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Organisations that provide checks and balances are seldom ‘listened to, even after events NO HOLDS BARRED Margaret McCartney Best birthday present? End the decline

he NHS is 70, and although After 70 years we have four devolved I want to celebrate the NHSs, and general practice is in a slow state endurance of a moral pact of understaffed and overworked collapse. that illustrates our collective Young people with mental illnesses best, I feel so dismayed at are often sent hundreds of miles for an Tthe way it’s treated that pride hardly inpatient bed. Management consultancies feels appropriate. are paid hundreds of thousands of pounds The NHS’s formation was contested by to tell the NHS where to save money (but many doctors and, famously, by the BMA. they never recommend spending less on Charles Hill, BMA secretary at the time, management consultancy). found “no reason whatever to bring doctors into Despite poor pay and conditions for many, NHS the position of the civil service as full time officers,” staff cite vocation as a reason for staying late and with “the cold hand of bureaucratic control . . . giving more than their contract requires. We all— administered by the state.” patients and staff alike—deserve better. The first wave of the NHS was about caring for The NHS has been characterised in recent decades people’s unmet needs. The early organisation by the political philosophy of the day, the political of district general hospitals, general physicians, need to make quick gains, and the increasing interest general surgeons, and GPs (who did some obstetrics of private companies in the financial opportunities and anaesthesia on the side) was primarily about the NHS presents. There is less concern for assessing doing just that. the known evidence of policy, realising the Then came Thatcherism, the 1990s, and the unknowns, or finding out whether policies work. creation of the internal market. Fundholding Organisations that provide checks and balances, allowed practices to pick and choose the healthcare such as the National Audit Office, are seldom on offer for their patients and to keep the profits, listened to, even after events. ostensibly to improve their own practices. If we’re to give the NHS a birthday present could Although the subsequent Labour government we please insist that every new policy is based on abolished fundholding, in its place came a evidence and has been tested (or is being tested) series of redisorganisations and competition, as and that its opportunity cost has been assessed and primary care trusts and strategic health authorities included? The vocation of staff is too good to waste. were brokered. The social good of the NHS would be a disaster to lose. We had hospitals trying to become foundation Yet I fear that it’s already been squandered, that trusts, independent sector treatment centres the slow decline of the NHS is the UK’s largest competing with the NHS, and new hospitals, preventable disease—and it’s staring us in the face. courtesy of private finance initiatives. The Health Margaret McCartney is a general practitioner, Glasgow and Social Care Act 2012 made the secretary of state [email protected] Twitter: @mgtmccartney no longer responsible for citizens’ health. Cite this as: BMJ 2018;361:k2740 the bmj | 30 June 2018 485 PERSONAL VIEW James Titcombe We must listen when patients or families raise the alarm The Gosport report gives a clear vision of how the NHS can improve safety while supporting openness and learning

ast week’s report by an the response of the hospital “appeared The hospital, relatives, whose interests some independent panel on to have the eff ect of closing down the police, the subordinated to the reputation of the Gosport War Memorial nurses’ concerns.” GMC, and the hospital and the professions involved.” Hospital makes for From Mid Staff s to Morecambe Nursing and shocking reading. The Bay to Southern Health, a common Midwifery Governance landscape inquiry L concluded that from 1987 theme has been the tendency of the The ramifi cations will be far reaching, Council could to 2001 at least 456 people died local health organisation, and also potentially with civil and criminal cases all have following prescriptions for opioids the wider system, to treat bereaved to follow. In the meantime, the debate which were made “without medical families as problems to be dealt intervened will shift to whether similar events justifi cation,” and a further 200 with or managed, rather than voices could happen today and what further patients whose medical records to be heard. changes are needed in response. The have been “lost” may have had their Events at Gosport paint an all too NHS’s governance and regulatory lives unnecessarily shortened. The familiar picture in which families were landscape has shift ed considerably inquiry found a “disregard for human dismissed as “troublemakers.” The since the events described in the life” and an institutionalised regime report lists organisations that could report. In 2009, the Commission for of prescribing and administering have intervened earlier, including Healthcare Improvement was replaced “dangerous doses” of drugs. the hospital, police, the GMC, and by the Care Quality Commission; more The report describes how, from the Nursing and Midwifery Council, recently, NHS England has introduced February 1991 to January 1992, a all failing to act in ways that would Learning from Deaths guidance; in number of nurses raised concerns, but have “better protected patients and April 2017, the Healthcare Safety

ACUTE PERSPECTIVE David Oliver England’s social care models harm the poorest people

Current models of local government Local government relies on three The 2010-15 coalition government funding systematically disadvantage main sources of income: direct support reduced support grants to all local people in deprived areas, grants from national government, authorities, with the National Audit compounding entrenched health business rates, and council tax. In Offi ce reporting a funding reduction inequalities. The Joseph Rowntree December 2017 the government gave of 28% from 2010 to 2014. Central Foundation found in 2015 that the local authorities the permission to funding support is projected to fall most deprived English local authorities raise an additional 3% of council tax by 77% by 2020. Council social care had experienced cuts of £182 more per as a specially earmarked “social care spending decreased by an estimated head than the most affl uent, “breaking Current social precept” to help tackle social funding 13% from 2010 to 2016. Independent the historic link between the amount care funding gaps locally. estimates show that around 400 000 a local authority spends per head and models The more affl uent the area, the fewer people were in receipt of social local deprivation levels.” don’t match higher the property values—hence the care in 2016 than in 2010. Unlike the A 2018 analysis showed that 25% population greater ability to raise income through NHS, such care is rationed, based on of services in England’s most deprived need. They council tax and precept. Business rate strict eligibility criteria that exclude areas were rated inadequate by the income is generally higher in areas people with lower level needs, and is Care Quality Commission, compared exemplify with thriving economies and higher means tested. These cuts aff ect lives. with only 15% in the 10 most affl uent the “inverse employment. Affl uent areas also have Old age is a key driver of care needs, areas. It was published by the care law” a higher proportion of homeowners and relatively affl uent areas oft en have Labour Party’s research team, but the and so commit a lower percentage of a higher proportion of older residents. conclusions are compelling. spend to council housing. But people in more socioeconomically

486 30 June 2018 | the bmj

Bereaved families call for justice for BMJ OPINION relatives who died in Gosport hospital Richard Smith them seriously, and ensuring they are investigated by someone with the right Revisiting “Stalinism” in the NHS expertise and independence. The appalling story of at least 450 patients in Gosport It’s a functional trust board, who Hospital being casually killed (p 464) and the failure know what information they need to of authorities to take action makes me remember understand and monitor the quality something I wrote in The BMJ in 1987 on “Stalinism and safety of care. It’s a flat hierarchy in the NHS.” (The events in Gosport ran from 1989 to that allows everyday conversations. 2000.) The story makes me think too of the marvellous It’s an organisation that reports its quote from Liam Donaldson, England's CMO from own near misses and incidents, 1998 to 2010: “To err is human, to cover up is and instigates learning processes unforgivable, to fail to learn is inexcusable.” Investigation Branch was established; without waiting for a complaint. It’s The 1987 article began: “Almost by definition it is and earlier this month the government an organisation that actively looks to difficult to obtain information on attempts by those confirmed that medical examiners will benchmark its outcomes and practice in power to keep information secret and stop people scrutinise every NHS death. against other organisations and takes talking publicly. Yet every day in our conversations with It is, of course, too early to evaluate all reasonable steps to adopt safer doctors, administrators, researchers, and others we the long term impact of these practice. It’s a regulatory system that hear stories of suppression of information about health measures, but there has never before encourages all of this. and the health service.” The article listed 20 examples been a time of so much focus on Perhaps most importantly, it’s where of suppression of important health information. patient safety and creating a culture every organisation involved in the Seven years later we returned to the theme, and I that supports openness and learning. delivery or regulation of healthcare wrote: “Recently I sat at dinner Gosport is another inquiry that treats patients or families raising the between a senior nurse and a shows the harm that can occur when alarm as vital voices to be heard and senior NHS manager, and much institutions put reputations before not problems to be managed. of the talk was of Stalinism in patients. The report also gives us a In the NHS, I believe we still have the NHS. These people were clear vision of where we need to get to. a long way to go before we reach this convinced that the NHS was place, but we owe it to those who becoming an organisation in Flat hierarchy suffered at Gosport to work towards it. which people were terrified to It starts with a staff nurse feeling James Titcombe, Patient Safety Learning speak the truth. This opinion is We can never confident to raise patients’ concerns, [email protected] heard time and time again.” develop the NHS knowing the organisation will take Cite this as: BMJ 2018;361:k2783 Censorship has a long without a lively tradition in Britain, and the debate ruling classes instinctively ACUTE PERSPECTIVE David Oliver suppress information. John Milton knew strict censorship at the beginning and the end of his life, England’s social care models harm the poorest people deprived groups have much shorter even posthumously, to fund care. but free speech flowered briefly in the middle of the disability-free or healthy life This would be a progressive move, 17th century. At this time Milton wrote, “Give me the expectancy after 65, so they may meet effectively taxing wealth, not income, liberty to know, to utter, and to argue freely according to the threshold of need earlier. And and would reduce inequalities conscience, above all liberties.” Truth, he argued, was wealthier areas will have more people reinforced by wealth passing down never “put to the worse in a free and open encounter who cross the means testing threshold the generations. The proposals— . . . It is not impossible that she [truth] may have more for “self funding”, meaning less crudely labelled by opponents as the shapes than one . . . If it come to prohibiting, there responsibility for local government. “death tax” or “dementia tax”—were is not ought more likely to be prohibited than truth Current social care funding models quickly binned. itself, whose first appearance to our eyes bleared and don’t match population need. They The prime minister’s commitment dimmed with prejudice and custom is more unsightly exemplify Julian Tudor Hart’s “inverse to increase funding to NHS England and implausible than many errors.” care law”, whereby those most in need by 3.4% a year did not include local We can never develop the NHS and the health of receive the poorest access to care. They government, public health, or social the British people without a lively debate, which also render council tax regressive— care. So, let’s hope the Department of will be debased if people cannot say what they truly further entrenching gaps between Health and Social Care’s review and believe. “Where there is much desire to learn,” wrote rich and poor. None of this aligns with resulting green paper can consider Milton, “there of necessity will be much arguing, much national policy ambitions to prioritise some radical solutions to reduce writing, many opinions; for opinion in good men is but prevention, reduce inequalities, and inequalities, not entrench them. knowledge in the making.”

improve population health. David Oliver is a consultant in geriatrics and Perhaps these truths should be quoted on the front The 2010 Labour and 2017 Tory acute general medicine, Berkshire page of all the many annual reports of the NHS. election manifestos both contained [email protected] Richard Smith was the editor of The BMJ until 2004. proposals to use property value, Cite this as: BMJ 2018;361:k2745

the bmj | 30 June 2018 487 ANALYSIS besity is an unsolved crisis, grain). A “healthy” diet (which confers generating long term health and helps prevent chronic diseases) distress and disabilities, will not necessarily prevent or treat obesity. Making reducing human capital, and Conversely, diets containing fewer calories increasing disease burdens may not always be healthy. Oand healthcare costs globally. Obesity has a Managing obesity demands understanding progress complex aetiology, incurring controversies how nutrients and diet compositions, foods, within both scientific and media arenas.1 eating patterns, cultures, and political and on the Poor education and socioeconomic commercial systems are responsible for situations are important drivers of severe weight gain, and how they can contribute to obesity, confounding country analyses by weight loss and prevent weight regain. global racial or ethnic groups. Age is important: Changing behaviours that people consider by age 65-70, as many as 40% of all normal is difficult, as a general principle. obesity people in the UK reach a BMI >30, and This is particularly true for diet because of 80% have a BMI >25.3 Many with BMI >30 the strong biological reward system that crisis will experience secondary medical effects, facilitates eating. although overall life expectancies of The relationship between food populations have increased steadily despite Willpower v societal responsibilities? obesity and the disabilities it brings. Although some people at risk can resist and weight gain is complex. Many factors have been associated obesity through vigilance, external factors Michael Lean and colleagues with weight gain, difficulty achieving and are hard to overcome. Evidence indicates a discuss what we know, and maintaining weight loss, and secondary recent environmentally led global epidemic, medical consequences of obesity. Some mediated by obesogenic factors such as what we don’t know, about have causal influences, many are innocent frequent eating out, large portion sizes, and weight management bystanders, and some have no basis in the commercial normalisation of routinely science. We focus on those related to food. consuming high sugar, high fat snacks and sweetened drinks between meals. Energy balance: is a calorie always a calorie? Hunger, greed, and temptation originate Obesity develops if absorbed dietary energy in the unconscious brain, which are affected (calories) exceeds energy expenditure for a by the environment in ways that are resistant considerable period (box 1). Similarly, excess to willpower: the sight or smell of attractive body fat is lost if energy intake falls below food triggers a cascade of hormone and expenditure. However, numerous multilevel sympathetic nervous system responses that factors contribute to determining energy increase the desire to eat. Thus calorie cutting expenditure, intake, and absorption, and strategies that increase hunger tend to fail small mismatches with food consumption because willpower is ineffective over the more over a long period can lead to large potent lower brain functions. Individually cumulative weight changes. directed willpower centric approaches Obesity is best considered not just towards prevention will therefore almost as a state of excess of body fat or BMI inevitably fail while the food environment above an arbitrary cut-off, but as the is unregulated. Collective responsibility is disease process, of excess body fat therefore required for effective progress at a accumulation that has interacting population level (box 2). (epi-) genetic and environmental causes and multiple pathological Current controversies in food and obesity consequences.5 Eat less, or exercise more? Many lay people believe that exercise Science and controversies linking food, is essential or sufficient for weight loss. obesity, and weight management However, although exercise has a small Individual foods seldom influence weight loss benefit when combined with an obesity. Instead, we consider energy restricted food plan,12 neither aerobic food groups, overall diets, and nor resistance exercise in typical amounts are the patterns of eating, resulting effective as a sole strategy.13 14 Recognising from food choices or restrictions. that reducing energy intake has the central Diets are analysed in terms of role in weight loss and prevention of regain their macronutrient contents will help prevent discouragement and (fat, protein, and carbohydrate), recidivism. Physical activity has a modestly micronutrients (vitamins, minerals), greater role in maintain weight loss15 16 and and other bioactive molecules and undoubted value for long term health and food properties (eg, fibre and whole preserving muscle mass.17

488 30 June 2018 | the bmj KEY MESSAGES Box 1 | Energy balance explained • The balance between calorie intake and calorie expenditure determines body weight and body fat changes Each kg of adipose tissue contains about 7000 kcal. • Different foods influence total energy consumption by modifying appetite, or by Thus consuming just affecting energy expenditure, eg through diet induced thermogenesis 100 kcal a day more than • Overweight people generally consume more food energy (calories) than thinner energy expenditure for a people to maintain their higher body weight year could result in a gain • Any diet plan that an individual can adhere to will cause weight loss, but dietary of 5 kg adipose tissue. patterns may influence adherence to different degrees in different subgroups A continued excess of half that size would be enough to reach 40-50 kg gain over Weight loss maintenance is a greater challenge than weight loss for many because • 20-30 years. However, energy expenditure it requires adapting to permanently eating less energy despite living in the same is not fixed and varies with diet and weight physical, social, and educational environments in which they developed obesity changes.

How many calories are needed? easily identified, and their avoidance In summary, the evidence is that adding The calorie requirements of adult humans tolerated without compensation from other a calorie source such as sugar will cause are lower now than in the past. US reference foods. However, such restrictive diets can weight gain and adverse metabolic effects, values for healthy adult men and women be difficult to maintain because dietary cutting a calorie source such as sugar or in energy balance are 2500 and 2000 kcal/ variety seems to be innately attractive, sugar sweetened drinks reduces weight gain day, respectively. Adults who are overweight persuasively marketed, and tends to by 2-3 kg, but there is no detectable sugar or obese typically have higher (not lower) increase energy consumption.24 specific effect on body weight, because calorie requirements than those who are Macronutrients and foods differ in body weight does not change when sugar is not obese.18 During acute negative energy their effects on appetite and satiation, removed from the diet and replaced with the balance (such as on a restricted diet), and on thermogenesis, and in how same calories from other carbohydrates.35 36 energy expenditure is reduced substantially, efficiently they are digested. There is As well as being a calorie source, sugar by about 15%-30% on average,19 20 but a hierarchy of obligatory diet induced may also have indirect influences on appetite contrary to widespread belief, once thermogenesis from macronutrients and eating. Evidence in humans is weak, someone has stopped losing weight, energy (protein>carbohydrate>fat), so high but frequent exposure to highly sweetened requirements are decreased relatively little, protein and whole grain foods increase drinks and foods may induce tolerance in direct proportion to weight loss.21 postprandial metabolism more than foods to unnatural sweetness and so facilitate The challenge of sustainable weight loss, higher in carbohydrate or fat.26‑28 Foods weight gain by promoting consumption of therefore, is to reduce food intake below the rich in various fibres, dairy foods such very sweet, energy dense foods.40 41 In real already low normal energy requirements as milk and yoghurts (perhaps related to life, a common dietary pattern associated and then to maintain a permanently lower calcium content),29 and with structural with obesity is characterised by frequent energy intake afterwards to prevent weight integrity that resist digestion such as nuts, consumption of sweetened drinks and regain. This is difficult for people who all show reduced absorption of energy sugary-fatty snacks between meals: theses have become obese leading what they from the gastrointestinal tract, likely by habits are recent, heavily promoted by social have regarded as normal lives, when living reducing the efficiency of fat absorption.30 marketing, and tend to travel together. under the same obesogenic conditions. However, these are relatively small effects, No particular dietary method for long easily overwhelmed by factors such as Intermittent fasting term maintenance has so far been shown portion size,31 so should not be considered Total fasting depletes essential nutrients to achieve superior results to others when in isolation when determining dietary and is unsustainable. Well designed implemented with appropriate support, recommendations. intermittent modified fasting regimens44 but individuals may have diet preferences reflect many long established religious which permit better outcomes. Sugar and obesity practices and probably match conditions It is difficult to establish a causal relation experienced throughout human evolution. Special effect foods: are all calories equal? between sugar and obesity: much of the Several models are under investigation, There is no evidence that any single food published research has been observational, including alternate day fasting or 5:2 diet carries special risks of weight gain and and “reverse causality” may apply.33 34 regimens, usually with “fasting” days obesity. Some people can lose weight, and The media are giving increasing attention restricted to about 500 kcal and either avoid regain, by focusing on restricting to the view that sugar is uniquely to blame usual eating or some form of conventional specific foods or food groups, including for obesity and its metabolic complications, healthy diet on other days. Current evidence (for different people) bread and cereals, based on the effect of glucose in raising suggests similar weight losses in completers red meats or meat products, cakes and serum insulin, which promotes fat but higher drop-out than with constant daily confectionery, milk and dairy foods, synthesis. Some have extended this concern restriction.45 Flexible approaches to suit sugar, and alcohol. These strategies to all forms of carbohydrate. However, individual preferences may be appropriate, are effective for weight control as long meta-analysis of randomised controlled but better long term evidence is needed as the foods are rich sources of energy, trials and prospective cohort studies finds for effectiveness and safety of intermittent consumed frequently by the individual, only modest effects. fasting for maintaining weight. the bmj | 30 June 2018 489 Reducing dietary carbohydrate or fat? Feeding the microbiota to combat obesity? Box 2 | Failures of willpower centric view Arguments abound as to whether Evidence is emerging that organisms in the National behavioural recommendations carbohydrates or fats are to blame for obesity. • gut may have a role in obesity.64 In humans, for weight management are largely based Some carbohydrates act as a more potent certain bacteria metabolise dietary fibre to on application of willpower and are poorly stimulus for insulin, possibly to promote fat short chain fatty acids that are absorbed to accepted because they are (accurately) deposition, but fats contain two to three times viewed as difficult and ineffective provide fuel for the gut itself (2-3 kcal/g), as many calories per gram as carbohydrate and act as insulin sensitisers and satiety • Uniquely for a major disease causing 65 and are more readily stored as body fat, stimulants. A Prevotella driven enterotype multiple pathologies, the perception of without raising metabolic rate. is predominant in people consuming more obesity is as a cost to healthcare and a 66 Epidemiological and long term intervention burden on society, rather than its disabling carbohydrate and fibre and seems to help studies are heavily confounded by other and distressing effect on individuals weight control. It remains to be determined if factors that also influence energy balance. these associations are on the causal pathway. • There is insufficient investment in effective Overweight people may consume more treatments, thus numerous profitable What policy actions are required? carbohydrate but must also eat more calories, non-evidence-based approaches are and they commonly under-report their promoted, with inflated claims to meet a Lack of progress against the obesity epidemic 46 47 food consumption. Advice to restrict desire for easier weight control has several origins. Research has been carbohydrate may be more effective in hampered by the assumption that the solution • Media coverage of “treatments” that are populations where a high proportion of not evidence based or are minimally lies in advice or support for individual carbohydrate is visible as sugar, and with effective contribute to confusion and decision making. Importantly, funding for manufactured foods which also contain fat, undermine professional advice research and treatment will be more rationally whereas the fat content of foods is often more planned if conditions such as type 2 diabetes, • The view that food companies are not difficult to identify. responsible for the obesity epidemic hypertension, arthritis, asthma, depression Evidence comparing low carbohydrate and leaves them free to create and promote an can be reframed as complications of obesity. low fat diets is not entirely consistent. The increasing variety of obesogenic products Potentially effective interventions include apparently conflicting outcomes of meta- those aimed at food marketing and taxing • Less obesogenic food products tend to be analyses may be explained by differences more expensive per calorie foods that are dominant contributors to in inclusion criteria for diets, study design, weight gain, reducing the price of less • Willpower centricity leads to a lack of how the other dietary components of the obesogenic products, and curbing portion population directed measures that avoid 71 diets were changed, and the characteristics individual accountability sizes in restaurants. Evidence is accruing, of participants. from Mexico and elsewhere, that in the short Government funding for obesity treatment • term there are behavioural shifts away from is less than for other diseases relative to 42 Personalised dietary management based on 11 taxed foods, but effects on weight gain numbers of resulting disability or deaths genetic or metabolic status? or obesity have not yet been reported. The Emerging evidence suggests that genetic UK is beginning to tax drinks with sugar or metabolic factors may affect a person’s difference between the two diets. In this content above 8%, encouraging product weight loss responsiveness to carbohydrate, study neither the presence of genes that reformulation with sugar content falling from such that normoglycaemic people achieve have been proposed to confer benefit from 10% to under 8%. greater satiety on low fat diets despite low carbohydrate diets, nor baseline insulin Misinformation is also a problem. a higher glycaemic load, whereas more secretion, helped to define which diet Governments can build platforms to foster insulin resistant people do better with lower was better for specific subgroups, but low appropriate ways to maintain healthy glycaemic loads.55 Specifically, people who adherence to the diet prescriptions may have weight without further disadvantaging the are more insulin resistant or have diabetes masked any possible effects.61 more disadvantaged in society, distribute may lose more weight, with benefits for The evidence is incomplete, but it suggests information about obesity prevention, and glucose control, lipid levels, and blood that people with normal insulin sensitivity support more research to identify effective pressure, when assigned to lower glycaemic can achieve marginally greater success interventions. Teaching about energy balance load regimens.56 on low fat regimens, provided very high early in schools, together with prominent, More evidence is required to define the best glycaemic loads are avoided. However ubiquitous, calorie labelling of foods, could range of carbohydrate intakes to recommend insulin resistance or diabetes exaggerates provide valuable effects at low cost. on metabolic grounds for people the responses to glycaemic loads, making Combined, these multiple initiatives could with type 2 diabetes, or whether lower total carbohydrate intakes preferable in have a major effect on the global obesity personal choice may be the most cases since this is easier than adhering epidemic and human health. dominant influence. to a higher carbohydrate regimen with the Michael E J Lean, professor, Human Nutrition, A recent large 12 necessary large amounts of dietary fibre and School of Medicine, Dentistry and Nursing, month trial comparing legumes.55‑63 These different dietary patterns University of Glasgow healthy low fat and healthy still need to be compared in randomised Arne Astrup professor, Department of Nutrition, low carbohydrate diets trials, but outcomes seem likely to be affected Exercise and Sports, University of Copenhagen in overweight adults more by adherence in real life settings, which Susan B Roberts, professor, Energy Metabolism reported weight losses in turn will relate to the effectiveness of Laboratory, USDA Human Nutrition Research Center of 5-6 kg in both groups, behavioural support and cultural and social on Aging at Tufts University, Boston with no significant factors, than by individual underlying biology. Cite this as: BMJ 2018;361:k2538

490 30 June 2018 | the bmj LETTERS Selected from rapid responses on bmj.com See www.bmj.com/rapid-responses

RISE IN MORTALITY patient wishes (Personal View, 26 How many deaths until the May). In the fine nuances of end of life decision making this was government takes note? allowing death to happen and In March, we raised concerns not causing it. The distinction is that over 10 000 extra deaths important on several levels. had occurred in the first seven That Black felt herself to be weeks of 2018, compared with in the position of causing her the average of the past 5 years mother’s death is disappointing. (Editorial, 17 March). When Putting relatives in this position, Jeremy Hunt was asked about especially those without this, he said that the figures knowledge of how the systems didn’t take account of changes work, is unacceptable. in population or demography This must be the time for and that the age standardised LETTER OF THE WEEK a public health campaign to mortality rate had remained encourage people to talk about stable over recent years. Brexit—an impartial view? the future and what would be We got a similar response from Brexit divides the country, the main political parties, and families. important to them and for us the Department of Health and One reason for this polarisation is the triumph of “opinion” over to put in the legal directions to Social Care when excess deaths hard data. Remainers and leavers are both guilty of confirmation enable this rather than relying on reached 20 000 on 8 May 2018 bias. In 1859 wrote that to understand a subject relatives in the pressured setting (This Week, 19 May). one should hear both sides of an argument. Now, 160 years later, of an emergency department. Figures from the Office for we need a dispassionate, disinterested, objective assessment of Andrew Thorns, consultant in palliative National Statistics published on whether genuine risks to health exist. The public needs it; doctors medicine, Margate 18 June 2018 confirm our fears— expect it; The BMJ doesn’t provide it. Cite this as: BMJ 2018;361:k2749 the age standardised mortality The BMJ is advising medical professionals to persuade their rate in the first quarter of 2018 patients to lobby for a second (people’s) vote on Brexit, using a No need to hasten death was 5% higher than in the first selected group of authors dedicated to this end, who use a one Black describes a scenario that quarter of 2017 and is at its sided set of references (Editorial, 26 May). Regardless of whether is not uncommon to clinicians highest since 2009. The BMJ should politicise the doctor-patient relationship, this but is to the families of patients So, we ask again: how many ignores the journal’s guidelines on evidence. (Personal View, 26 May). Her deaths will it take for the The BMJ should re-acquaint itself with the principles of its mother’s wishes for the end of her government to take note? various, famously and rightly lauded, campaigns: evidence based life were asked about, recognised, Lucinda Hiam, GP and honorary medicine, too much medicine, and open data. In each of these we and facilitated. research fellow, are told how we should handle data scientifically, scrupulously, and Black mentions her mother’s Danny Dorling, Halford Mackinder professor of geography, Oxford fairly. I wonder also where the eventual targets of this article, the support for Dignity in Dying, the Martin McKee, professor of European patients, were. organisation that advocates public health, London The BMJ’s editorial office should turn over the page to Woloshin physician assisted suicide. But Cite this as: BMJ 2018;361:k2747 and Schwarz who remind us, in a different context, that “journals her death had nothing to do with ЖЖNEWS, p 464 are not selling treatments, they are honest brokers of information” the aims of the organisation and NHS APOLOGY FOR RACISM (Essay, 26 May). should not be regarded as an David Barlow, emeritus consultant physician, London example to support its causes. BMA responds to Cite this as: BMJ 2018;361:k2743 In this case, after considered racism in the NHS assessment and conversations The incidents described by at increased risk of experiencing with key stakeholders and between the treating team, the Menon reflect the real—and bullying and harassment from experts to come up with clear patient, and those close to her, completely unacceptable— both colleagues and patients. recommendations and actions to the decision was made to respect experience of many foreign born They are more likely to be eradicate racial bias in the NHS. the patient’s wishes and allow a and black and minority ethnic referred to the GMC, have their Chaand Nagpaul, BMA council chair, natural death. (BME) doctors working in the cases investigated, and face London We do not necessarily need NHS (Commentary, 2 June). tougher sanctions than their Cite this as: BMJ 2018;361:k2748 to “speed death” but can allow Overseas doctors have been white colleagues. We need DEATH death to happen naturally, with the backbone of many services concerted action to bring high quality, responsive, and in the NHS; we owe them an about change. Encouraging people readily available palliative and enormous debt of gratitude. This is why the BMA will be to talk about death supportive care at the end of life. BME staff are still twice holding a summit in July to bring I am glad that medical colleagues Iain Lawrie, consultant in palliative as likely to be affected by together BME doctors, medical listened to Black and her mother medicine, Manchester discrimination at work and are students, and medical leaders and came to a decision driven by Cite this as: BMJ 2018;361:k2752 the bmj | 30 June 2018 491

Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

OBITUARIES

Begoña Anne Bovill Maria Theresa Goretti Frank Arthur Fairweather Consultant physician Thaddeus Consultant pathologist in infectious diseases, Campbell and toxicologist (b 1928; tropical medicine, and Consultant psychiatrist q Middlesex Hospital HIV North Bristol NHS Newcastle and County 1954; FRCPath, FRSB), Trust (b 1963; q Royal Durham (b 1951; died from heart failure on Free Hospital School of q Birmingham 1975; 29 November 2017 Medicine, London, 1987; MRCGP, FRCPsych), died Frank Fairweather MSc, DTM&H, FRCP), in a fall while walking in became chief medical died from metastatic adenocarcinoma of the the Alps on 30 August 2017 adviser and consultant pathologist at the pancreas on 3 April 2018 Maria Theresa Goretti Thaddeus Campbell Benger Laboratories in 1962 while sharing After training in London, Begoña Anne Bovill attributed her remarkable list of names to her his growing expertise with the Royal College took over and expanded the infectious maternal grandmother, who, she said, was of Surgeons as honorary senior lecturer. From diseases department in north Bristol. She a McGregor and thought the daughter of a 1978 to 1982 he was director of the DHSS walked 16 km on the Black Mountain five Campbell would need to have a claim on as toxicology laboratory at St Bartholomew’s weeks after having a Whipple procedure. Half many saints as possible. After hospital and Hospital and held honorary professorships. Spanish, she wed in Andalucia days after GP training posts, Maria worked in Zambia. When head of safety and environment for she and some of the guests heard they had She returned to Britain in 1984 to train in Unilever (1982-93), he spent time conducting passed their membership exams for the Royal psychiatry in the northern region, where research in the US and teaching at Harvard College of Physicians. She instilled her love of she remained for the rest of her career. She University. He was Physician to the Queen Spain and its language in her children, and in specialised in psychiatry of the elderly. In in 1977-80 and was awarded an honorary her final year she saw her youngest graduate. retirement Maria was particularly active in her fellowship by the Faculty of Occupational Begoña socialised, sewed, gardened, favourite interests of trekking, climbing, and Medicine in 1991. Predeceased by his first hillwalked, photographed, and worked with travel. It was on a walking holiday in Austria wife, and one of his two sons, Frank leaves vigour. She leaves her husband, Simon, and that she fell to her death. She is greatly missed his second wife, Dorothy; a son; and two three children. by friends, colleagues, and family. grandchildren. Simon Rose P Cronin, E Whitfield, K Hurren Dorothy Fairweather Cite this as: BMJ 2018;361:k2265 Cite this as: BMJ 2018;361:k2273 Cite this as: BMJ 2018;361:k2276

Romayne McAuliffe Ian Douglas Ramsay Grizel D'Rastricke Stewart Consultant in anaesthesia Consultant Medical assistant North Moorfields Eye Hospital, endocrinologist Regional West Special Care Services, London (b 1944; q Sydney Endocrine Centre, North Northern Ireland (b 1924; 1968; FFARCS), died from Middlesex Hospital, q Queen’s University type A aortic dissection on London (b 1935; Belfast 1946; DPM), died 11 March 2018 q University of Edinburgh after many years of vascular Romayne McAuliffe 1959; MD, FRCP, FRCPE), dementia on 11 May 2017 was born in Sydney but died from progressive Grizel D'Rastricke Stewart trained in anaesthesia in England. In 1982 supranuclear palsy on 14 February 2018 (née Carr) accompanied her husband to she was appointed consultant in ophthalmic Ian Douglas Ramsay was known by friends Burma (and later Assam), where he worked in anaesthesia at Moorfields Eye Hospital in and colleagues as “Muscles Ramsay” the oil industry. After the birth of her daughter London, where she practised until she retired because of his pioneering research into in 1949 she took time out of medicine. In in 2007. In 1995 she ruptured her aorta thyroid disease and muscular dysfunction. 1958 she trained in psychiatry at Lancaster with an antegrade type B dissection treated While at Edinburgh, he sat in on history of art Moor Hospital and in 1959 she moved to medically. After only six months of recovery, lectures and retained this passion for the rest Derry to work in general practice. A special she returned to full time work for a further 12 of his life. At the Regional Endocrine Centre, care and learning disability service was set years. Throughout 45 years of married life she his research was largely concerned with up in the former City and County Hospital in lived in Kingston-upon-Thames. Unfortunately, thyrotoxicosis in pregnancy and metabolic 1960, and Grizel was appointed specialty her sons and grandchildren are dispersed muscle disease. From 1979 Ian served as doctor, later associate specialist. In her worldwide, so much of her retirement consisted the UK director of medical education and retirement Grizel moved to a farm, where she of travelling with her husband, Robin. In 2018, then associate UK chair of medicine for St kept cattle, bred geese, and reared dogs and she had an acute retrograde type A dissection. George's University School of Medicine in donkeys. She leaves her daughter, Désirée She was buried in Sydney. She leaves Robin, Grenada (West Indies) for many years. He (“Daisy”); three grandchildren; and three three sons, and four grandchildren. leaves his wife, Patricia, and four daughters. great grandchildren. Robin Walesby Anna Ramsay Ailbe Beirne, Désirée Mules Cite this as: BMJ 2018;361:k2255 Cite this as: BMJ 2018;361:k2247 Cite this as: BMJ 2018;361:k2249

492 30 June 2018 | the bmj

another invaluable attribute for a Thomas controversial columnist.

Stuttaford Life and career Born in 1931 in a remote part of Media doctor and , where his father, uncle, and celebrity patient grandfather had all been doctors, the studious young Tom was educated at Irving (b 1931; Gresham’s School in Holt, where he q Oxford 1959; MRCS Eng), died from a was head boy and captain of rugby. suspected heart attack on 8 June 2018 He went on to captain the Norfolk Thomas Stuttaford was the medical and schoolboys’ rugby correspondent and columnist for teams, eventually playing for Eastern newspaper for more than Counties. Reported to devour a book 25 years. He was also an MP, medical a day, he read medicine at Brasenose adviser to Conservative Central Office, College, Oxford, where he wrote for broadcaster, renovator of historical student publications and became houses, and ornithologist, as well as a editor of the British Medical Students’ highly controversial celebrity patient Journal, forerunner of the Student BMJ. (by virtue of his prostate gland) and a After two years of national great believer in the healing power of a service with the 10th Royal Hussars glass of red wine. and Territorial Army service with “Dr Tom” was one of those charmed the Scottish Horse regiment he NEIL SPENCE/ALAMY NEIL men who pick up life’s glittering experienced two extremes as a young prizes by being in the right place at 9 December 1997, as part of the Stuttaford doctor: the prestigious Hammersmith the right time with the right people— Times Christmas appeal, he described exploited Hospital in west London and his particularly Harold Evans, one of prostate cancer as “a hidden killer his Times uncle’s East Anglian practice, where, his patients and then editor of the that can strike without warning.” platform to it was reported, no one had opened a Times. Stuttaford’s journalistic career He suggested that, while radical powerful textbook in more than 40 years. spanned the explosion in health prostatectomy was a routine procedure effect to Life as a rural GP would never have reporting over the past 40 years and in the US, where screening was satisfied a man who went on to belong the new era of mass market magazines routinely available for men over 50, the promote to seven London clubs, including the devoted to health, complementary operation was less common in Britain screening Garrick and the Athenaeum. In 1970 medicine, and general fitness. because of financial considerations. for prostate he was elected MP for Norfolk South; His column was parodied in specific he lost his seat in 1974. In two further Embracing controversy , which nicknamed him antigen elections he was selected as the Tory He maintained that the media “Thomas Utterfraud.” But the satirical candidate in the Isle of Ely to oppose revolutionised the relationship magazine’s founder, Richard Ingrams, . In 1996 he received an between doctors and patients and was a good friend and once nominated OBE for his services to politics, which told me in 1999: “I’ve always believed Stuttaford as the person he would had started on a parish council. that informing patients was well done most like to get stuck in a lift with. It’s I first met him over breakfast during by the media. I’m not sure whether easy to see why. Tall and courteous a medical meeting in Florida, where doctors would have moved down the but imposing, with his trademark half he shocked waitresses by speaking line of informing patients if the media moon spectacles and pinstripe suits, loudly about his extensive experience hadn’t done so.” Stuttaford was engaging company: of genitourinary medicine. Being away His way of informing patients was his charm helped him to build up from home, he said with a twinkle in occasionally highly controversial. an encyclopaedic contacts book, a his eye, reminded him of the many He exploited his Times platform to prerequisite for any medical columnist. men he had seen who had returned powerful effect to promote screening He recalled: “In 1982 I was asked to from the Far East with more than just a for prostate specific antigen (PSA)— cover the delivery of Princess Diana’s successful deal. despite evidence that it resulted in first child and rang her gynaecologist, Stuttaford was married to Pamela more cases of latent cancer being Sir George Pinker, when she was in Ropner, a bestselling children’s author, treated radically but unnecessarily. the first stages of labour. Sir George’s for 56 years. Devoted to one another, Although asymptomatic, he wife called him to the telephone to the couple did up ruined houses in followed his own advice and had his take my call, even though he was in Norfolk to help pay school fees. Pamela own PSA checked: it was high. He the garden pruning his roses, as she died in 2013 after a lengthy illness described his subsequent surgery knew he would speak to me, but no during which he nursed her. in the Times. His brother, William other journalist.” Was this really true? He leaves three sons. Stuttaford, had already developed We will never know, but he certainly John Illman, London metastatic prostate cancer. On believed it. He radiated confidence— Cite this as: BMJ 2018;361:k2704 the bmj | 30 June 2018 493 PROVOCATIONS James Le Fanu Mass medicalisation is an iatrogenic calamity Profligate prescribing has brought a hidden epidemic of side effects and no benefit to most individuals

is impossible these physiological variables to the left treatment for the individual by as to separate the than identifying and treating those in much as 50-fold. chance of good whom they are significantly elevated. The triumph of Rose’s vision for his from the risk of ill,” Rose’s paper, and its subsequent population strategy would come with wrote David Hume elaboration in The Strategy of its incorporation, as the Quality and “Tpresciently, anticipating, by 250 years, Preventive Medicine, is a masterclass Outcomes Framework, in the 2004 medicine’s current existential crisis. in intellectual sophistry predicated general medical services contract, with There is no drug or procedure with its on the well recognised ecological family doctors financially remunerated “chance of good” that may not harm The simple fallacy: the assumption that the for success in hitting targets for some. The more doctors do, the greater expedient of study of the attributes of groups is numbers of patients treated. But the that risk. redefining informative about the individuals QOF’s perverse incentives have, if And doctors are certainly doing hypertension of which they are composed. He inadvertently, put Rose’s population much more with, over the past 20 increased its provides no empirical evidence in strategy to the test. For if everyone’s years, a dizzying fourfold rise in favour of his “population strategy” physiological variables are indeed prescriptions for diabetes treatments, prevalence in (as there is none). As for his proposed too high, then shifting the bell curve, sevenfold for antihypertensives, and the US by 35% method for shifting the blood pressure albeit by pharmaceutical means, 20-fold for the cholesterol lowering distribution of the population, should have the effect he predicted statins. Meanwhile the number of dietary salt restriction, this had been of markedly reducing the prevalence people taking five or more different investigated in the classic Glyncorrwg of circulatory disorders. On the drugs has quadrupled to include community study in South Wales and contrary: “The introduction of QOF almost half of those aged 65 or over. found to be ineffective. was not associated with significant And “the risk of ill” from this changes in mortality for the diseases massive upswing in prescribing? A Theoretical rationale targeted by the programme.” So the hidden epidemic of immiserating But while modest dietary changes do population was not “sick” after all symptoms such as fatigue, muscular not influence physiological variables, but has certainly been made sick by aches and pains, insomnia, and drugs certainly do, and from then on the iatrogenic consequences of that general decrepitude; a 75% rise in Rose’s proposed strategy of prioritising profligate prescribing. emergency admissions to hospital for treating the many rather than the few “History is a high point of advantage adverse drug reactions (an additional would provide the theoretical rationale from which alone we can see the 30 000 a year); and almost certainly for the drug industry’s goal of mass age in which we live,” wrote G K a contributory factor to the recently medicalisation. This “close alignment Chesterton. It is sincerely to be hoped noted decline in life expectancy (an of the priorities of public health with that a better historical appreciation additional 600 deaths a week). the marketing practices of this most by the profession of the exploitation This polypharmacy induced profitable of industries” has been by the drug industry of the false iatrogenesis is deeply entrenched achieved by lowering the threshold for doctrine of the population strategy (to within routine medical practice, initiating treatment to include those its immensely profitable advantage) irrevocably so without the profession’s whose physiological variables are only might provide the necessary incentive recognition of its origins, more than marginally elevated, if at all. to reversing the burden of medication 30 years ago, in Geoffrey Rose’s The simple expedient of redefining imposed on the many. influential “Sick individuals and sick diabetes, hypertension, and The obstacle remains that prominent populations”—arguably the most hypocholesteraemia in this way epidemiologists remain wedded to the harmful (in its consequences) medical increased their prevalence in the US by, population strategy and remain vocal paper of the 20th century. respectively, 14%, 35%, and 86%—an advocates of mass medicalisation. It was not just individuals that additional 56 million cases, more than “[The population strategy] is now so are sick, Rose argued, but the entire a third of the total adult population of widely accepted it is hard to realise population. Everyone’s blood pressure, 187 million. The many, indeed. how radical it was,” argues Michael blood sugar, and cholesterol levels are The role of the drug industry Marmot. “It has changed our whole too high. “A large number of people at in fostering this redefinition of approach to improving health.” Their small risk may give rise to more cases disease is well documented, as is its goose is cooked, and we should not of disease than a small number at high universal resort in clinical trials to hesitate in emphatically saying so. risk,” he wrote. There is thus more the meaningless statistical metric of James Le Fanu is a retired GP and journalist to be gained in preventing illness by “relative risk reduction,” exaggerating [email protected] shifting the bell shaped distribution of the miniscule absolute benefit of Cite this as: BMJ 2018;361:k2794

494 30 June 2018 | the bmj