this week POETRY page 339 • WORKFORCE PLAN page 340• ANTIDEPRESSANTS ROW page 342 ROGER ASKEW/THE OXFORD UNION/SHUTTERSTOCK OXFORD ASKEW/THE ROGER NHS will plug holes in public health

EXCLUSIVE The NHS will step in to pressures on GP services and accident and NHS England chief executive commission public health services in places emergency departments.” Simon Stevens stated the need where cuts to council spending are putting Stevens said that there were also further for an overall “health balance sheet” for the country as a pressure on services, NHS England’s chief opportunities for the NHS to make public whole executive has told The BMJ. health interventions in people’s day to Simon Stevens said that, if councils day interactions with health services couldn’t allocate enough of the funding and by influencing actions on a broader they received from central government to scale. “There are the much wider policy public health, the NHS would quickly need improvements that will drive prevention to commission services itself. Stevens spoke and inequalities reduction,” he said. to The BMJ at the Health Foundation’s “Air pollution, obesity, alcohol, tobacco, annual event at the end of May. poverty—part of our role there is to help Stevens said that, since the transfer of advocate for public health policy.” responsibility for public health services In a speech at the same event Stevens from the NHS to local councils in 2013, said there was a need to look more broadly some councils had failed to provide at the country’s health. “A lot of the way in LATEST ONLINE adequate support services such as smoking which we discuss and debate the NHS is cessation, drug and alcohol and sexual looking at the flow of healthcare treatments Coroner calls for health services, and school nursing. and the numbers of people passing through national asthma policy after death “We all want to see those services our doors each year,” he said. of 10 year old supported and enhanced over the next five “If we are increasing our overall risk years, in contrast to what has happened in factors for illness, that in a sense is future Indian government told to ban some places over the last four or five years,” healthcare need and cost that we are storing e-cigarettes he said. up, and it would be good if we could more “If councils don’t get the backing they systematically begin to have a sort of health WHO teams arrive in need then there are obvious consequences, balance sheet for the country. Pakistan to from pressures on sexual health services “And then that enables us to make establish that show up very quickly in terms of smarter trade-off choices.” source of HIV outbreaks and increased prevalence Tom Moberly, The BMJ infections of sexually transmitted infections, and Cite this as: BMJ 2019;365:l4039 the bmj | 8 June 2019 337 SEVEN DAYS IN Medical manslaughter: police should consult “super-experts,” review advises A cadre of “super-experts” to help the police considering prosecuting doctors for gross negligence manslaughter has been recommended by an independent review commissioned by the General Medical Council. The review of medical manslaughter followed widespread unease over recent cases, including those of the trainee paediatrician Hadiza Bawa-Garba and the consultant surgeon David Sellu (left, centre), in which individual doctors seemed to carry the can for systemic failures. The UK-wide review, chaired by the consultant cardiac surgeon Leslie Hamilton, also concurs with the Williams review of gross negligence manslaughter commissioned by the UK government, which recommended last year that the GMC lose its power to appeal against decisions by medical practitioners tribunals. Hamilton’s review recommends that police forces should be able to draw on a pool of experts for advice on whether a case reaches the required threshold. These experts, who would be skilled in the same specialty as the doctor under investigation, would receive training in the law. When an untoward death occurs that looks as though it may lead to a police investigation, the review recommends independent oversight of the local investigation into the incident.

SPL Clare Dyer, The BMJ Cite this as: BMJ 2019;365:l4045

Litigation it put services for combined Climate change progress,” because smoking Ex-NHS England director positron emission tomography Doctors form Extinction is now banned completely in sentenced for voyeurism and computed tomography out Rebellion group the grounds of 69% of NHS Jonathan Fielden, former deputy to tender. At the committee’s Over 200 doctors from various acute care trusts in England, it medical director of NHS England, request Hancock is considering specialties joined forces to fight acknowledged that more work has been given a five month the case and its potential impact climate change and was required to meet suspended prison sentence after on patients. NHSE insisted that it promote planetary and the NHS’s 2014 admitting watching a 15 year old had engaged with the committee. public health as part of commitment for all girl showering through a hole a new group, Doctors trusts to be fully in the ceiling at a private home. Conference row for Extinction Rebellion. smoke free by spring Fielden, who was also director RCGP withdraws speaking The group initially met 2020. Duncan Selbie, of specialised commissioning invitation to journalist through social media PHE chief executive, services at NHS England, took The Royal College of General and is now holding said, “It cannot be leave in January 2017 and Practitioners withdrew an meetings around the right that it is more later resigned. He has been invitation to the journalist and UK. Its creation comes acceptable in some hospitals to suspended from the UK medical right wing commentator Julia in response to the Extinction smoke at the front door than it is register on an interim basis and Hartley-Brewer (below) to speak Rebellion movement, which held outside a pub.” now faces a fitness to practise at its annual conference protests in April calling for people hearing that could see him in October, after members to take part in “non-violent civil Sure Start found to have suspended for up to a year or voiced concerns about her disobedience to achieve radical improved children’s health struck off. “highly controversial views,” change” and to minimise the risk The government’s Sure Start including a previous tweet of “human extinction and programme had major health Outsourcing referencing Enoch Powell. In ecological collapse.” benefits for children in poorer NHSE’s cancer scanning a statement the RCGP said, neighbourhoods, a report procurement is criticised “It has become clear that Public health published by the Institute Oxfordshire County Council’s some of the views she has A third of NHS for Fiscal Studies concluded. joint health overview and scrutiny expressed are too much hospitals aren’t Researchers analysed the effects committee strongly criticised at odds with the core smoke free among children born over the NHS England over plans to values of RCGP Almost a third entire period from the scheme’s outsource local cancer scanning and our members, of NHS hospital inception in 1999 to its peak services to a private company, and our work to trusts have not yet in 2009-10. They found that it InHealth. In a letter to England’s promote banned smoking reduced the likelihood of primary health secretary, Matt Hancock, inclusivity on their grounds, school children being admitted seen by The BMJ, councillors within the said Public Health to hospital and the risk of injuries accused NHSE of “flagrant profession and England. Although at all ages. It also saved the NHS disregard” for a legal obligation among the agency around £5m through reduced to consult the committee before patients.” reported “steady admissions.

338 8 June 2019 | the bmj SIXTY SECONDS MEDICINE ON . . . Concussion Former Chelsea FC POETRY Most UEFA players’ head doctor Eva Carneiro collisions aren’t assessed was censured by ISN’T THIS A MEDICAL JOURNAL? the team’s manager It is, but these are medical poems— An average of one potential for attending to the Hippocratic hymns, if you will. In Scotland all concussive event occurred in each injured Eden Hazard lucky doctors graduating in 2019, 2020, and football game during the 2016 (right) in 2015 UEFA European Championship, 2021 will be given a volume of verse called yet nearly three quarters of Tools of the Trade. the head collisions were not THAT’S A NICE IDEA. HAS IT EVER BEEN medically assessed by healthcare DONNE BEFORE? staff, a review published in BMJ This is the second instalment of the book. Open found. A team of trained The first edition was given to doctors observers reviewed all 51 games graduating in 2014 and 2015. This follow-up and identified 69 potential diabetes, raised blood pressure has been produced with the help of the concussive events, an average and cholesterol, and high use of FLU Medical and Dental Defence Union of Scotland and the Royal College of General of 1.35 per match. But only 19 alcohol and tobacco. Adjuvanted (27.5%) had led to a medical Practitioners Scotland. influenza vaccine assessment on the sidelines, and Sexual health JUST SCOTLAND? THAT’S HARDY FAIR! provided about all 19 concluded with the athlete MPs call for action on lack Alas, this initiative is north of the border only. returning to play after a brief of access and inequality But copies are available from the Scottish assessment. The latest sexual health statistics 60% Poetry Library (www.scottishpoetrylibrary. seem positive but mask some effectiveness org.uk/shop), which is overseeing the Conflict worrying underlying trends and for over 65s in project as part of its wider efforts to use Gaza’s health system sees inequality in access, MPs warned. England’s last poetry to support health and wellbeing. The influx of gunshot wounds library’s director, Asif Khan, says, “Poetry is A report by the health select winter flu season Hospitals in Gaza are struggling committee said that though the an ideal medium for helping to build one’s to deal with a “staggering” number of STIs and teenage [Public Health resilience and emotional intelligence.” number of gunshot wounds, pregnancies is falling, syphilis England] BUT WHAT ARE WORDS WORTH? which make up 25% of the total and gonorrhoea diagnoses are As the editors Lesley Morrison, John Gillies, casualty caseload and are the rising, antimicrobial resistance is and Ali Newell write in their introduction, “In highest cause of death among becoming a big problem in treating order to look after patients, we need to look casualties, the World Health gonorrhoea, and Mycoplasma after, and be kind to ourselves.” The book is Organization reported. In the year genitalium, a newly discovered STI, being offered as a “compassionate friend” to 30 March 2019 some 6872 is a growing threat. for juniors to turn to in challenging times. gunshot wounds were recorded, DO SCOTTISH BARDS FEATURE with 210 people dying. Many Regulation HEAVILY? Trainee GP warned over No. It’s not solely a “Burns unit.” It also fake prescribing for herself includes verse from poets who are (or were) A trainee GP who faked a doctors, such as Dannie Abse, Rafael Campo, prescription for antibiotics Glenn Colquhoun, and Martin MacIntyre. from another doctor to treat her own “embarrassing WHAT IF I’M NOT WILDE ABOUT medical condition” was given RHYMES? a written warning by a medical Never fear. The editors have survivors were left with excessive practitioners tribunal. Ashleigh consciously included poems to suit different situations and varying damage to bones, neurovascular Williams wrote another doctor’s readers’ tastes. structures, and soft tissue. name on the top of a prescription for amoxicillin, even though SO, MIGHT WE SEE POETRY Living in war zone affects she had already signed her own PRESCRIBED ON THE NHS SOON? long term heart health name at the bottom. GMC counsel Maybe on a complementary basis. As People who live in war zones may acknowledged that patient safety the authors say, “Carry the poems with have a higher risk of heart disease was not an issue but that a finding you and enjoy them. Speak them out and stroke even years after of impaired fitness to practise loud and use them as tools to connect with the conflict ends, a systematic was necessary to maintain public your patients, your colleagues, and yourself.” review showed. Conflicts were confidence in the profession. Abi Rimmer, The BMJ linked to an increased risk of coronary heart disease, stroke, Cite this as: BMJ 2019;365:l4025 Cite this as: BMJ 2019;365:l2405

the bmj | 8 June 2019 339 WORKFORCE

Allow more Workforce plan: Let doctors overseas doctors to work in NHS, halve pension contributions committee says “It is clear that enior clinicians will be lists, fill rota gaps or take on further by itself this able to halve their pension supervisory responsibilities.” All doctor roles should be added to proposal will contributions to avoid the official list of jobs that don’t not remove the significant tax charges, Greater flexibility have enough UK resident workers disincentive under new proposals England’s health and social care to fill vacancies, the Migration Soutlined by the government. The new secretary, Matt Hancock, said, “The for doctors Advisory Committee has “50:50” offer was unveiled as part of reforms we are setting out today will recommended. Doctors in certain to reduce the long awaited interim workforce give clinicians greater flexibility to grades and specialties and all their working plan for the NHS in England. manage their pensions, have more nurses are already on the shortage hours” Currently, the NHS scheme does not control over their future, and offer a occupation list. Chaand Nagpaul, offer any flexibility in the rate at which deal that’s fair to doctors, taxpayers, The committee said it had made BMA chair of the pension builds, with the highest and the patients they care for.” the recommendation “as there council earning consultants contributing Chaand Nagpaul, the BMA’s chair is sufficient and overwhelming 14.5% of their pensionable pay each of council, welcomed the plan, but evidence of a UK-wide month. This has led to doctors taking he added, “We have modelled the shortage” of doctors. early retirement or cutting clinical proposed 50:50 scheme, and it is clear It said that, hours, as they are unable to control that by itself this proposal will not while the move their contributions and thus exceed remove the disincentive for doctors to to include all the pensions allowance, which limits reduce their working hours. It needs doctors on the list what NHS staff can pay into their to be part of wider reform. Given the would not solve pensions before tax charges apply. complexities of the NHS scheme and the workforce Many doctors are thus left with large the fact that individual circumstances crisis in the long tax bills. vary, it is essential that any flexibility Danny Mortimer term, it would The government said that it had offers far more than simply paying of the Cavendish “alleviate some listened to doctors’ concerns and half of the employee’s contribution for Coalition said the difficulties” in would now consult on the new half the accrual of pension.” recruitment of the short term. pension proposal, which it hoped The interim plan also outlines social care staff was also of Danny would enable clinicians to “freely take several other proposals, including “huge concern” Mortimer, on additional shifts to reduce waiting devolving major responsibilities co-convener of the Cavendish Coalition of health and social care organisations, THE NHS SCHEME does not offer any flexibility in urged the government to enact the the rate at which the pension builds, with the highest earning consultants recommendations quickly to ensure continued recruitment to shortage contributing 14.5% of their pensionable pay each month occupations. He said, “The international recruitment of social care staff Trainees bring small rise in GP numbers remains of huge concern, and the government will need to look closely The number of GPs working shows that the headcount of practice remains an absolute at this sooner rather than later for the in England has crept up in the fully qualified GPs fell by 494 priority for us.” sector to be able to recruit and retain past year, a rise almost entirely year on year, while the number GPs who feel an increasing staff at the levels required to meet the accounted for by an increase in of trainees increased by 760. workload each year despite level of need.” GP trainees. The great majority of these new these numbers will identify Chaand Nagpaul, BMA council In March 2019 England’s GPs recruits to the GP workforce with data showing that the chair, said that the BMA was totalled 44 847, a rise of 350 were trained in the UK, lending time available for each patient delighted with the recommendation, (0.8%) on the same month in credence to NHS England’s has fallen steadily for the past as it had been calling for such 2018. The full time equivalent claim that plans to increase four years. In that period the a change for some time. “The count, which allows for some recruitment are working. amount of GP time available per government must now move swiftly GPs working only part time, Nikki Kanani, interim medical patient per year has fallen from to implement the committee’s also showed an increase, rising director for primary care at NHS 70.4 minutes to 68.3 minutes. proposals,” he said. from 34 424 to 34 736 (0.9%). England and a London GP, said, GP numbers have risen over Abi Rimmer, The BMJ But closer examination of the “Recruiting, retaining, and the same period, although only Cite this as: BMJ 2019;365:l2374 data released by NHS Digital supporting more doctors into modestly if measured as full

340 8 June 2019 | the bmj COMMENTARY BY ANDY COWPER The plan is a fantasy

The Interim NHS People Plan is fantastic, in the sense that it is derived from fantasy. What it sets out is simply not credible for tackling the NHS’s workforce challenges. The plan is wholly unequal to the scale of the problem facing nearly every NHS organisation, with providers reporting a shortage of more than 100 000 full time equivalent staff. Instead of measurable (and thus “failable”) numerical targets, the interim plan promises concordats, engagements, offers, and scorecards. This all sounds much like the things you do when you don’t for workforce planning to regional original target date of 2020. have a proper plan. The consequence is that NHS staff integrated care systems to reflect The plan said that medical schools will carry on experiencing workforce shortages and rota differing priorities will “prioritise and support generalist gaps as the NHS normal, and so will patients. careers” and work to “create more Insofar as there is any strategy, the plan aims to use Regional autonomy flexibility” in medical training and the new integrated care systems (ICSs) as the local units Professional regulation, careers, including expanding part- of workforce planning in the new NHS. But the network credentialing, prescribing rights, pay, time training and opportunities for of ICSs scarcely exists, and they have no statutory basis and pension rules will continue to portfolio careers. Junior doctors will as organisations. The notion that the ICSs will have the be set at a national level, but areas get better support at the start of their capacity and capability to do more workforce planning, such as non-medical education, careers, and greater attention will training, and education is, erm, interesting. educational opportunities and be paid to their mental health and No document can get everything wrong, and the support for junior doctors, wellbeing, the report added. plan does acknowledge serious cultural problems in relationships with higher education Dido Harding, chair of NHS the NHS and its leadership. It wants leaders of NHS institutions, and pay rates for bank Improvement, said, “The NHS needs organisations to model more humane and kinder staff will be able to be led locally. more staff. But that, on its own, is not behaviour. But it doesn’t seem to recognise that most Regions will also be able to access enough. NHS leaders have been working in a highly directive and new frameworks listing approved “We need to change the way people frequently bullying and toxic leadership culture. Nor international recruitment agencies work in the NHS to recognise the would many be convinced that national organisations to ensure “consistent operational changing needs of patients and to consistently model the desired behaviours. and ethical standards” and support create a modern, caring, and exciting It is a positive sign that the document is honest about increased international recruitment, workplace that should be the best the shortcomings of senior managers, stating as it does the plan said. place to work in England.” that “everyone who has worked in the NHS can think of The plan reiterated an earlier The full workforce plan is due to a manager or a working environment that they would commitment by the government to be released later this year, after the rather forget.” But it is unclear what is going to be done tackle shortages of GPs by increasing government’s spending review. differently in the wake of this plan. their number by 5000, but only “as Elisabeth Mahase, The BMJ Andy Cowper is editor, Health Policy Insight soon as possible” rather than by the Cite this as: BMJ 2019;365:l4019 Cite this as: BMJ 2019;365:l4036

In March 2019 England’s The headcount of fully Patient numbers have GPs totalled 44 847, a rise qualified GPs fell year on year risen more quickly, by of 350 (0.8%) on the by 494. The number of 2.2 million (3.8%) same month in 2018 trainees rose by 760 since March 2016 time equivalents, and the total corresponding rises since 2016, health professionals over the hours worked by GPs has also while the number of locums next five years. “As these multi- increased. But patient numbers cannot be compared over this disciplinary teams ease the GP figures do show a recent rise in have risen more quickly, by 2.2 period, as the methods of workload, it is hoped doctors overall GP numbers, including million (3.8%) since March 2016. counting have changed. will be able to offer longer those in training, but it is The small print in the data NHS England summarises the appointments to patients who nowhere near sufficient to deal provided by NHS Digital shows data by saying that the “loss need them,” it said in a press with the reality of what is needed a continuing fall in GP partners from the workforce is stabilising” release. to address the crisis facing (down by 3.6% in the past year and promises that planned Richard Vautrey, chair of the general practice.” and by 11.9% since 2016). extra resources will support BMA’s General Practitioners Nigel Hawkes, London Salaried GPs have shown the recruitment of 20 000 more Committee, warned, “These Cite this as: BMJ 2019;365:l2393 the bmj | 8 June 2019 341 Royal college adds voice to concerns over NICE depression guidance

atients who are coming off antidepressants have a wide range of experiences, and some have severe symptoms, the Royal College of Psychiatrists Phas acknowledged in a statement urging the National Institute for Health and Care organisations Excellence to update its guidance. 35 called for a “full and The college is a late recruit to a campaign that has been waged in The BMJ, the press, proper revision” of and on social media over what is seen as NICE’s guideline, complacency in the face of many complaints which is now not from patients. At the heart of the argument is expected to appear NICE, strongly criticised for a draft revision of until February 2020 its 2009 guidance published in July 2017. —two years late

Patients’ views “ignored” Critics have said that the 2017 draft relied on inadequate data and largely guideline deem to be the wrong side. In adviser to a panel set up by Public Health ignored the views of patients. Last month, a letter to the Times in February 2018, England to review the effects of withdrawal. 35 organisations, including the British psychiatrist David Baldwin and college Burn said that his resignation was “a great Psychological Society and the South London president Wendy Burn wrote that “in the pity” and that she was disappointed any and Maudsley NHS Foundation Trust, vast majority of patients any unpleasant resignation should take place in such called for a “full and proper revision” of the symptoms experienced on discontinuing circumstances. guideline, which is now not expected to antidepressants have resolved within two Campaigners celebrated the college’s appear until February 2020—two years late. weeks of stopping treatment.” new statement as a victory. James Davies, But until now the college has been silent, This attracted a barrage of online abuse, a psychotherapist from the University of save for weighing in on what critics of the and Baldwin felt unable to continue as an Roehampton and strong critic of the NICE Collusion alleged to have resulted in 700% price rise

The UK competition watchdog The CMA has provisionally prochlorperazine. Medreich Alliance said in a has accused four companies found that the companies obtained a licence to supply it statement it had of unlawfully colluding in an entered an agreement for Alliance in January 2014 but did not start “no involvement in agreement that hiked the price to provide the drug exclusively supplying till November 2017. the pricing or distribution of of a prescription only drug used to Focus. Lexon received a share Ann Pope, the CMA’s senior prochlorperazine since 2013, to treat nausea and dizziness by of the profits that Focus received director of antitrust, said, when it was out-licensed 700% over four years. on sales of the drug and shared “Agreements where a company by the company to Focus The Competition and Markets these payments with Medreich, pays a rival not to enter the Pharmaceuticals on an exclusive Authority has provisionally the watchdog said. market can lead to higher prices basis, as is normal market concluded that Alliance, Focus, It alleges that, before entering and deprive the NHS of huge practice.” It added, “Alliance has Lexon, and Medreich agreed the agreement, Lexon and savings that often result from not had control of or influence not to compete for the supply of Medreich had been planning to competition between drug on, and nor has it benefited from, prochlorperazine 3 mg buccal or launch their jointly developed suppliers.” any price increases.” dissolvable tablets to the NHS. Lexon and Medreich have The four companies have the The price of a From 2014 to 2018 the not issued statements. Advanz right to make representations Pharma (which now owns Focus) 50 tablet pack of cost of the drug to the NHS before a final decision is reached. told the Times some of the price If the watchdog determines that prochlorperazine rose from rose from £2.7m to rises predated its ownership and competition law has been broken £6.49 in December £7.5m a year, even said it didn’t believe competition it can impose a maximum penalty 2013 to £51.68 though fewer packs were law had been infringed. of 10% of each company’s Clare Dyer, The BMJ in December 2017 dispensed worldwide turnover. Cite this as: BMJ 2019;365:l2362

342 8 June 2019 | the bmj As psychiatrists, we are duty bound to take on board the FIVE MINUTES WITH . . . Royal college adds voice to concerns concerns of patients who’ve experienced more severe and long lasting adverse effects of withdrawal from these drugs Pala Rajesh over NICE depression guidance Wendy Burn, Royal College of Psychiatrists president The RCS Edinburgh vice president on the college’s new international draft, told the Daily Mail, “This is a huge, for treating moderate to severe depression, dramatic shift in opinion by the college. It’s particularly in combination with talking postgraduate deanery a real step forward.” Psychiatrist Joanna therapies, and what we want is guidance Moncrieff of University College London told that best supports their use.” he Royal College of the paper, which has campaigned on the The college’s statement says that Surgeons of Edinburgh matter: “I’m really pleased to see this shift.” evidence of the effects of withdrawal is has been working with limited, since the original trials were not international medical Limited evidence designed to assess it. Differences of opinion graduates for the past The college’s report recommends a exist, and it is important to distinguish “T25 years. Our previous programmes have monitoring system to measure when between symptoms caused by withdrawal evolved and come together to form the new and why patients are prescribed and by relapse, it says. International Postgraduate Deanery. antidepressants; training for doctors in “However, while there are not “The surgical trainees come to work in the best prescribing practice; adequate support comprehensive data, the potential for UK for between 12 and 24 months, and at for patients worst affected by withdrawal; and existence of more severe and long the end of the programme they return to their and high quality research into the risks and lasting symptoms reported by patients home countries. Every doctor placed on the benefits of the drugs. needs greater recognition, including scheme has already done their postgraduate Burn said, “We know that NICE is in NICE clinical guidelines and patient surgical training in their home country. They working on updating its guidelines and information,” the statement says. have assessed the needs in their country and want to see them more in keeping with what Physicians should explain possible are coming to the UK to gain experience in a we’re hearing from some patients—and adverse effects to patients, advise them specialist area, such as maxillofacial surgery, GPs—about the range of experiences of not to miss doses or come off the drugs paediatric cardiac surgery, or specialist coming off antidepressants. rapidly, and monitor any adverse effects of orthopaedic practices. We are extremely “As psychiatrists, we are duty bound discontinuing treatment. Gradual tapering aware of not creating a brain drain, and the to take on board the concerns of patients of the dose is advised, and the longer a immigration policy is such that we could not do who’ve experienced more severe and long patient has been on the drugs the longer the that anyway. lasting adverse effects of withdrawal from tapering period should be. “The surgical trainee, the training these drugs. Nigel Hawkes, London organisation they come from, and the UK “Antidepressants can be very effective Cite this as: BMJ 2019;365:l2399 organisation they are trained in all benefit. Trainees are often placed in organisations where the consultants are fellows of our college. GP at Hand network gets green light Sometimes these consultants select the candidates that they want to send to the UK, The clinical commissioning concerns to the BMA’s criteria.” The CCG told but most of the time the trainees themselves group that hosts Babylon’s GP committee in light of Londonwide LMCs: “The choose to come here because of the quality of GP at Hand service has the announcement. A consensus within North education they will receive. said it “would welcome” spokesperson said, “We West London is that the “The UK trusts who train these doctors also an application from the remain of the view that best fit would be for the benefit, because if they impart good education provider to manage a single the Babylon GP at Hand Babylon GP at Hand practice they’ll get positive feedback, which will in turn primary care network. position does not meet to consider an application help them recruit other trainees. Having good But Londonwide Local the nationally negotiated to be its own individual quality doctors from overseas coming to train Medical Committees, which criteria regarding the network.” in the UK allows local trainees to spend more raised concerns that such an geographical contiguity of A spokesperson for time training and can help tackle the workforce agreement would contradict these new networks.” Babylon GP at Hand said, shortage we have in this country.” requirements agreed by the “This is a significant step Abi Rimmer, The BMJ “Detriment to practices” BMA and NHS England, towards delivering the Cite this as: BMJ 2019;365:l2402 said it was “dismayed” Londonwide LMCs digital first aims of the NHS that Hammersmith and especially wanted to know long term plan.” THE SURGICAL Fulham CCG had decided how Babylon GP at Hand CCGs are expected to TRAINEE, THE TRAINING that Babylon should be could establish itself as a ensure that all patients in ORGANISATION THEY permitted to manage its own primary care network “with England are covered by a COME FROM, AND THE “pan-London primary care no detriment to practices, primary care network by UK ORGANISATION network.” and their patients, who 1 July. THEY ARE Londonwide LMCs most definitely do meet Gareth Iacobucci, The BMJ TRAINED IN ALL said it had escalated its the nationally negotiated Cite this as: BMJ 2019;365:l2384 BENEFIT

the bmj | 8 June 2019 343 THE BIG PICTURE Katie gets a new face

Silence fills the room as the large team of medical professionals regard the face they have just surgically removed from a donor. This will soon be Katie’s face. At 21, Katie, who suffered a self inflicted gunshot wound at age 18, is the youngest person to receive a full face transplant. Over 30 hours the team at the Cleveland Clinic, Ohio, undertake this pioneering and transformational procedure, a potentially life changing solution for people with facial disfigurements resulting from severe injury or disease. The clinic has conducted a total of three face transplantations, including Katie’s, which because of the severity of her injuries was one of the most extensive ever attempted. The procedure effectively replaced all of her facial tissue, with transplantation of the scalp, forehead, upper and lower eyelids, eye sockets, nose, upper cheeks, upper jaw and half of the lower jaw, upper teeth, lower teeth, partial facial nerves, facial muscles, and skin. The photo, taken by Lynn Johnson during the operation in May 2017, and entitled Katie’s New Face, captures a pivotal moment in the complex procedure, which is by no means a quick fix. Patients undergoing this transplantation need follow-up surgery and long term postoperative care, as well as lifelong immunosuppressive drugs. It is one of 28 images that have been shortlisted for the 2019 Wellcome Photography Prize, the winner of which will be announced on 3 July. All shortlisted entries for the Wellcome Photography Prize 2019 can be seen at https://wellcome.ac.uk/what-we-do/our-work/ wellcome-photography-prize/2019. Elisabeth Mahase, The BMJ Cite this as: BMJ 2019;365:l4041

344 8 June 2019 | the bmj LYNN JOHNSON / WELLCOME / JOHNSON LYNN the bmj | 8 June 2019 345 EDITORIAL A health crisis is a social crisis Falling life expectancy and rising inequality are twin indicators of a society in trouble

omething is going badly Worsening scale than in the US.15 These trends expectancy began in 2011 and has wrong with society in the inequalities, combined have led to a rise in been accompanied by an increase UK and the US. Is it linked mortality in young and middle aged in health inequalities must lead to worsening 10 to Brexit and Trump? Of child poverty, adults. serious questions about whether the course, but they are the cuts to Alongside other rich countries, the government elected in 2010, with its Sconsequence not the cause of the UK rejoices in an infant mortality of flagship austerity policies, made a problem. A simple summary measure services and, three to four deaths per thousand live difference for the worse. It is difficult of the success of a society is its health: indeed, voting births. Even here, there is a worrying to answer such questions with life expectancy has fallen in the US for for Brexit or trend: between 2015 and 2016, infant precision, particularly since health three years in a row,1 and in the UK it Trump, will all mortality increased to nearly six per inequalities arise over a lifetime of has stalled since around 2011.2 continue thousand deaths in the most deprived cumulative disadvantage. When attention was first drawn to to make neighbourhoods, compared with a the slowing of life expectancy gains society worse stable rate in the most affluent 10%.11 Policy research in England,3 4 concern was raised It is important not only to Barr and colleagues entered this that it was not “real”—perhaps a document these trends but to tricky domain with an evaluation severe winter was causing a short understand the underlying causes of a government strategy to reduce term fluctuation. That speculation is and to do something about them. health inequalities, implemented given the lie by the latest publication In the US, deaths of despair follow between 1997 and 2010.12 They from the Office for National Statistics the social gradient—the shorter the examined the gap in life expectancy showing that life expectancy has duration of education, the higher the between the poorest 20% of areas stopped increasing in England and Michael Marmot, rate. Case and Deaton speculate that in England and the rest and found marginally declined between 2015 director, Institute cumulative disadvantage exacts a that inequalities in life expectancy of Health Equity, and 2017 among men and women in heavier toll on less educated people, were increasing before the strategy, Department of Scotland and Wales and among men with deteriorating job prospects, diminished during the strategy, 2 Epidemiology and in Northern Ireland. Public Health, stalling incomes, social isolation, and increased again when a new As a further indicator of societal University College and relationship breakdown all government came in with different ills, health inequalities are increasing London, London, UK contributing. policies. These researchers reached in both the UK and the US. In women m.marmot@ In the UK, the fact that the similar conclusions about infant particularly, life expectancy has ucl.ac.uk break in the long term rise in life mortality.13 Their results chime fallen in the most deprived areas of with analyses from the US of the England—the more deprived the area, long term downward trend in infant the steeper the decline.6 Inequalities mortality from 1965 to 2010. When in health derive from inequalities in a Republican was in the White House society.7 the downward trend slowed a little; when it was a Democrat, the trend Deaths of despair was a little faster.14 Initially, the slowing of life expectancy A stalling or reversal of long term in the UK seemed to come from a rise improvements in health and increases in mortality in older men and women. in health inequalities are of great The US experience, by contrast, concern to anyone who cares about was marked by a rise in mortality in health. They should also be a concern middle aged, non-Hispanic white to anyone who cares about the men and women. The big contributors society in which we live. Worsening were deaths from unintentional inequalities in social conditions, poisonings, opioids, suicide, and worsening child poverty, cuts to alcohol. In case there was any doubt services and, indeed, voting for Brexit that this rise in mortality reflected or Trump, will all continue to make important social trends, leading society worse. Health inequalities are economists Case and Deaton labelled telling us something fundamental these as “deaths of despair.” 8 about our society. And we must listen. The UK may now be heading in Cite this as: BMJ 2019;365:l2278 the US direction. Deaths of despair Find the full version with references at are increasing, albeit on a smaller Hartcliffe, Bristol: one of England’s most deprived areas http://dx.doi.org/10.1136/bmj.l2278

346 8 June 2019 | the bmj EDITORIAL Government in denial over poverty in the UK Health professionals have a duty to speak out as the NHS picks up the pieces

he UK is the fifth largest was eventually overturned by an economy in the world. independent tribunal, shortly before For almost three years, he died. this has been repeated The government’s reaction to by politicians and the UN report was predictable. A Tmedia commentators celebrating spokesperson described it as “a the country’s achievements and completely inaccurate picture of our looking forward to an even better approach to tackling poverty,”11 and future outside the European Union. the secretary of state for work and In May 2019, the same fact featured pensions is reported to be making a prominently in two important formal complaint to the UN. Alston reports that present the UK in a less was unimpressed.11 The response positive light. was, he said, “a total denial of a set Nothing Left in the Cupboards, by of uncontested facts,” so that his Human Rights Watch,1 describes a initial thought was that “it might country in which tens of thousands actually be a spoof.”11 of families lack enough food to live THOMOND/GUARDIAN/EYEVINE CHRISTOPHER Since 2010, mortality has UN special rapporteur on poverty Philip Alston (left) visiting a 13 on. The second report, by Philip food bank in Newcastle upon Tyne during his 2018 UK tour been stagnating and, for some Alston, the UN special rapporteur on groups, increasing.14 Noting these extreme poverty and human rights,2 A Salford has been chaotic, with many of developments, Alston recalled the also examines food poverty but goes general the most vulnerable people falling words of Thomas Hobbes, writing much broader, covering the many practitioner through the cracks. about England in the 17th century, ways in which successive British describes food This will resonate with the describing life as “solitary, poor, governments have been “dismantling general practitioners in the nasty, brutish, and short.”15 the social safety net.” Neither report insecurity north east of England, who makes comfortable reading for the as “a life- have described how their Brexit paralysis British government. The Human and-death workload is increasing because Without action to rebuild a caring Rights Watch report talks of “a grim situation” for of universal credit, with at least and supportive society, things picture of the grinding reality that some patients one consultation in every surgery can only get worse. Yet the British teachers are dealing with,” with “universal credit based.”4 Their government is currently in a state children arriving at school hungry, local council published a report of near paralysis as it struggles with without warm clothes or dry shoes. describing how universal credit the Brexit process. And as Alston Alston describes a situation that was worsening the health of people notes, “If Brexit proceeds, it is likely is not just “a disgrace, but a social with long term conditions, with to have a major adverse impact on calamity and an economic disaster some considering suicide.5 Alston’s the most vulnerable.” When added to rolled into one.” condemnation of the enormous the damage that any Brexit will do to growth of foodbanks6 will be no the NHS,16 the outlook is extremely Falling through the cracks surprise to the general practice in concerning. Those working on the frontline in Salford that has partnered with a When, as Alston argues, the NHS should be concerned. The local one, with one GP describing “the government has remained concept of “health in all policies” food insecurity as “a life-and-death determinedly in a state of denial,” recognises that many of the situation” for some patients.7 it is time for all health professionals determinants of health lie outside Selina Rajan, Alston’s criticism of “cruel, to stand up for those who are falling the health system in areas such as research fellow inhuman, and degrading” sanctions, through the increasingly large holes in employment, welfare, education, Martin McKee, imposed in a manner that is “harsh our social safety nets. We must do so and housing.3 When they fail, it is professor of and arbitrary” on people receiving not only for the individuals concerned European public left to the NHS to pick up the pieces. welfare payments, will be welcomed but for the future of the NHS, which, health, London And, as both these reports show by the doctors in Liverpool who as Wanless pointed out in 2002, School of Hygiene in graphic detail, in Britain today and Tropical fought on behalf of a man who was cannot continue to pick up the pieces they are failing on a grand scale. Medicine, London, assessed as able to work and had his following failures by others. Alston is especially critical of the UK benefits removed despite multiple Cite this as: BMJ 2019;365:l2360 government’s flagship welfare policy, martin.mckee@ illnesses that left him emaciated and Find the full version with references at universal credit. Its implementation lshtm.ac.uk barely able to walk.8 The decision http://dx.doi.org/10.1136/bmj.l2360 the bmj | 8 June 2019 347 The UK needs to legislate because current measures aren’t keeping rates high enough HEAD TO HEAD yes to ensure herd immunity Is coercion Eleanor Draeger, sexual health doctor and medical unvaccinated children received vaccines in the writer, Gravesend [email protected] six months after the law was passed in 2015. The UK legislates in many ways to improve the answer Last year Unicef published a sobering report individual or public health. Examples include on vaccination, and last month said that an a law to prohibit tobacco sales to under-18s, to low rates estimated 169 million children worldwide and a law to prohibit smoking in enclosed had missed a first dose of the measles vaccine public places, reducing passive smoking. in 2010-2017—21.1 million children a year The UK now needs to legislate to increase of measles on average, including more than 500 000 vaccination rates because current measures children in the UK. aren’t keeping rates high enough to ensure vaccination? Uptake of the measles, mumps, and rubella herd immunity. A recent article by Trentini (MMR) vaccine in the UK is 94.9% for the and colleagues simulated the effect of current first dose, but 87.2% for the second, short of vaccine strategies on future susceptibility to the 95% needed to produce herd immunity. measles, concluding that the UK may need If rates continue to decline we risk measles to introduce compulsory vaccination to becoming endemic again. bring susceptibility low enough to eliminate Beyond free access to government measles. recommended vaccines, which the UK Vaccination has previously been already has, there are many ways to increase compulsory in the UK: the Vaccination vaccination rates. Broadly, they are education Act 1853 was passed to increase smallpox (including communication and public immunisation. This led directly to the engagement), incentives, and legislation. formation of the Anti-Vaccination League, Education is the most widely practised, but which organised protests around the UK legitimate online sources on vaccination and eventually got the law changed to allow must compete with fake news and “antivax” conscientious objection. The arguments of rhetoric. A 2010 study found that viewing a vaccine sceptics today are very similar to website criticising vaccines increased people’s those used in the 1800s, and many parents perception of risk from vaccinations and wrongly believe the rhetoric that vaccines are decreased intention to vaccinate. harmful, unnatural, and an infringement of civil liberties. Punitive policies Vaccination is compulsory for at least one Protecting the vulnerable childhood disease in 11 other European Ethicists have argued, however, that countries, nine of which include measles. compulsory vaccination is acceptable Italy increased its number of compulsory because people who don’t vaccinate their vaccinations from four to 10 in July 2017, to children are potentially putting other include measles vaccine. Parents are fined if people’s health at risk—particularly those children attend primary school unvaccinated. who can’t be vaccinated for reasons of age or In January 2018 Italy’s ministry of health immunosuppression and are therefore more reported that 29.8% of unvaccinated children vulnerable. Brennan, for example, says, “One born from 2011 to 2015 had been vaccinated can justify mandatory, coercively enforced since the new law was enforced. vaccinations, not on paternalistic grounds, Australia doesn’t have compulsory but instead on the grounds that individuals vaccination as such, instead using financial may be stopped from participating in the incentives and quasi-mandatory vaccination. collective imposition of unjust risk of harm.” Its national policy of “no jab, no pay” stops Passing a law that stops children attending parents from receiving some financial nursery or school unless their vaccinations benefits unless their children are up to date are up to date or they are medically exempt with their immunisations or have a valid would allow philosophical objection, in that medical exemption certificate. Four states parents who disagreed with vaccination could have an additional “no jab, no play” policy, decline vaccines for their children without where children can’t be enrolled at school or posing a risk to any schoolchildren who can’t nursery without proof that they’re up to date be vaccinated for medical reasons. This would or medically exempt. These policies have allow free choice while protecting vulnerable increased uptake: more than 5000 previously children.

348 8 June 2019 | the bmj Before considering mandatory vaccination, we should HEAD TO HEAD rectify some of the infrastructure problems. Does each general practice have a lead for immunisation? Mandatory vaccination would no increase uptake to protect all Helen E Bedford professor of children’s health, settings child and family friendly? Are schoolchildren, says Eleanor David A C Elliman consultant paediatrician, session times appropriate for young Draeger. But Helen Bedford UCL Great Ormond Street Hospital, London families, or do they coincide with siblings [email protected] being collected from school or nursery? and David Elliman worry Is opportunistic immunisation offered about the potential impact on Despite the highest ever rates of measles in other settings attended by children, trust of health professionals immunisation in Europe, 2018 saw the such as hospital outpatient departments largest number of cases this decade and nurseries (especially important for and would explore obstacles (82 596), with 72 deaths. This included children with overdue vaccinations)? Do to vaccine uptake first 966 cases in England, the most for five staff have adequate time to talk to parents, years. and have they been trained to tackle the An inexpensive, highly effective limited number of issues that arise? vaccine with an excellent safety record is available, but measles is once again a Uncertain consequences global problem. As unimmunised children Only when these components are in pose a risk not only to themselves but place should we consider mandatory to others who can’t be vaccinated, it’s vaccination. Even then, would it be unsurprising that mandatory vaccination appropriate for the UK, or could it have has reappeared on the agenda, with senior unintended consequences? Evidence that members of the health service considering mandatory vaccination has been effective its introduction. Before embarking on this, in other countries is not conclusive, however, we should consider the reasons and no evidence exists in relation to the for this resurgence of measles and review UK. Would parents still trust the NHS the evidence for possible interventions. and healthcare professionals if GP data In the UK the uptake of a single dose of were used to decide whether a child was MMR vaccine at age 2 has fallen gradually, admitted to school or whether a family from a peak of 92.7% in 2013-14 to was allowed certain welfare benefits? We 91.2% in 2017-18. At age 5, uptake of believe that mandatory vaccination could one dose is nudging 95% and is 87.2% for prejudice this. two doses. But these overall figures hide Just as importantly, would it work? If a wide variation around the country that school entry were denied, some parents explains why outbreaks are localised. who were determinedly opposed to vaccination may resort to home schooling, Infrastructure challenges or groups of like minded parents may The reasons for non-vaccination vary set up unregulated, informal childcare between and within countries. Vaccine groups. Is it right to compromise resistance has been suggested as a children’s life chances—which are so major factor for this and is important in dependent on education—because of some countries, but how important is their parents’ beliefs? If vaccination were it in the UK? In high income countries attached to welfare benefits it would be the proportion of parents refusing all the less well off, but determined, parents vaccines is around 1-2%. An important who would suffer disproportionately. minority of parents may have concerns, Some parents who were undecided may but these can usually be dealt with become more resistant, not wishing to effectively in discussion with informed be told by the state how to bring up their healthcare professionals, in whom the children. overwhelming majority of the public still We were pleased to see that a recent have considerable trust. Challenges to House of Lords debate favoured accessing services are more important. improving services rather than So, before considering mandatory compulsion; and, unlike Trentini and vaccination, we should rectify some colleagues, we believe that the UK of the infrastructure problems. Does should concentrate on improving its each general practice have a lead for infrastructure and not risk alienating immunisation? Do we have adequate call- parents unnecessarily.

P MARAZZI/SPL P recall systems in place? Are immunisation Cite this as: BMJ 2019;365:l2359

the bmj | 8 June 2019 349 KEY OPINION LEADERS Doctors and patients paid for influence on Instagram and YouTube If you’ve got followers, opportunities abound to make money by promoting health and drug brands on social media. Kim Thomas discovers who’s doing it and how it works PIERRE-PAUL PARISEAU PIERRE-PAUL

n 2015, Kim Kardashian If you’ve got a medical problem, THE RULES OF INFLUENCE published a post to her and you’re young, you’re It doesn’t take much imagination to realise that the followers on Instagram (now susceptible to what a good influencer phenomenon could be open to abuse. In numbering 140 million) looking person going through the UK, what health influencers can and can’t post extolling the benefits of Diclegis is regulated. the same thing as you is doing I(doxylamine succinate–pyridoxine), Firstly, the Committee of Advertising Practice’s a morning sickness drug. Kardashian, sociology of science at the University mandatory code states that influencers must who was pregnant, was reportedly of Pennsylvania. mention that they have received money from paid $500 000 (£400 000) for the Today, social media influencers a brand for a piece of content. The Advertising Standards Agency, which enforces the code, has post. The investment apparently paid can command thousands or even guidelines which state that paid-for content over off because within a few months sales millions of followers. Instagram, which another party has “control” must be clearly of the drug had increased by 21%. with one billion users, a third

labelled as an advert. The US Food and Drug of whom are aged 25-34,is a Secondly, the promotion of prescription-only Administration was less impressed particularly attractive proposition medicines to the public is prohibited in the UK and reprimanded the manufacturer for medical or wellness companies and health professionals cannot be offered any Duchesnay because the post did not that want to reach young, perhaps pecuniary advantage to promote medicines. disclose the drug’s side effects. In impressionable, people. The US allows promotion of prescription 2017, Kardashian promoted Diclegis medicines to the public, but the FDA insists that on Instagram again but this time Extremely susceptible any risks must be mentioned. Federal Trade included the required information. “If you are on social media a lot, Commission (FTC) guidelines state that influencers Companies have long recognised and you’ve got a medical problem, must disclose brand relationships. that using trusted individuals—key and you’re young, you’re extremely Karen Koslow, chief executive of US marketing opinion leaders, as they used to be susceptible to what a good looking agent Wellness Amplified, says: “I don’t think known—is an effective way to promote person going through the same thing everybody does it to the same extent that we their products. as you is doing,” says Moreno. require it.” Wellness Amplified tells its influencers “The phenomenon has, however, In the UK, no one commands that they must follow the FTC guidelines, including, been supercharged by the internet,” the same kind of social media for example, using hashtags such as #ad (for says Jonathan Moreno, professor of following—or fees—as Kardashian. advertisement). medical ethics and the history and Nonetheless, opportunities are

350 8 June 2019 | the bmj available for online influencers who things that you can use to measure DRUG MANUFACTURER CELGENE want to work with health brands. health, like cholesterol and blood AND PATIENT LOUISE ROE Josh Wolrich, an NHS surgeon who pressure. So I was able to promote Louise Roe is a fashion blogger with 700 000 Instagram joined Instagram to chart his weight their brand in a way that completely followers. She has psoriasis and is in a “paid loss, now has 155 000 followers. His fits the message that I have on social partnership” with biotech company Celgene, which account emphasises the importance media.” makes the prescription treatment for psoriasis Otezla of a healthy relationship with food In one Instagram post marked (apremilast). Without naming this product, Roe used her and condemns what he calls “the “AD” (for advertisement), for Instagram feed to link to a story on the Celgene website diet culture that comes with weight example, he wrote: “Exercise about “swapping worlds” for a day with another patient loss.” shouldn’t be about weight loss. with psoriasis in New York. There are SO many better reasons. “#Ad I recently had a blast swapping worlds for a “Picky” about what to promote Muscle mass is one of the biggest day with Alycia, a financial analyst who also lives with He also accepts sponsorship from determinants of health, and psoriasis. I learned a ton from her, and I hope she feels businesses, charging a minimum although you can improve your the same. www.psoperspective.com for more! xoxo,” of £400 for each post. As a full time cardiovascular health at home, I’m she posted. The post was tagged as an advert, and doctor, he says that he can afford to a massive advocate for getting in the the link Roe posted redirects to a US Celgene website be “very picky” about what he’s paid gym and lifting some weights.” promoting Otezla. to promote. Other doctors use social media to One recent deal was with Nuffield promote their own products. Sam Health, which owns several gyms: Bunting, for example, is a private “I was happy to work with them to dermatologist who uses YouTube, promote a message of not exercising where she has 77 000 subscribers, to through guilt, and also about the give skincare advice and market her problematic nature of using things skincare products. like body mass index and weight Consumers find it hard to know as the only method of measuring where to go for “quality information” health.” on the internet, she tells The BMJ; He adds: “And then I talked marketing her own products allows about how there are lots of other her to be “transparent and open. the bmj | 8 June 2019 351 SPORTSWOMAN SANTIA DECK PROMOTES WELLNESS AND WEIGHT LOSS PRODUCTS Santia Deck is a US rugby and such as coconut water and vitamin would get using any other product on flag football player who goes by supplements—though she will agree the market! The active ingredients in the name Queen of Abs on social to a deal with a brand only if she this product are Tumeric, Moringa, media. She has 309 000 followers really believes in the product. and curry leaves, so taking this on Instagram, where she posts Endorsing the company GNC’s product along with regular exercises photographs of herself in training weight loss product Slimvance in will allow you to lose weight in record as well as occasional inspirational Instagram and Facebook posts, Deck time!!” The posts were marked #ad messages. The success of her social wrote: “This is a new and amazing and accompanied by disclaimers. media account has led to paid all natural herbal weight loss blend Deck’s starting fee is $650 a post speaking engagements, television that is taking the market by storm. for smaller brands, but it can be a lot appearances, and sponsored Slimvance is also STIMULANT FREE, more for big brands, which means posts, mainly for wellness products so you will not get the jitters you that being an influencer is now effectively a career. “You no longer Deck’s starting fee is $650 a post for smaller brands, which have to work the nine to five if you means that being an influencer is now effectively a career don’t want to,” she says.

“It’s clear what’s in the the importance of prenatal vitamins “If you have to do lots of click- ingredients list: we’re not making without mentioning the brand. throughs to get to the casual, unrealistic claims.” For example, She also brought in fi tness ‘Oh, and I’m being paid by the Bunting says of her sunscreen professionals, dietitians, and company,’ ethically, I don’t fi nd that that it “dries quickly” and “calms “wellness moms” to promote very satisfactory.” But in terms of blemishes.” the vitamins and link to the breaching law or advertising codes it She has occasionally had deals professionals’ blogs. Koslow wouldn’t may not be an easy call, he says. to promote other brands but says name the infl uencers, but searching Policing paid promotion online her promotion was “in line with the for #oneadayprenatal reveals posts can be diffi cult: “In the US there’s brands that I would recommend by the fi tness blogger Amy Kiser overlapping jurisdiction between anyway.” These deals involved Schemper and mommy blogger the FDA and the Federal Trade addressing a press or consumer Courtney Horan. Commission if they choose to use it. I audience on topics relevant to the Typically, says Koslow, infl uencers would imagine that their power over brands, such as dry skin or acne. create at least two to four posts posts originating in other jurisdictions for a campaign, but sometimes is limited by practicality—note how Matching brands to influencers brands work with an infl uencer for hard it is for Facebook and Google To the outsider, the relationship up to six months. Infl uencers may to track what goes through their between brands and infl uencers may earn from $2000 at the low end (a platforms,” Moreno says. seem opaque. So how does it work? handful of Instagram posts by a The Advertising Standards Karen Koslow is chief executive and micro infl uencer) to $20 000 for an Authority does not have any cofounder of Wellness Amplifi ed, a infl uencer with a million followers authority over infl uencers based New York based marketing agency producing multiple pieces of outside the UK, even if those that matches health brands (over- content. infl uencers are targeting UK the-counter medicines and consumer Marketers are now wise to the fact consumers. If, however, the relevant products rather than prescription that some infl uencers have paid to foreign authority does not operate drugs) with infl uencers in the agency’s acquire large numbers of followers, a “cross-border complaint system,” 4000 strong database. so the success of a campaign is the authority states that it will “take These infl uencers range from measured by how much engagement what action it can.” medical professionals through sports (such as “likes”) a post has, or how The infl uencers I spoke to see their coaches and yoga teachers to patients many people click through to the work as a force for good: Wolrich with chronic illness. A few will have product website. argues that he uses his platform to millions of social media followers. Koslow believes her agency is Pharma is promote evidence based messages Others—the people Koslow terms doing a public service by providing involved in a context where much of online “micro infl uencers”—have between quality health information amid the in using medical information is dubious. But 5000 and 25 000. Some will use blogs “much misinformation out there that social media not all infl uencers are so choosy, or Facebook to share longer form consumers are reading.” through and the question of whether the use content, while others prefer Instagram sponsored of doctors and patients to promote or YouTube. Open ethical debate health products is entirely ethical For a recent marketing campaign There’s no doubt, says Moreno, that content remains open to debate. for prenatal vitamins, for example, “pharma is involved in using social and the Kim Thomas, freelance journalist, Koslow matched Bayer’s One A Day media through sponsored content disclosures Hertfordshire brand with health professionals who and that the disclosures are often are often [email protected] used their blogs to talk generally about buried.” buried Cite this as: BMJ ;:l 

352 8 June 2019 | the bmj