly 25 times as much on locum agency fees as they spent on recruiting doctors to permanent positions.

FIVE DEVELOPMENTS AFFECTING LOCUMS IN 2016

Language and communication skills become impaired. You’re more likely to speak in clichés

The number of hospital doctors choosing to work as locums has almost doubled since 2009, National Statistics data show (figure). Between 2009 and 2015 the number of locum doctors in hospitals rose by 96%, from 8176 in 2009 to 16 002 in 2015. This represents a 12% average annual rise. On average, 1304 more doctors each year are choosing to work as locums.

Brookson, an accountancy firm for contractors, freelancers, and small businesses, commissioned the figures from National Statistics, which used its Labour Force Surveys to collate the figures.

Using data on locums who use its services and National Statistics data on medical practitioners, Brookson calculated that locum doctors are earning 44% more on average than their salaried counterparts.

The company’s analysis of pay rates found that median annual pay is £95 040 for medical locums and £65 843 for salaried medical practitioners. A Brookson spokesman told The BMJ that he believed that medical locums who used Brookson were likely to be fairly typical of those working as locums in hospitals.

In November 2015 a cap was introduced on the hourly rate that NHS trusts could pay locums. NHS Improvement has calculated that, before the cap was introduced, NHS spending on locums was rising by 25% a year. It estimates that since the introduction of the cap 73% of trusts had successfully reduced their spending on agency staff and that trusts had saved £604m.

Kathy Mclean, executive medical director of NHS Improvement, believes that NHS trusts are relying too much on locum doctors and still employing too many locum doctors at rates of pay above the cap introduced in 2015.

NHS Improvement has calculated that the 2015-16 bill for medical agency staff in the NHS in England was £1.3bn.Tom Moberly, BMJ CareersCite this as: BMJ 2016;355:i6207

were very likely to be sleep deprived because they were out of sync with their circadian rhythm. He said that night workers might not even be able to recover on their days off because of a combination of “acute desynchrony” with their circadian rhythm and chronic sleep loss.

One way that workers could reduce the effects of shift work, he said, was to maximise the amount of sleep they had before the night shift “or even during the night shift.”

Dijk also warned against 12 hour shifts. “From a theoretical perspective, which is based on data in the laboratory, 12 hour shifts probably will not result in a very good work performance at the end of those 12 hours,” he said. He added that if people were going to work 12 hour night shifts then the timing was important. “In our analysis the worst timing of the 12 hour shift would be from 7 pm to 7 am, because 7 am is the trough of the circadian cycle.

“From a circadian perspective it would probably make more sense

Locum numbers have doubled since 2009

5 PROTECTION FOR WHISTLEBLOWERS

Whistleblowing protection for agency workers, including locum doctors, has been clarified by a legal ruling that ensures that they have the

same protection as employees (see p 374).

FIVE DEVELOPMENTS AFFECTING LOCUMS IN 2016

to work from 4 am to 4 pm, because then the circadian trough would fall halfway through the shift, or to start a 12 hour shift at midnight.”

Lower recall of trainingJohn Axelsson, associate professor at the Karolinska Institute in Stockholm, addressed the issue of junior doctors being able to learn during or after night shifts. He said that research had shown that sleep deprivation lowered people’s chance of remembering what they had been taught. “Sleep deprivation prior to doing something does affect learning. Also if you learn and then are sleep deprived afterwards you have reduced [memory] of the subject, because during sleep you transfer memories,” he said.

“We know that sleep deprivation both prior and afterwards affects the capacity to learn. I haven’t seen studies of doctors [on long night shifts], but I’m pretty sure it’s going to be a blur for those working 80 hours a week.”Cite this as: BMJ 2016;355:i6255

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2009 2010 2011 2012 2013 2014 2015

Source: National Statistics, data analysis commissioned by Brookson

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What starts as a song and dance spectacular about receiving a cancer diagnosis takes an abrupt turn.

Thoroughly demolishing the theatre’s “fourth wall,” the cast of A Pacifist’s Guide to Cancer reassemble without their glittery outfits, and talked to the audience about cancer, leading to tears all round.One collaborator, Lara Veitch, has had cancer six times in her 27 years. “Being diagnosed with any serious illness is one of the most shocking things in the world.” she told The BMJ. “That’s why it had to be a musical: it’s big and loud and colourful and mad.”

Kathryn Mannix, a palliative care doctor, also advised the creative team. “Three generations ago, by their 30s people would have seen several deaths,” she said. Today’s doctors are similarly less exposed to dying. Mannix wants witnessing dying several times to be as mandatory a part of medical training as delivering babies. “Doctors need to be able to describe the process up to the moment of death with the person likely to be experiencing it soon. Without many opportunities it will always feel uncomfortable.”Richard Hurley, features and debates editor The BMJ [email protected] Pacifist’s Guide to the War on Cancer runs at the National Theatre, London• Read more on thebmj.comCite this as: BMJ 2016;355:i6318

THE BIG PICTURE

A musical about malignancy


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EDITORIAL

Child refugees: the right to compassionThe UK must do more to meet its moral and legal obligations to migrant children

The United Nations refugee agency estimated that the number of people forcibly displaced around the world

topped 60 million in 2015.1 In the same year, 270 000 asylum seeking children arrived in southern Europe. The phenomenon of globally mobile populations is not short term; it is the “new normal,” and the UK—like other high income countries—might have been expected to have had a clear, predefined response.

Ninety five per cent of the refugees who have recently arrived in Europe came by sea; a quarter of them were minors.2 In 2015, a third of the refugees who drowned in the Aegean were children.3 Sadly, arrival on the European mainland does not bring safety. At the time of writing, the UK has managed to take in only about 300 children from the Calais refugee camp.4 Even for children with relatives in the UK, the response to right of entry has been prevarication, at best. By contrast, since 2007, the UK has deported almost 3000 children, mainly to Afghanistan, Iran, Iraq, Libya, and Syria.5

False impressionDomestic concern about migrants has resulted in increasingly stringent national policies and controls in the UK and across Europe. The terms “refugee,” ”asylum seeker,” and “migrant” have been allowed to merge in public discourse into a single category of disapproval and disavowal. The impression given is that the UK is experiencing a sustained surge of claimants. In reality, asylum applications peaked in 2002 at just over 80 000, falling to around 17 000 in 2010 before rising again to 32 000 in 2015.6 According to the Home Office, asylum applications “increased by 29%, to 32 414 in 2015, the highest number of applications since 2004.”7 Had the government chosen to set its benchmark two years

earlier to 2002, the 2015 figure would represent a fall of almost 60% from the postmillennial high.

The forcible displacement of families, the trauma of violence and flight, hit children hard.8 The physical and mental health needs of children seeking asylum are complex. Without adequate health checks, diagnosis, and access to care, the consequences of unmet needs are likely to be severe.9 But the current political and policy environment raises the serious risk that the previous insults of refugees’ experiences are compounded by a harshly bureaucratic, punitive, and hostile reception.

The Convention on the Rights of the Child, to which the UK is a signatory, is founded on four Ps: participation of children in decisions affecting them, prevention of discrimination and exploitation, protection from harm and neglect, and provision of basic needs.10 In each of these categories, the UK government’s response to Calais and the wider phenomenon of global conflict, displacement, and flight has been inadequate. Commenting on the current behaviour of the French and British administrations, the Committee of the Convention of the Rights of the Child notes: “The failures regarding the situation of children in Calais are not isolated events but highlight the shortcomings of a migration system built on policies that are neither developed nor implemented with children’s rights in mind.”11

Moral responsibilitiesChildren are children, wherever they happen to be. The UK government has underperformed against its moral and legal responsibilities, and it is difficult to see any justification for this stance. Looking ahead, the UK needs systematic improvements in data gathering to understand the needs of child refugees, cross party commitment to accept higher numbers of unaccompanied minors, child friendly reception centres with adequate numbers of skilled staff, and clear routes into healthcare and education.

More broadly, a more compassionate discourse around children and refugees is warranted. Overwhelming evidence shows that the meaner and more isolating the initial experience of reception, the poorer the physical and mental health of refugees, the weaker their sense of inclusion and wellbeing, and the lower their educational performance and chances of employment and economic productivity.12‑18 Systematic exclusion within resettlement communities can lead to alienation and exposure to radical influences. There is a clear moral case for the UK to do better. But there are also practical benefits when child refugees are treated with the humanity and compassion they deserve.19

Cite this as: BMJ 2016;355:i6100Find this at http://dx.doi.org/10.1136/bmj.i6100

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The physical and mental health needs of children seeking asylum are complex

Sebastian Taylor, head of global operations Sebastian.Taylor@ rcpch.ac.ukGeoff Debelle, child protection officerNeena Modi, president, Royal College of Paediatrics and Child Health, London


EDITORIAL

The shadow of the law in cases of avoidable harmThe law’s intervention in patient safety can be haphazard and inconsistent

The headline of Bob Wachter’s patient safety blog about the Ohio pharmacist Eric Cropp proclaimed: “Jail time

for a medical error.”1 When Cropp’s professional colleagues saw him clad in an orange jumpsuit in a prison visiting room, they knew it could have been them. A pharmacy technician mistakenly mixed chemotherapy drugs with 23% saline, not 0.9%. A child died. It was a rushed, understaffed day, with computer failures. Cropp’s supervisory check failed to spot the error. He was convicted of manslaughter in 2009.

A junior doctor in Nottingham, England, was jailed in 2003 for killing a cancer patient who was given vincristine through the wrong route. The investigator had identified some 40 systems failures,2 yet individual accountability won the day in court. It had happened before in the UK in similar circumstances, but other doctors had been quietly counselled.

A look back from 2005 at the doctors charged with manslaughter in the UK found 85 since records began, and 38 between 1990 and 20053; there were a further 15 during 2006 to 2015.4

One of those was NHS surgeon David Sellu. On parole, part way through a two and a half year prison sentence for manslaughter of a patient in a private hospital, Sellu learnt last week that the Court of Appeal had quashed his conviction.5 This was because of an aspect of the legal process in the lower court.

The chronology of events, set out in the Appeal Court’s judgment,6 has the chilling momentum and sense of inevitability characteristic of most patient safety narratives. It is a complex mixture of system and human factors with elements of poor

clinical decision making. As such, there were questions of individual accountability. These could have been properly dealt with by local clinical governance procedures or by serious medical regulatory scrutiny. Awful though the case was, few doctors would say that it reached the threshold for a prosecution. This is especially so given no apparent pattern of past poor practice.

Blame freeShould a doctor, or other health professional for that matter, ever be charged with manslaughter? If there is no suggestion of reckless behaviour or wilful misconduct, then treating the failure as a crime creates a negative and punitive climate in which the instinct for self preservation becomes stronger than the motivation to make a report that could save lives. Good practice in safety in healthcare and other high risk industries points consistently to the necessity of an approach free of blame and retribution if learning to protect future patients is to be successful.7 Understandably, many patients and families affected by a serious incident can find this difficult to accept.

The initial legal processes that come into play in patient safety incidents are often problematic. I once asked a group of senior police officers why some doctors are prosecuted and others not, in similar situations.

They said that it depended whether someone made a complaint. If they did the police were obliged to set up an inquiry team. This police work can last years. Healthcare organisations and the General Medical Council cannot proceed because of the risk of contaminating evidence. The victims get angry, suspecting a cover up. The staff member concerned suffers enormous stress. All progress is paralysed. Sometimes the investigation is dropped, and words such as “exoneration” are then used, despite ongoing concerns about safety.

AdversarialIn the courts, an adversarial approach is taken to establish causation. The focus is on the accused. From the word go, the wider systemic context hardly gets a look in. Juries have to cope with the emotion, perhaps relating the events to their own experience of care.

Like many past controversies involving doctors, the Sellu case raises important questions of policy. For example: why do so many acutely ill deteriorating patients have to die? The patient here slid into sepsis because delayed decision making, failure to escalate, and poor communication meant that he could not be rescued. A third of all deaths related to patient safety in England were found to result from mismanagement of the deteriorating patient.8 This clear systemic vulnerability causes major harm. The NHS shows a lamentable failure to tackle it. Also, what can be done about private hospitals that do not have adequate skilled cover for acutely ill patients?

The law’s interventions in the complex and subtle territory of avoidable harm in healthcare are too often haphazard and inconsistent. Its perspective and processes make more difficult the task of creating a system to make care safer and inspire health professionals to lead the way.Cite this as: BMJ 2016;355:i6268Find this at http://dx.doi.org/10.1136/bmj.i6268

Should a doctor, or other health professional for that matter, ever be charged with manslaughter?

Liam J Donaldson, professor of public health, Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London [email protected] Eric Cropp was jailed when a child died from wrongly mixed drugs

Ж See FEATURE, p 348


MEDICAL ERROR

Where should the buck stop? Doctors, medical error, and the justice systemAfter the Court of Appeal quashed surgeon David Sellu’s manslaughter conviction, Clare Dyer reports on fears of the criminalisation of doctors

When David Sellu, a respected senior surgeon with an unblemished 40 year career in the

NHS, was taken away in handcuffs to Belmarsh Prison the medical community was stunned. It was November 2013 and an Old Bailey jury, by a 10-2 majority, had convicted Sellu of the manslaughter of a patient by gross negligence.

The QC who defended Sellu at his trial told him there were no grounds for an appeal. “My barrister said there was nothing to be gained by appealing because he’d explored all there was to explore,” Sellu remembers. So the 28 day time limit for appealing lapsed.

In February 2010 Sellu, a consultant colorectal surgeon with Ealing Hospital NHS Trust, had been called in to the private Clementine Churchill hospital when James Hughes, a 66 year old builder, developed abdominal pains days after a successful knee replacement. Sellu performed an operation 25 hours after he first saw Hughes, but the patient died from a perforated bowel.

A six and a half year journey, which

David Sellu, left, was convicted of manslaughter after the death of James Hughes, right, following an operation at Clementine Churchill hospital, above

Sellu describes as “very long and bruising,” has taken the Sierra Leone born surgeon through a coroner’s inquest, hospital investigation, police inquiry, prosecution, conviction, 15 months in prison, and, eventually, to the Appeal Court, where three senior judges quashed his conviction on 15 November.

The Appeal Court judgment reveals failures throughout the system, including problems in obtaining an anaesthetist in a private hospital without an anaesthetic on-call rota.

Influence of expert witnessesMore than 300 doctors, most of them consultants, signed a letter that was circulated to all the medical royal colleges last year, voicing concern about the increasing criminalisation of doctors and calling for a review of the role of expert witnesses in such complex cases.

Sellu served half his 30 month sentence in jail and half on licence. While he was still behind bars, his supporters, most of them fellow doctors, campaigned for reform of the legal process and worked to have his conviction overturned. A fresh team of


lawyers came up with new grounds for appeal, and his case finally reached the Appeal Court last month.

The three judges ruled that the conviction was unsafe because the trial judge, Mr Justice Nicol, had given an inadequate direction to the jury. The jurors had not been given enough help to decide whether the negligence that Sellu was accused of was “gross”—in other words, so bad as to amount to a crime. The expert witnesses for the prosecution had opined that a particular failure or delay constituted gross negligence, but that was precisely the question the jury had to decide—the “ultimate issue,” as lawyers call it. Nicol had not made it clear enough to the jury that they did not have to take the experts’ word for it. It was for the jury to weigh up those opinions along with all the other evidence and decide the issue.

Growing problemProsecutions of doctors for gross negligence manslaughter in the UK were rare until the 1990s. Even after prosecutors started bringing such cases in greater numbers, most doctors were acquitted, and until recently those who were convicted usually received suspended prison sentences.

However, between 2012 and 2015 four doctors were convicted of gross negligence manslaughter—two after pleading guilty—and three went to prison. The fourth, Hadiza Bawa-Garba, had her jail term suspended, and is seeking to appeal. All four are from ethnic minorities.

“The number of ethnic minority people involved is very disturbing,” says Sellu. “The Crown Prosecution Service has questions to answer in that regard. The same prejudice carries on into the criminal justice

system. As a black person standing at the Old Bailey, you are guilty until proven innocent.”

Successful appeals are rare. Sellu is the first doctor since 1993 to have a manslaughter conviction quashed. That year, the Court of Appeal quashed the conviction of two young doctors, Michael Prentice and Barry Sullman, who mistakenly injected vincristine into a patient’s spine instead of into a vein. The appeal judges in that case called on the Law Commission, the law reform body for England and Wales, to examine, as a matter of urgency, the state of the manslaughter law.

One problem identified by the commission in its 1996 paper on homicide is that the test for deciding guilt is circular. The jury must be directed to convict the doctor of a crime if they think his or her conduct is criminal. But because juries don’t give reasons for their decisions “it is impossible to tell what criteria will be applied in a particular case,” the commission noted. “This must lead to uncertainty in the law. The CPS has told us that prosecutors find it difficult to judge when to bring a prosecution, defendants have difficulty in deciding how to plead, and there is a danger that juries may bring in inconsistent verdicts on broadly similar evidence.” The Law Commission looked at manslaughter again in 2006, but the law remained unchanged.

In a 1996 appeal by John Adomako, an anaesthetist convicted of manslaughter after failing to notice that his patient’s endotracheal tube had become dislodged, the UK’s then highest court, the House of Lords, rejected an argument that the test for manslaughter should be recklessness, rather than gross negligence. In a 2004 case the Court of Appeal again declined to change the test.

“My view is that it would be more appropriate to raise the bar to recklessness,” says Oliver Quick, senior lecturer in law at Bristol University, who has published several papers on medical manslaughter. “You would reduce the risk of weak

cases being prosecuted in the first place and it might be easier to understand for the jury.” He adds, “David Sellu should never have been sent to prison in my eyes.”

Sellu’s case has also focused new attention on the role of prosecution expert witnesses. If an expert gives an opinion on the ultimate issue—in this case, whether the negligence was gross—the judge must make sure that the experts are not usurping the jury’s role.

Brian Leveson, president of the Queen’s Bench Division, who gave the judgment in Sellu’s appeal, said the Appeal Court judges were reinforced in their view that Nicol’s directions were insufficient by his response when the jury sought assistance, asking whether they were “deliberating legalities or . . . judging as human beings, lay people.” Nicol had repeated his directions, underlining that sympathy and emotion played no part, but again without identifying where the line should be drawn.

“The jury deliberated for more than three days, then came out and said, ‘We don’t understand what we’re deliberating on,’” recalls Sellu. “The judge never explained to them the answer to that question.”

He still faces an investigation by the General Medical Council and has told Hughes’s family of his regret that Hughes did not survive the operation. “He died on my watch. In retrospect, I could have done more for him.”

Jenny Vaughan, the consultant neurologist who chaired the campaign group Friends of David Sellu, is “delighted” at the outcome of the appeal. However, she said, “as a practising doctor I am only interested in what makes patients safer so that lessons are learnt. It is never usually one person’s fault when things go wrong and criminal prosecution is not the way to ensure patient safety can be assured for future generations.”Clare Dyer, legal correspondent, The BMJ [email protected] this as: BMJ 2016;355:i6274

Ж See EDITORIAL, p 347

Hadiza Bawa-Garba, had her jail term for manslaughter suspended, and is seeking to appeal against her conviction

Between 2012 and 2015four doctors were convicted of gross negligence manslaughter—two after pleading guilty—and three went to prison

Prosecutions of doctors for gross negligence manslaughter in the UK were rare until the

1990s


Getting enough vitamin D to protect musculoskeletal health requires eating the right food and getting short bursts of daily sunshine in the summer. However, for many people this can be harder to achieve than it sounds, and some people will need to take supplements in autumn and winter.

The Scientific Advisory Committee on Nutrition (SACN) reviewed previous recommendations1 in the light of public health advice to stay out of the sun and wear sunscreen, and accumulation of new evidence on vitamin D. It has recommended a reference nutrient intake—the amount sufficient to meet the needs of 97.5% of the population—for vitamin D of 10 μg a day to protect people aged four or older.2

Population protectionSACN based its recommendation on a review of the evidence on musculoskeletal health outcomes, concluding that there was insufficient evidence to make dietary recommendations on non-musculoskeletal outcomes and the risk of poor musculoskeletal health is increased at serum 25-hydroxyvitamin D concentrations below 25 nmol/L.2 This concentration is not diagnostic of disease but indicates the level below which risk of poor musculoskeletal health is increased; it represents a population protective level. On the basis of modelling work, SACN estimated that 10 μg/day is the amount of vitamin D needed for 97.5% of the population to maintain blood concentrations at or above 25 nmol/L when exposure to sunshine is minimal.2

SACN’s evaluation adhered to its evaluation framework,3 which is based on an evidence hierarchy used to judge the strength of each study according to design. Most weight is generally placed on randomised controlled trials since only this study type can demonstrate a causal relation between an intervention and a health outcome. This approach takes into

account the full body of evidence, not simply single studies.

It’s not easy through diet aloneVitamin D is found in only a small number of foods, including oily fish, red meat, liver, egg yolk, and fortified breakfast cereals and fat spreads so it’s not easy to get what you need from diet alone. 4

Most people’s skin will make vitamin D in the summer, but the National Diet and Nutrition Survey shows that around 20% of people in the UK do not have blood levels above 25 nmol/L even in the summer.5 As it is not possible to identify these people SACN recommended 10 μg daily all year.

Public Health England advises that eating a healthy, balanced diet and getting some sun will provide enough vitamin D during spring and summer. But during autumn and winter diet is the only source and so everyone should consider a daily supplement of 10 μg during these months.

Some population groups—including those who spend a lot of time indoors and those who habitually wear clothing that covers most of the skin while outdoors— are particularly at risk of deficiency, and should take a supplement all year round.

People with darker skin, from African, Afro-Caribbean, and South Asian backgrounds, may not get enough vitamin D from summer sunlight2 and should also consider a supplement all year round.

Avoiding harmTaking 10 μg of vitamin D daily is unlikely to result in harmful levels of vitamin D.2 6 The tolerable upper level is 100 μg/day for those aged 11 or older and 50 μg/day for children aged 1-10.2 6 Excess intake can result in hypercalcaemia, demineralisation of bone, soft tissue calcification, and renal damage. People with vitamin D deficiency will need higher doses and should take their healthcare professionals’ advice.

A key role for PHE is to keep the public informed of new evidence about nutrition. Getting enough vitamin D is important as poor musculoskeletal health is in the top 10 causes of disability adjusted life years.7 For many, a supplement will be necessary.

yes In darker months diet is the only source of vitamin D, but it’s found in only a small number of foods

HEAD TO HEAD

Louis Levy, head of nutrition science, King’s College London [email protected]


noWe have a strange love affair with vitamin supplements that makes the message that everyone should take vitamin D in winter an easy sell. But is this recommendation evidence based? With a fifth of the population reported to have low levels is this a real modern epidemic or a pseudodisease? Will tablets cure us or prevent problems and, importantly, are they completely safe?

Thresholds of when to worry about blood levels of vitamin D (25-hydroxyvitamin D) are poorly defined and confusing. Deficiency and insufficiency levels were arbitrarily decided by clinical societies and international bodies without consensus. Thresholds for insufficiency vary from 25 to 75 nmol/L, but studies suggest 30 nmol/L is adequate for most people.8 Clinical deficiency (<10 nmol/L, although some use <25 nmol/L) is usually clear cut because it is accompanied by raised parathyroid hormone concentrations. However, labelling people as deficient based on vague moveable thresholds that fail to account for genetic influences that explain half of the variation will cause many false positive results and potentially overtreatment.9

Risk of harmMost people assume that calcium and vitamin D supplements are safe. My clinical practice changed when evidence suggested that calcium supplements, as well as being ineffective prophylaxis against fracture, may cause heart disease.10

While the new recommendations for widespread vitamin D supplementation are modest in terms of dose (10 μg or 400 IU), they will inevitably lead to overdose in some. Many people already take additional sources of the vitamin—for example, in cod liver oil tablets or fortified food—or they buy high dose supplements. Patients with very high vitamin D levels (100-180 nmol/L) are becoming routine in clinical practice. Worryingly, several randomised trials have reported that patients with high blood levels or taking large doses (above

800 IU) had an unexpected increased risk of falls and fractures, suggesting this vitamin can have unexpected toxic effects.11 12

Limited evidenceThe government should not recommend any intervention without convincing evidence of benefit. Despite a few hundred systematic reviews and meta-analyses, a recent review found highly convincing evidence of a clear causal role of vitamin D does not exist for any of 137 outcomes.13 As an example, it was widely believed that vitamin D supplements prevented cardiovascular disease, but most meta-analyses and, importantly, Mendelian randomisation studies have not shown any effect in humans.15 The same is likely for osteoporosis.

The supplementation recommendation assumes data on preventing osteoporosis and fracture is good. It is not. An independent Cochrane review team recently reviewed 31 trials and found no overall effect of vitamin D supplementation on fractures.16 They reported a small effect on hip fracture (but only with calcium) and had to treat 1000 elderly people before preventing one fracture. The evidence is slightly better for elderly people in care homes with poor diets. But this is based on striking results from some early trials whose results were not replicated. More worryingly, the studies in elderly people show no clear benefits on muscle strength or mobility.17

We have created another pseudodisease that is encouraged by vitamin companies, food manufacturers, and charities. Healthy people should get vitamin D from small doses of sunshine every day plus dietary sources and trust evolution will have dealt with the fact that in northern climes our vitamin D level naturally drops in winter without us snapping our limbs.

Although vitamin D treatment has a role in people with proved deficiency or in high risk groups, the rest of us should avoid being “treated” for this pseudodisease, save NHS resources, and focus on having a healthy lifestyle, sunshine, and a range of real food.Competing interests: TDS is author of The Diet Myth. Cite this as: BMJ 2016;355:i6183

HEAD TO HEAD

We have created another pseudodisease that is encouraged by vitamin companies, food manufacturers, and charities

Tim D Spector, professor of genetic epidemiology, King’s College London [email protected]

Do healthy people need a vitamin D supplement in the winter?Louis Levy argues that recent dosage recommenda-tions can only benefit the public’s musculoskeletal health. But Tim Spector counters that the guidance is based on weak evidence and is no substitute for daily sunshine and good food


BMJ CONFIDENTIAL

Waheed ArianTelemedicine pioneer

Waheed Arian, 33, is a radiology specialist registrar in northwest England who has established a telemedicine scheme, Arian Teleheal, whereby UK medics use Skype to advise their clinical colleagues at emergency departments of major hospitals in Afghanistan. Arian was born in Kabul during the Soviet-Afghan conflict and narrowly escaped death many times before making his way to Britain aged 15. He graduated from Cambridge University and gained additional qualifications from Harvard University and the Imperial School of Medicine. He is passionate about using education to help communities across the globe, and this informs the long term goals of his charitable trust.

What was your earliest ambition?I’ve always wanted to be a doctor.Who has been your biggest inspiration?My father, who has always told me to think big and to believe that, with hard work, almost anything is achievable.What was the worst mistake in your career?Life and careers are full of challenges. Learning from each challenge to become a better person is my personal motto.What was your best career move?Founding the Arian Teleheal charitable trust (www.arianteleheal.com).What poem or song would you like at your funeral?Hang on, let’s talk about living in peace and happiness for now.Who is the person you would most like to thank, and why?My parents, for protecting me during my childhood in the Afghanistan war.If you were given £1m what would you spend it on?Reducing healthcare inequality through our charitable trust.Where are or were you happiest?When surrounded by family and friends.What single change has made the most difference in your field in your lifetime?Telemedicine. Do you support doctor assisted suicide?No.What book should every doctor read?My autobiography, which will hopefully be out in 2017.What is your guiltiest pleasure?Late night eating while working on creative ideas.What is your most treasured possession?The love of my family.What, if anything, are you doing to reduce your carbon footprint?I prefer using public transport.What personal ambition do you still have?To reduce healthcare inequality significantly worldwide in the next five years.Summarise your personality in three wordsHardworking, kind, visionary.What is your pet hate?My wife leaving the Hoover in awkward places around the house!What would be on the menu for your last supper?Qabuli pilau (traditional Afghan cuisine) with British fish and chips.Do you have any regrets about becoming a doctor?I have no regrets about becoming a doctor, scientist, innovator, and pioneer.If you weren’t in your present position what would you be doing instead?Working with and helping people in a different way.Cite this as: BMJ 2016;355:i6143

ILLUSTRATION: DUNCAN SMITH

Health policies lack transparency - BMJ 2018-03-19 · this week LATEST ONLINE • Plans for improving care are being derailed by acute care deficits, GP leader warns • Government

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