comment “Most cancers were diagnosed through GP assessment and referral” DAVID OLIVER “Health and social care are run on entirely different models” HELEN SALISBURY PLUS Doctors and "wellness" ventures; public utility antibiotics

WOUNDED HEALER Clare Gerada Doctors’ mental health and stigma

’ve recently been unwell. Thankfully, nothing was appointed to take this work forward as the NHS’s too serious—a broken bone in my foot and chief people officer. some dental surgery. Both resulted in visible More recently, independent reports commissioned manifestations of illness: an orthopaedic boot by the GMC (its gross negligence manslaughter review for my foot, and heavy swelling and bruising to and Fair to Refer?) have made recommendations that Imy face. The overwhelming response from medical should substantially tackle some causes of mental colleagues and friends was sympathetic, with a illness in doctors. The gross negligence manslaughter constant chatter of advice, suggestions for healing, and review made recommendations to help employers tales of their own injuries and operations. reduce the stress of serious complaints against staff It set me wondering what my experience would and bring in fairer, more consistent processes for have been if, instead of obvious physical injuries, serious incidents. Fair to Refer? focused on improving I’d admitted to hidden psychological ones. Would inclusivity for all staff, but especially those who the sympathy have been as free flowing, or—as the experience the most isolation and discrimination, literature on sick doctors would suggest—would I have such as doctors who have trained overseas or those been shunned and left feeling ashamed? Even a half from BME groups. decade ago I might have been, but I think that the tide There’s still much to do to stop against the stigma of mental illness generally, and needless morbidity and mortality of mental illness among doctors, is finally turning. doctors due to mental illness, but at This was evident at the recent BMA annual least the issue is now in the open. representative meeting, which I attended as a BMA Maybe some day discussing mental Council member. Many motions focused on issues illness, and suggesting solutions, relating to doctor burnout and psychiatric illness, will be as normal as talking about a the need to support doctors and medical students, broken metatarsal. and the need to tackle the impact of inspection and Clare Gerada is GP partner, regulation on doctors’ mental health. My own motion, Hurley Group, London on having to deal with the psychological burden [email protected] of complaints, also received a sensitive hearing. Cite this as: BMJ 2019;366:l4583 Speaker after speaker—including medical students, junior doctors, seasoned doctors, and the chair and The tide president—talked poignantly from their various against professional and personal perspectives about mental the stigma illness in doctors and NHS staff. Some recent reports highlight this problem and how of mental to tackle it. Earlier this year Health Education England illness among undertook a major review of NHS staff’s mental health doctors is and wellbeing, making sensible recommendations. finally The NHS Long Term Plan, published earlier this year, also looked at staff wellbeing. It prioritised reducing turning discrimination, violence, bullying, and harassment (all causes of psychological distress), and Prerana Issar the bmj | 20 July 2019 105 OBSERVATIONS Daniel Sokol close to where I live where customers can sit The drip, drip, and be infused with a cocktail of vitamins and minerals. drip of the Get a Drip’s website features a page of frequently asked questions, where it states profit motive that its “team of healthcare professionals” is made up of GMC registered doctors, an Doctors should stay clear advanced nurse practitioner, registered of “wellness” ventures nurses, a nutritionist, paramedics, and a technician. few years ago I was It emphasises that it “does not diagnose, instructed to advise a treat, prevent or cure any conditions” client on the lawfulness of and that its “drips and boosters have no people who weren’t doctors evidence to cure, prevent or treat cancer of practising hair transplant any type or any other conditions.” It says Asurgery. I discovered that there was no law that IV drip hydration can benefit “anyone prohibiting an unregistered, unlicensed, combating hangovers, feeling run down, or unqualified person from practising most tired, lacking energy or wanting to detox.” types of medicine. Should doctors be involved in such This permissive legal landscape has commercial ventures? contributed to the growth of aesthetic procedures performed by non-clinicians Good evidence is lacking and a lucrative beauty and “wellness” My worry is not so much that good evidence sector. on the medical benefits of the IV drips is Perhaps lured by the money, doctors are lacking, or that the price of the drips seem entering the scene and offering all sorts of high relative to the cost of the contents, or treatments from Botox to penis fillers. even that clients may be misled into thinking Get a Drip is one of several companies in that benefits exist. A doctor endorsing the UK and the US that provide intravenous I am prepared to accept that the drips such products will have “wellness” drips, injections, and shots. Its may provide some benefit, subjective or strayed too far from the products have names such as “party drip” otherwise, to some people, whether through Hippocratic arena in (£125), “slim drip” (£250), “anti-ageing the ingredients in the drip or the placebo which doctors fight drip” (£200), and “hair enhancement drip” effect. I am prepared to accept that the their battles against (£200). It has a booth in the shopping mall risks of adverse events are relatively low illness and suffering

BMJ OPINION Els Torreele

In the face of the growing crisis of drug resistant less profitable areas such as antibiotics is to Fixing the wrong “superbugs,” and the shortcomings of the encourage these unhealthy dynamics. We antibiotics business model, opinion leaders disagree. problem in have been calling for expensive fixes to the Why must we allow the stock market, rather the search for market. Although these commentators are than clinicians and public health systems, sounding a much needed alarm, both their to decide which new lifesaving drugs are new antibiotics diagnosis of the problem and proposed developed and made available to patients? solutions of offering billion dollar rewards to Totally different strategies for developing drug companies are missing the mark. and delivering effective new antibiotics The current market based research and must be considered—ones that rely on development (R&D) business model fails public responsibility instead of incentives for when it comes to antibiotic development. This commercial markets. model—in which the goal is to maximise the In the UK’s 2016 Review on Antimicrobial financial return on medical products—is made Resistance, the economist Jim O’Neill called for possible by allowing companies to charge market entry rewards of around $1bn (£800m) exorbitant prices with little to no transparency. each. Three years on, however, he has changed It has led to price gouging in multiple health his mind. Realising that even this type of areas, such as cancer and hepatitis C. financial incentive is unlikely to get results, he Yet, somehow, many commentators believe now wants to explore the idea of a public utility that the only way to “fix” the lack of R&D in with public purpose ownership for antibiotics,

106 20 July 2019 | the bmj if the drips are administered safely and ACUTE PERSPECTIVE David Oliver under medical supervision. I am prepared to accept that the price, though steep, may reflect the high costs of staff, rent, and other Don’t blame GPs for expenses and the need to make a profit. I am even willing to accept that customers can be late cancer diagnoses appropriately informed about the uncertain eing a GP isn’t easy. Under- cancers were diagnosed as emergencies benefits and real risks of harm and can resourcing, workforce gaps, and only 6% through screening—so autonomously consent to the interventions. and a media narrative often most were in fact diagnosed through Yet, as an ethicist, I would advise doctors laden with blame make GP assessment and referral. to stay clear. Why? Because it debases the it harder. On 28 June the Public Health England’s bespoke role of the doctor and brings the profession BDaily Telegraph stated, “GPs failing to GP profiles show that cancer still into disrepute. spot two thirds of cancers.” The article represents only a small percentage of a was more measured than the headline. GP’s caseload. And some patients, with Morally uncomfortable But readers’ fear and anger are rarely vague symptoms of cancer not specific How would a virtuous doctor feel when tempered by less conspicuous details. to one organ, risk being sent urgently recommending, endorsing, administering, It reported a Cancer Research UK down the wrong specialist route. or overseeing a £200 “hair enhancement” study, which focused on two common Patients’ own circumstances or drip, knowing that in all probability cancers (lung and bowel), analysing care preferences also play a part in there will be no enhancement? Morally 135 000 cases. The Telegraph reported delayed diagnosis. A study by Abel uncomfortable, I suggest, because he “average waits of more than eight and colleagues on NHS patients with or she will have strayed too far from the weeks for diagnosis,” adding that “the a cancer diagnosis from presenting as Hippocratic arena in which doctors fight vast majority of cases that turned out an emergency found that 29% reported their battles against illness and suffering. to be cancer were never suspected by no GP consultation. Percentages were The temptation is strong for enterprising family doctors.” substantially higher in older, male, and doctors to explore the fringes of medicine The study, based on 2014-15 data, deprived patients. for gold, often in the fast growing wellness concluded that only 37% of cancers A Nuffield Trust analysis of cancer and aesthetic industries. That siren song had been diagnosed after urgent waiting times showed that we’ve must be resisted, for at stake are far greater GP referral. This was true in 32% of generally maintained the operational riches: the reputation and moral integrity of bowel cancer cases and 28% of lung standard of at least 94% of patients the doctor and the very soul of the medical cancer cases. Patients who had not who are referred by GPs as “urgent” profession. been referred for urgent assessment being seen within two weeks, with only Daniel Sokol, medical ethicist and barrister, waited weeks longer for diagnosis. And a recent dip. However, it also showed 12 King’s Bench Walk, London 35% of lung and 28% of bowel cases that the metric of at least 85% starting [email protected] Twitter @DanielSokol9 were diagnosed only when patients treatment within six weeks of referral Cite this as: BMJ 2019;366:l4692 presented to hospitals as an emergency. was breached for the past four years GPs see a whole range of and recently declined further. conditions, often in early stages with Cancer Research UK has a fantastic BMJ OPINION Els Torreele undifferentiated symptoms that track record of raising awareness. It’s could be many things. The 2015 NICE just a shame that the resulting media likening it to the way some banks were taken over guidelines on recognising and referring narrative here placed excessive blame by the government after the 2008 global financial suspected cancer lowered the positive on GPs, using old data. I’m not sure crash. Public utility drug manufacturing already predictive value threshold for that this helps patients or doctors. exists in some countries, and could be expanded referring cases from 5% to David Oliver is a consultant in to encompass public interest medical R&D. 3%. Cancer Research’s geriatrics and acute general medicine, Many researchers today are keen to work in Cancer in the UK 2019 Berkshire a capacity where health needs are prioritised report showed that, even [email protected] over profit, including through open source in 2015-16, only 19% of Cite this as: BMJ 2019;366:l4625 and not-for-profit initiatives. We need to create the frameworks of collective ownership and responsibility in which these scientific Cancer still breakthroughs can thrive. represents This is the kind of new thinking we need, only a small supported by enlightened governments who percentage seek to take responsibility for tackling one of the greatest challenges in global health today. We of a GP’s must find the courage to explore radical solutions caseload beyond business as usual, because medicines shouldn’t be a luxury. Els Torreele, executive director, MSF Access Campaign

the bmj | 20 July 2019 107

PRIMARY COLOUR Helen Salisbury LATEST PODCASTS Do we need integration? recently went to a city-wide remains is unfairly distributed, with integration workshop, involving arbitrary distinctions between (funded) about 200 people from the new health needs and (unfunded) social primary care networks. I was needs—leaving many older patients, Ihoping to learn about local especially those with dementia, with a progress towards an integrated care wholly inadequate service. system, as foretold in the NHS Long Term Currently, health and social care Plan, but I was disappointed. There systems are run on entirely different seemed to be no big plan. There wasn’t models. A crucial question is whether even a small plan, unless our leaders were integration would mean social care Fertility awareness based keeping it to themselves. becoming like healthcare: relatively methods of contraception Instead, we were seated in multi- comprehensive, mostly publicly professional groups and were asked to provided, and funded by general Fertility awareness based methods for talk about our vision for integrated care taxation. The alternative—regarded by pregnancy prevention are increasingly popular, and what we’d do to bring it about. It most doctors as a nightmare scenario—is yet substantial misinformation exists around wasn’t even clear what we were aiming that healthcare becomes like social care: them. Rachel Urrutia and Chelsea Polis, the to integrate: primary and secondary patchy, mostly privately provided, and authors of a recent education article on the care? Healthcare and social care? means tested. topic, joined us to discuss the evidence. Here, Polis describes what motivated her research: Mental health and physical health? With The Lords Economic Affairs Committee its connotations of streamlining and clearly favours the former. It recently “In some circles I hear reflexive dismissal efficiency, integration is an attractive published Social Care Funding: time to of these methods based on concerns about concept. But, without clear parameters, end a national scandal. It called for an effectiveness, which is perhaps partially based it’s just a hazy idea, certainly beyond the immediate injection of £8bn into social in fact and partially based in misunderstanding influence of jobbing GPs like us. care to restore provision to 2010 levels of the evidence. On the other hand, I’m very Theoretically, integrating social care and recommended universal access to concerned when I see people promote fertility and healthcare should be a winner, free personal care by 2025. awareness based methods by cherry picking with hopes that joined-up provision Discussing our vision of integration in evidence or by disparaging other contraceptive will return patients home speedily after our small group, we concluded that our options in non-scientific ways. A personal admission or even keep them out of priorities were adequate funding and goal has been to try to bridge that divide by hospital altogether, thus saving money. good communication. We could do very encouraging a focus on the data.” However, one large pilot study found that well without structural upheaval: we integrated care resulted in higher not just want enough staff of all varieties to Talk evidence lower costs per patient, possibly because care for our patients, and for us—and our The BMJ’s Helen Macdonald, and Carl thorough assessments revealed so computer systems—to be able to Heneghan, editor in chief of BMJ Evidence much unmet need. talk to each other. Based Medicine, discuss what’s new in the Local authority budgets have Helen Salisbury is a GP in Oxford world of EBM, including research on gloves for been slashed, leaving social [email protected] control. A campaign started by nurses care in crisis. What little care Cite this as: BMJ 2019;366:l4614 at Great Ormond Street Hospital is encouraging people to revise the way they use non-sterile gloves, based on evidence that shows they We concluded that are associated with an increased risk of cross our priorities were contamination. Macdonald talks about how adequate funding and she was interested in evidence about “the kind good communication of physical barrier that having gloves on your hands introduces between you and the patient.” “There are obvious examinations which you would always put your gloves on for, but maybe if you’re taking someone’s temperature or using a stethoscope there’s a relationship building quality of examining someone and sort of ‘laying your hands on’ the patient. That feels like a validating part of the consultation.” Catch up on all of The BMJ’s latest podcasts at bmj.com/podcasts

Edited by Kelly Brendel, deputy digital content editor, The BMJ

108 20 July 2019 | the bmj ANALYSIS on-communicable nutrition and NCDs—and consider diseases (NCDs) the implications of the evolving constitute half the international trade regime. The global rise global burden of disease,1 and are Impacts of food imports and exports Nassociated with high health, social, Global markets encourage countries of nationalism and economic costs.2 The 2030 to specialise in particular agricultural Agenda for Sustainable Development, and food production for export, and the threats adopted in 2015, recognised NCDs including “cash crops” (crops as a major challenge for sustainable grown for profit, such as wheat). development—and identified This increases global output of such to health 6 international trade as an important products. Countries can use imports structural driver.3 to increase access to a greater variety and nutrition Trade and investment are of foods, such as tropical fruits associated with potential benefits to during winter; this leads to greater Trade and investment policies strongly 4 5 12 health. However, since the 2008 homogenisation of food availability. influence diet, nutrition, and risk of food crisis—which saw a surge in The health impacts are dependent non-communicable disease. Helen Walls international cereal prices—and in largely on the mix of foods (healthy and colleagues consider how recent the context of the growing global and unhealthy) a country trades. prevalence of obesity, the possible Exporting primary produce, international political developments harmful impacts of trade on diet and such as unprocessed fruits and could affect health in trading nations nutrition have gained attention from vegetables, can negatively impact researchers and policy makers.6 domestic food consumption if Poor diet and nutrition are strongly affected farmers might otherwise linked to NCD risk, accounting have grown food for a country’s own for around 40% of annual deaths use. The promotion of crop exports from NCDs.7 8 Trade and investment can lead to increases in prices in agreements and policies influence local markets and have detrimental diet through their impact on local effects on local food security (such food environments—including as quinoa in Bolivia13 and teff, the price, availability, composition, and staple grain of Ethiopia14). Several promotion.9 This impact results from studies suggest, however, a larger changes relating particularly to the share of land devoted to cash crops import and export of agricultural improves child nutrition through and food products, foreign direct better incomes for farmers—at investment, and the effects on least when certain conditions are domestic policy.6 10 met regarding women’s roles in The evolving international trade household decision making.15 16 regime has taken a recent turn, For the importing country, however, as seen in the current nutritional impacts largely depend

GUSTAVO RAMIREZ/GETTYIMAGES GUSTAVO nationalist rhetoric evident in many on the nutritional quality of the Quinoa prices have risen in Bolivia as more of the crop is exported countries but signified especially products imported. Unfortunately, 11 KEY MESSAGES by the UK vote to leave the EU and foods with the longest shelf lives and the election of to the those most easily traded and stored • The 2030 Agenda for Sustainable Development US presidency—one of whose first are “ultra-processed” foods—those identified international trade as a structural actions was to withdraw the country that are generally more energy dense driver of sustainable development, including from the Trans Pacific Partnership and higher in fats, sugars, and salt. identification of the risk posed by international Agreement. The trend towards They have a commercial advantage trade to the prevalence of non-communicable increasing trade liberalisation over fresh, perishable products, and disease (NCD) may therefore be at an end—and are associated with overweight and Poor diet and nutrition are risk factors for NCDs, • with it, concerns for nutrition obesity and NCDs.17 accounting for 40% of annual deaths from NCDs related health problems. Evidence is mixed regarding Trade and investment policy impact diet and • International politics and changes the impact of food imports on nutrition through the food system and by to global trading relationships pose nutrition and NCDs. A number of affecting domestic policy and regulatory space unpredictability. Trade is unlikely to studies suggest positive outcomes, relating to nutrition contract, however, and its impact on such as improved dietary quality, We outline key pathways of this trade-nutrition • health will remain critical to analyse. food security, and reductions in impact on nutrition related NCD risk and consider We draw on existing literature to underweight in low and middle their implications in the context of an evolving discuss three key pathways of the income countries (LMICs). An analysis global trade regime impact of trade and investment on of 30 LMICs, for example, found no

the bmj | 20 July 2019 109 World Trade Organization The World Trade Organization (WTO) is an intergovernmental organisation that regulates international trade. It was established in 1995, replacing the General Agreement on Tariffs and Trade, which began in 1948. The WTO deals with regulation on trade in goods, services, and intellectual property between participating countries by providing a framework for negotiating trade agreements and a dispute resolution process aimed at enforcing participating countries’ adherence to WTO agreements, which are signed by representatives of member governments. The WTO oversees about 60 agreements, which have the status of legal texts. Some of the most important include: • Agreement on Agriculture—with three central pillars covering domestic support, market access, and export subsidies • General Agreement on Trade in Services—which covers the service sector • Agreement on Trade Related Aspects of Intellectual Property Rights—which sets minimum standards for many forms of intellectual property regulation • Agreement on the Application of Sanitary and Phytosanitary measures—which sets constraints on members’ policies relating to food safety, as well as animal and plant health • Agreement on Technical Barriers to Trade—which ensures that technical negotiations, standards, testing, and certification procedures do not cause unnecessary obstacles to trade Since the breakdown of the Doha round of negotiations in 2008, many high income and some middle income countries have chosen to pursue trade and investment liberalisation through other means, including bilateral investment treaties and, increasingly, large regional trade and investment agreements. THIERRY FALISE/LIGHTROCKET /GETTYIMAGES FALISE/LIGHTROCKET THIERRY evidence of significant associations Foreign direct preferred method for transnational Impacts on policy and regulatory space between more tariffs (taxes applied to investment food and beverage companies, for tackling nutrition goals imports and exports) and mean body has been such as Pepsico and Unilever, and The World Trade Organization (WTO) mass index (BMI), although they did retailers, such as Carrefour and is responsible for global trade rules found to be an 6 suggest higher tariffs were associated increasingly KFC, to enter new markets. between countries, but since the 1990s with a lower BMI for poorer, rural important Several studies have found FDI an increasing number of regional populations.6 to be an increasingly important and bilateral trade and investment While current trade conflicts driver of ultra- driver of ultra-processed food agreements have been negotiated between the US and China, for processed consumption, and increases in outside its system (see box). These example, are likely to affect food overweight and obesity, particularly new trade and investment agreements overall volume of trade growth,18 consumption in LMICs.6 Increases in soft drink have problematic implications for it is unlikely that the overall consumption in Mexico after domestic policy making.22 23 Especially trend, including in foodstuffs, increases in food imports and FDI concerning is the inclusion of the will be significantly affected by US firms, following the North “investor-state dispute settlement or reversed. This is further American Free Trade Agreement mechanism,” through which evidenced by the Trans Pacific in 1994, have been clearly companies can directly sue states if Partnership proceeding, despite US documented. By 2010, Mexico had governments implement regulation withdrawal. Thus, the patterns of the highest consumption of soft that might lead to reduced profits.24 health impact through food import drinks globally: 300 L per capita Under these new generation and export will likely remain. annually.19 20 Similarly, studies agreements there have been legal have found significant increases in challenges to domestic policy Impacts through foreign per capita soft drink consumption affecting tobacco control (as well direct investment attributable to removal of FDI as through WTO mechanisms).25 Foreign direct investment (FDI) is restrictions in Vietnam and Peru.6 Tobacco control shows how trade and controlling ownership in a business The public discourse around investment agreements have been in one country by an entity based in globalisation has changed in recent used to increase corporate influence, another. FDI provides opportunities years, and Trump, for example, and serves as an example of risks for companies to enter new markets campaigned on an explicit anti- to nutrition policy. In 2011, Phillip for processed foods, advertise globalisation platform. In 2017, Morris Asia challenged the Australian and market their products more global FDI dropped by 16%. government’s plain tobacco efficiently, and create demand for This, however, was largely because packaging policy, based on a foreign their products while adapting to of a decline in FDI in the UK investment protection provision in local consumer characteristics. It is and US, while it remained stable a 1993 bilateral investment treaty thought that FDI, not trade, is the in LMICs.21 between Australia and Hong Kong.

110 20 July 2019 | the bmj Some countries have developed to control after they enter a market, nutrition policy that is compliant with with regulation required at many trade commitments. Ghana’s policy points, from processing to packaging, to tackle the trade in fatty meat, a advertising, and distribution.22 32 Some standard applied to imported and commentators have argued that the domestic meat, is one example.30 establishment of large companies Another is Samoa reversing its 2007 constrains domestic policy space ban on turkey tails (a fatty meat) as for tackling poor nutrition through part of its accession to the WTO in lobbying and relocation threats.33 2011, and subsequently developing Domestic nutrition labelling policies a trade compliant nutrition policy.31 have sometimes been influenced by The WTO working party overseeing WTO concerns. However, with the types Samoa’s accession raised two of provisions often included in regional concerns about the ban—these related or bilateral trade and investment to its effectiveness in tackling diets agreements, there is now scope for and NCDs, and the principle of non- countries to be sued by corporations discrimination between imported for domestic policy making in regard and domestic foods, given that many to nutrition. Exceptions in some cases high fat foods were still available for negotiated for tackling tobacco control purchase in Samoa. After removing should be extended to nutrition. the ban and acceding to the WTO, There is, however, further scope Samoa undertook a study of its policy for development of trade policy options and in 2016 implemented coherent with nutritional goals, with a nutrition policy compliant with its an important role for governments. In trade commitments.31 addition to the scope for countries to The effects of trade and investment develop a nutrition policy compliant While the tobacco company failed in agreements on state regulatory and with trade commitments using its bid to overturn Australian tobacco policy space is less obvious and harder import barriers, governments can use laws (2017), some authors have noted to tackle than other problems—and yet domestic policies to improve local food the risk of such foreign investment it limits governments’ ability to tackle environments (such as availability provisions to nutrition policy26: increasing rates of NCDs, including and access, prices, and affordability), the implementation of domestic in regard to nutrition. Again, much although dietary quality of the foods sugar taxes, for example, could be like the direct impact on overall levels available also requires consideration.34 threatened by such provisions. of trade or FDI, it seems unlikely Given the high burden of malnutrition However, WTO mechanisms, this trend will dramatically change. and NCDs globally, there is a critical such as the Technical Barriers to The progression of the Trans Pacific need for further policy initiatives to Trade Committee meetings, are Partnership Agreement certainly tackle trade, diets, and nutrition. also concerning for nutrition policy suggests so. We may be entering a new era in making. Specific trade concerns trade and health; a change that will Helen Walls, have been raised at these meetings Discussion and conclusion undoubtedly provide opportunities and assistant professor, regarding nutrition labelling initiatives Faculty of Public Tackling the unfolding NCD crisis risks for nutrition and NCDs. If current in Chile, Ecuador, Indonesia, Peru, Health and Policy, means tackling trade and investment trends continue, there are likely to be 27 and Thailand. Questions were asked London School of policy, as it plays an important role in further rises in overweight and obesity about the justification of proposed Hygiene and Tropical shaping diet and nutrition globally. and NCDs. labelling measures, their consistency Medicine While the current trade regime may Despite increasing isolationist with international standards, and the helen. walls@ be evolving into something new, rhetoric by some leaders, trade will evidence of their effectiveness. Such lsthm.ac.uk analysis of past trade-nutrition likely continue and will remain developments may weaken nutrition Richard Smith, deputy relationships suggests various fundamental to diets and nutrition. policy initiatives—in Thailand, pro-vice chancellor impact pathways. In particular, It is important that the public health after several WTO member states and professor, trade openness appears to have community does not allow this rhetoric University of Exeter raised concerns about Thai food contributed to shifts in dietary to detract attention from the importance policy, a “children should take less” Soledad Cuevas, patterns, and FDI is most strongly of trade for nutrition, especially the research fellow, SOAS message and a traffic light system associated with increases in obesity importance of changes to bilateral trade University of London (showing sugar, fat, salt, and energy and NCDs. and investment agreements and away Johanna Hanefeld, content) was abandoned in favour While policy makers can exert from trading blocs (such as Brexit and associate professor, of a food labelling system preferred Faculty of Public control over FDI and transnational the decline of the WTO). Such changes, 28 by industry. Such challenges to Health and Policy, food companies by setting in fact, provide greater imperative for domestic policy also result in “policy London School of standards for processing, labelling, public health community involvement chill,” with regulations less likely to be Hygiene and Tropical packaging, and retailing, large in matters of trade and health. 29 initiated in countries elsewhere. Medicine investor companies can be difficult Cite this as: BMJ 2019;365:l2217w the bmj | 20 July 2019 111 LETTERS Selected from rapid responses on bmj.com

LETTER OF THE WEEK THE FIRM

Continuity 15 June 2019 Shared experiences build confidence 365:379-420 No 8203 | ISSN 1759-2151 Abolition of Medical manslaughter review p 382 is key Reasons to eat less red meat p 395 the firm was Risks of storing red blood cells p 403 The experience of “firm” attachments was key to Carbon monoxide poisoning p 409 The firm was an organic 1.5 CPD hours in the education section maintaining my enthusiasm throughout my career. As a a key catalyst social structure in which junior, the support of colleagues, who often became lifelong to my work and learning friends, compensated for long hours and sleep deprivation. retirement could take place, with Over a dozen consultant “bosses” led by example. Harold emotional and technical Ellis, quoted by Rimmer (This week, 1 June), was renowned support. It enhanced as a hard taskmaster, but many of his trainees delight in recounting their team working and beneficial apprenticeships. Sharing confidential clinical experiences requires improved morale (This intimate confidence among colleagues, which the companionship of firm week, 1 June). Should we bring back continuity permits. I disagree that work THE FIRM? As a consultant, I delighted in the support and skill of many trainees. I hope intensity has increased. that in return they felt confident in trusting my advice and guidance. Abolition In my first post I worked an 11 hour day of the firm, the anonymity of attached visitor trainees, and the consequent and every second night and weekend. Two uncertainty about who was caring for “my” patients was a key catalyst to my years after graduation I was in charge of retirement. take, medical wards, and high dependency John L B Carter, retired oral and maxillofacial surgeon , Plymouth and intensive care units with the support Cite this as: BMJ 2019;366:l4573 of one pre-registration house officer. I paced, placed central lines, and enrolled Discarded too hastily patients in clinical trials without senior Everything Godlee says about the return of the firm is true (Editor’s Choice, 15 support. Nevertheless, junior doctors now June), but there are other factors. The quality of teaching and supervision needs have poorer morale than my peers and to be monitored. My peers and I are largely autodidacts. Now the pendulum may feel demotivated compared with the raw have swung too far—juniors are submerged in paperwork and are risk averse to a enthusiasm of medical students. concerning degree. Rimmer identifies support and educational Another benefit of teamwork is that the extent of responsibility is apparent— aspects of the firm but neglects one further for wards X and Y, for example. Being responsible between the hours of A and B is aspect. Firms admitted patients, cared for not the same, and continuity suffers. them, and discharged them. Things going A major factor in my early retirement was being obliged to work in a manner well led to shared happiness with patients, that I deemed to be unsafe. There are no substitutes for the established doctor- but poor outcomes prompted a mental audit patient relationship, for the intricate shaping of a style of practice that suits the of our performance. Both were powerful clientele, or for hands-on consultations. motivators. Positive feedback encouraged Reacquiring models of care that were discarded too hastily is good behaviour, negative experiences were progress. incentives to learn and improve. Cause and Steven Ford, retired GP , Haydon Bridge effect in our actions were apparent. Cite this as: BMJ 2019;366:l4568 Now, patients pass between teams. Individual doctors have less ownership. Why bother? Especially when on call, the junior’s role is I retired early at age 56 after being a GP not care and review but a tick box list of tasks, principal for 27 years. I intended to work each rather meaningless in isolation. as a locum, but for various reasons, mainly The solution is difficult. The past cannot due to supporting family members with be recaptured. We need to acknowledge our illnesses, this was not possible. I recently key role in helping trainees get the most out inquired about returning to work part time, of themselves. Continuity gives ownership, especially now that indemnity will not be an Harold Ellis and responsibility, feedback, good morale, and issue. As I have been away for more than two years, I have to firm colleagues internal motivation. Medicine continues to jump through hoops to be able to work as a GP again. Some of these hoops I can be a vocation rather than a series of tasks. It understand, but they are a major barrier for someone in my situation. The bottom remains difficult technically and emotionally; line is: why bother? There is no flexibility in the system. Despite there being a success requires practitioners’ rewards and shortage of GPs and people like me who might be able to help, the system puts feedback to be intrinsic to their practice. you off. Roderick Lawson, consultant in respiratory and Mayur Shah, retired GP principal , Milton Keynes general internal medicine , Sheffi eld Cite this as: BMJ 2019;366:l4567 Cite this as: BMJ 2019;366:l4597

112 20 July 2019 | the bmj NHS ON TRUMP’S TABLE? confined spaces. Increasing use of CO alarms JUNIOR DOCTORS’ MESSES in UK homes is important for secondary Ignorance, foolishness, and greed prevention, particularly where wood burners Rest facilities must be are used. accessible on night shifts Clinicians also have a role in secondary The new government funding for rest prevention. Midwives and stop smoking facilities should not be labelled as only services check carboxyhaemoglobin levels for the junior doctors’ mess (This week, in relation to smoking; these might also 22 June); the remit needs to go far beyond indicate non-smoking related exposure to that. carbon monoxide. Satellite rest hubs are key to ensuring Sarah J Jones, consultant in environmental health that all doctors have access to rest facilities protection; Amber Horton, environmental public on night shifts. Intensive care registrars tell health programme support officer; Huw Brunt, lead me that the on-call rest room is too far from consultant in environmental health protection; Giri Shankar, professional lead consultant in health the intensive care unit; their concern is for The NHS is under immediate threat (This protection, Public Health Wales patient safety and not being able to respond week, 15 June). Many UK doctors are very Cite this as: BMJ 2019;366:l4613 quickly enough in an emergency. concerned, although the NHS Confederation Key barriers to rest after night shifts seems less so. Niall Dickson recently said LISTERIA OUTBREAK were identified in the national survey of that the risk of American companies running anaesthesia trainees on fatigue. Facilities the NHS was “a fuss about nothing.” The Review is justified as deaths from were often either unsuitable or inaccessible, confederation describes itself as “the food poisoning are unacceptable and doctors “just want to get home.” They authentic voice of NHS leadership,” but might be more willing to stay if the facilities perhaps that needs re-evaluation. I disagree with Hawkes—a review of UK were good. NHS top management should be out of the hospital food services is justified if high risk This funding is a step in the right direction, hands of single political parties as no one foods such as processed chicken meat are but cautious planning should be undertaken party has the integrity and skill. Alternative being served in UK hospitals (This week, to ensure it has the maximum impact for all models are slowly being explored by a few 22 June). Such foods were identified as too doctors. enlightened politicians. hazardous for serving to vulnerable patients Lydia J Earnshaw, junior clinical fellow in critical care, The NHS must be publicly owned and in Australia more than 10 years ago. London publicly provided. Some “leaders” don’t Multiple outbreaks in hospitals have Cite this as: BMJ 2019;366:l4621 understand that fragmentation damages been associated with high risk foods that complex systems, but ignorance, foolishness, are notoriously difficult to keep free of NO EXCUSE FOR PREJUDICE and greed must not be allowed to prevail. The listeria. Regular and independent audits of Dictators ban free speech health service can never stagnate; it must compliance with food safety standards might evolve and adapt, and this can be achieved be a better investment than Free speech is abused by some people with as a genuine public service if politicians and bringing food preparation back under prejudices (Partha Kar, 22 June), but banning other leaders have enough skill, integrity, and hospital control—menus should also be it would be counterproductive. backbone. regularly audited. Robust debate between competing views David Levine, retired consultant physician, Sennen Hospital ownership of food services will is the bedrock of a well functioning liberal Cite this as: BMJ 2019;366:l4604 not necessarily guarantee compliance with democracy. Some well meaning people appropriate standards. The exclusion of some have the tendency to shut down discussion CARBON MONOXIDE high risk foods (as in Australia) is arguably or debate on certain topics by claiming an over-reach and limits the diet of hospital “phobias” or “isms.” Expression of non- Wales is working on prevention patients, but the alternative of occasional violent political views should not be By improving clinical awareness of the signs, listeria outbreaks and deaths among patients banned, even if people listening strongly symptoms, causes, and treatment of carbon is not acceptable. disagree. monoxide (CO) poisoning, we can reduce Craig B Dalton, public health physician and conjoint Shutting down debates because of this avoidable burden on health and health associate professor, Callaghan disagreement is not a sign of an enlightened services (Easily Missed? 15 June). Cite this as: BMJ 2019;366:l4618 society; it would be a step back to the dark Public Health Wales and the Welsh ages where whimsical edicts by those in government recently aimed to increase power were enforced without question. clinician knowledge of CO poisoning with a Dictators ban free speech because it is series of guidance letters. CO poisoning is such a powerful tool. Prohibiting it ultimately not notifiable, but reporting to Public Health harms the minorities and those who are Wales is encouraged to help find and manage oppressed. the source and prevent more cases. Suffering the rambling of a few fools is Public health agencies can also support better than banning free speech. prevention. Primary prevention includes Santhanam Sundar, consultant oncologist, encouraging autumn boiler checks and Nottingham summer reminders not to use barbeques in Cite this as: BMJ 2019;366:l4626 the bmj | 20 July 2019 113

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OBITUARIES Patricia Jane Lowry James Fraser Taylor Christopher Willcox Consultant cardiologist Industrial medical officer General practitioner Heartlands Hospital, (b 1928; q Aberdeen Selsey (b 1940; Birmingham (b 1952; 1954; DPH, DIH, FFOM), q St Mary’s 1966), died q Birmingham 1976; died from old age on from Parkinson’s disease MD, FRCP), died from 6 May 2019 on 9 June 2019 secondary breast cancer Having experienced Christopher Willcox on 26 May 2019 six years of general was born into a medical Patricia Jane Lowry played practice in Aberdeen, family. He trained at hockey, tennis, and the piano in her youth. She James Fraser Taylor (“Jim”) took up a career Emmanuel College, Cambridge, and St Mary’s held a lectureship in cardiology in Birmingham in industrial medicine. He became chief Hospital. He married Marie-Christine in 1966, before becoming consultant cardiologist at medical officer to Chloride Group outside and travelled with her to Borneo, where he Redditch, where she contributed to setting up Manchester for 25 years. He had a dedicated worked for two years, as the only doctor in district cardiology services in Worcestershire. interest in alcoholism, disability, and a district hospital serving an area of 500 She had moved back to Heartlands Hospital as lead pollution in industry; his views were square miles. On returning to the UK in 1971, a consultant before retiring on medical grounds widely sought, and he served on numerous he became a GP partner in Selsey, where at the age of 50 to live near her parents and related committees. Always the genuine he served his patients diligently for almost sister in Perthshire, Scotland. Here she enjoyed couthy Scot, he returned to his roots and 30 years. He enjoyed 10 years of retirement 16 more years (11 of which were before the settled in Rhynie in Aberdeenshire, where until, during a charity concert at St Peter’s final recurrence), playing golf, bridge, and he developed a unique garden, full of the Church (Selsey) in 2011, he had a major enjoying the arts (literature and the theatre) bird life he so adored. His holiday love was stroke. This left him with left side paralysis. and her new circle of post-retirement friends. Ardnamurchan. He remained a dedicated He subsequently developed Parkinson’s Her strong faith was a sustaining constant fan of Manchester United and Aberdeen disease, which led to increasing apathy and, during her life and illness, which she accepted football clubs. Predeceased by his wife, finally, difficulties in swallowing, which he with grace. She leaves her mother; two siblings; June, in 2008, he leaves three sons and endured without complaint. He leaves his and their families. four grandchildren. wife, brother, son, and granddaughter. Raymond Lowry Pierre Fouin, Michael Williams Merlin Willcox Cite this as: BMJ 2019;365:l4286 Cite this as: BMJ 2019;365:l4227 Cite this as: BMJ 2019;365:l4284 Bryon Edward Roberts Fleming Carswell Marie-Joseph Albert Menagé Consultant haematologist Consultant paediatrician General practitioner General Infirmary at Bristol (b 1937; q Glasgow White Lodge, Enfield, Leeds (b 1933; q Leeds 1962; MD, FRCP Glas, Middlesex (b 1922; 1957; MD, FRCPath), died FRCP Lond, PhD, DSc), q Oxford 1953; MA, after a stroke on died after a long battle DObst RCOG), died from 10 January 2019 with Lewy body dementia bronchopneumonia on Bryon Edward Roberts on 24 May 2019 3 November 2018 was a major figure in Fleming Carswell became Marie-Joseph Albert the development of modern haematology senior lecturer at Bristol University in 1973, Menagé (“Albert”) was the eldest of 13 practice in Yorkshire and the UK. In 1961 with an honorary appointment as consultant children of an established Franco-Mauritian he became a haematology registrar at paediatrician at the Bristol Royal Hospital for family. Initially a sugar chemist, he studied the Hammersmith Hospital, then the pre- Sick Children. Over the next quarter of a century at Worcester College, Oxford, and the eminent UK centre. On returning to Leeds he developed an international reputation in Radcliffe Hospital with a scholarship from as a lecturer in pathology in 1963, Bryon paediatric respiratory medicine. He was a the Fondation Mauritienne. Summoned started a dedicated haematology laboratory lifelong socialist. He first joined the Labour back to Mauritius by his father’s illness, he and became consultant haematologist in Party when only 14 years old. Fleming retired was physician to the sugar estates and in 1970. Over the following two decades, he in 1999. He published over a hundred peer independent practice with high standing for built up the consultant clinical haematology reviewed articles and was recognised by Leeds obstetrics. In 1967 he returned to the UK. He team in Leeds, developing an excellent University for his achievements with a doctorate retired at 70, although he had had a triple routine haematology laboratory, and in 1998. In retirement Fleming studied English coronary artery bypass graft at the age of 57. establishing the Yorkshire registrar training literature at the Open University and began A keen sportsman, he played his last tennis scheme. A great fan of Leeds United writing poems. He also worked at the Emmaus match the day before a life changing head Football Club, he pursued his interests in Charity in Glasgow and Bristol, which provides injury, after stumbling on a London pavement local history and gardening after retiring. work and accommodation for homeless people. on 25 December 2010. He leaves his wife, He leaves his wife, Audrey; a son; and He leaves his wife, Anne; three children; and Françoise de Chazal; three children; and a sister. three grandchildren. seven grandchildren. Derek Norfolk, Graeme Smith, David Roberts Andrew Carswell Hélène Apthorp Cite this as: BMJ 2019;365:l4220 Cite this as: BMJ 2019;365:l4222 Cite this as: BMJ 2019;365:l4216 the bmj | 20 July 2019 125

OBITUARIES Powerful photographs of In 2017 Godley became people taken on his travels the UNC School of Medicine’s lined the walls of his office and inaugural vice dean of diversity Paul Godley helped put his patients at ease. and inclusion. Nationally, he Oncologist, epidemiologist, researcher, In a 2012 video, he discussed was recognised as a leader in his love of photography and his specialty. He developed and photographer how it related to his work as an and led the programme oncologist. He posted images on ethnicity, culture, and Paul Alphonso Godley (b 1957; from colon cancer, influencing from every continent on his health outcomes, aimed at q Yale 1984; MD, PhD, MPP), his choice of specialty and personal website. Whether understanding and eliminating died after a myocardial sparking an ongoing research photographing a child in the racial health disparities through infarction on 31 March 2019 interest in cancer prevention. He streets of Vietnam or consulting multidisciplinary research, became a world class oncologist with a patient about his education, training, and Paul Alphonso Godley was born and cancer researcher, and a diagnosis, Godley was guided community partnerships, and in Detroit, Michigan, the son of professor in the department of by his canny intuition to put built longstanding research Alegro J Godley, an internist, medicine at the University of the person in front of him at collaborations. and Juanita, a nurse. He grew up North Carolina (UCN) at Chapel ease, regardless of if they were a in a home where medicine was Hill School of Medicine—the student or a patient. Honours discussed every day. The studious first African-American to do Paul Godley became the young Godley was educated at so. He dedicated his life to Racial disparities research school of medicine’s executive the Friends School in Detroit, compassionate care for patients Godley, who became a associate dean for faculty affairs where he excelled at science and with prostate cancer. luminary in racial disparities in 2011, and its vice dean for developed a love for music and research, dedicated his career finance and administration the visual arts. Photographer to investigating differences in in 2015, and a distinguished While Godley was working He married Adaora Adimora, prostate cancer treatment and professor. In 2017 he became towards his MD, his mother died an infectious disease outcomes. His research focused the school of medicine’s A luminary in racial physician, who also became on how prostate cancer affected inaugural vice dean of diversity disparities research, an epidemiologist. He was a a high proportion of African- and inclusion. Nationally, devoted husband and loving American men. He said: “There Godley was recognised as he dedicated his father. An adventurous traveller, are almost no control data on a leader in his specialism, career to investigating he visited six continents with his screening African-Americans for serving as chair of the data and differences in prostate family, and it was through his prostate cancer. Since African- safety monitoring committee cancer treatment and travels that he honed his passion American men have much for the SELECT Prostate outcomes for photography. higher rates of both prostate Cancer Prevention Trial, NCI/ cancer and death from prostate South-west Oncology Group, cancer, I felt it was important and on the North Carolina we have some sort of data to try Advisory Committee on Cancer and figure out if screening is the Coordination and Control. same as Caucasians, or worse, Godley was awarded the or better.” American Cancer Society’s In a career that spanned clinical oncology career over 30 years, Godley made development award. He was a great contributions as a member of the American College prostate cancer specialist, of Physicians, American Society researcher, and educator. He of Clinical Oncology, and was a generous mentor to American Medical Association. junior faculty and brought a He was the associate editor tireless energy to his multirole for the Journal of the National profession. He was an Cancer Institute. accomplished physician leader After a myocardial infarction at UNC, where he was the several weeks previously, he Rush S Dickson distinguished died suddenly at his home in professor in the division of North Carolina, surrounded by haematology and oncology at his family, on 31 March 2019. the school of medicine, adjunct He leaves his wife, Adaora professor of at Adimora; two children; and his the Gillings School of Global father. Public Health, and senior Rebecca Wallersteiner fellow at the UNC Sheps Center [email protected]

UNIVERSITY CAROLINA NORTH OF for Health Services Research. Cite this as: BMJ 2019;365:l2174

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