Prescribing Incentives Are Grubby Ast Week It Emerged That Finances and Nimbly Calculates That, with Oxfordshire Clinical Enough of a Push, Money Can Be Saved

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Professionalism means doing the right ‘thing, not the cheapest or easiest thing NO HOLDS BARRED Margaret McCartney PPA COLUMNIST OF THE YEAR Prescribing incentives are grubby ast week it emerged that finances and nimbly calculates that, with Oxfordshire Clinical enough of a push, money can be saved. Commissioning Group has Scotland, having thrown off the noose suggested that GPs should of the Quality and Outcomes Framework, review patients in nursing still makes regular nods to prescribing Lhomes and “rationalise” prescribing. If incentives. We’re still given payments for enough drugs are stopped or switched medication switches and for decreasing to meet the threshold, the GPs keep half percentages of one drug compared with the cash saved. Cue righteous outrage another. This is a process of diminishing from the national press. It feels grubby returns. So we have a handful of people because it is. with difficult medical histories who There’s little doubt that incentive programmes, are given, say, lignocaine patches and have tried particularly the Quality and Outcomes Framework managing without but would reasonably prefer these in general practice, have led to reflex prescribing to gabapentin. and overprescribing. Doctors must satisfy their General practice is often practised at the edge of paymasters’ suspicions in justifying why they haven’t evidence, with constant compromise, persistent prescribed, rather than why they have. Yet evidence uncertainty, and fluctuating choices and priorities. shows that single disease guidelines for prescribing in Stopping one or two of those prescriptions means multimorbidity aren’t fit for purpose. hitting a target, meaning payouts for practices—but Financial incentives are rotten to the core. Money what about the impact on patients? The conflict of is used to make GPs prescribe, and then to make interest is obvious and unnecessary: we don’t want us not prescribe. This is, in essence, manipulation overtreatment or undertreatment. of the trusted relationships between doctors and It would be possible to pay staff to do medication patients by unseen puppeteers, who suppose that the reviews for people at high risk of overtreatment, while desired outcomes will occur if just the right amount of making flat payments. Better would be to assume that pressure is correctly applied. this should be done anyway. Self employed contractors, many wobbling For every payment by specific incentives, resources financially, are in a bind. Not doing the work means will be concentrated in one area, leaving less loss of income. But doing the work is anti-professional. elsewhere. Why can’t we put the money in centrally No one should support wasting money on poorly and aim for basic, good quality care for everyone, evidenced products. And overtreatment is a harmful using professionalism and transparent data—rather waste of resources. Professionalism means doing the than financial targets—to help us? right thing, not the cheapest or easiest thing. Margaret McCartney is a general practitioner, Glasgow The proposed Oxford scheme is just a continuation [email protected] of the regressive path of general practice in England. Follow Margaret on Twitter, @mgtmccartney Someone sees a chink of light in the black hole of Cite this as: BMJ 2017;357:j2695 the bmj | 10 June 2017 433 PERSONAL VIEW Colin Drummond Cuts to addiction services are a false economy “Savings” in specialist services are increasing pressure elsewhere in the NHS

hocking images of training posts in England; and drug users sprawled there can be no further cuts to unconscious or local authorities’ budgets for these standing statue-like services. in an intoxicated state Before 2012, drug and alcohol Shave begun to surface in the media services in England were jointly recently. commissioned by the NHS and local People 50%. In Birmingham, for example, Meanwhile deaths involving heroin authorities. Substantial government with drug the addiction treatment budget was or morphine have more than doubled investment meant a long track record or alcohol cut from £26m to £19m in 2015-16. since addiction services were of success since the 2000s. The dependence The main opportunity to make cuts transferred from NHS control to local Health and Social Care Act made local are is in the workforce, meaning fewer authorities in 2012, and are now at authorities solely responsible for stigmatised specialist addictions psychiatrists, the highest level on record. Last year commissioning these services—and clinical psychologists, and nurses, there were more than 15 000 drug unlike the NHS, council spending on and so their and a greater reliance on doctors related, and over one million alcohol drug and alcohol services is no longer services are without specialist training and related, hospital admissions. The ring fenced. With reduced central often the volunteers with limited training. need for better access to addiction government funding, councils have first to be The number of training posts in services is clear. been forced to cut services to make axed addictions psychiatry has decreased The Royal College of Psychiatrists savings. by 60% since 2006. While 10 years has three solutions: Sustainability People with drug or alcohol ago there were 52 trainees, a Royal and Transformation Plans must dependence are stigmatised and so College of Psychiatrists survey found ensure a return to joint addiction their services are often the first to be that in 2016 just 21 senior trainee service commissioning between the axed. Typically, addiction services in posts were filled. Addictions services NHS and local authorities; there must England have seen cuts of 30% but increasingly struggle to find qualified be at least 60 addictions psychiatrist some areas are planning cuts of up to specialists, leading to lower standards

ACUTE PERSPECTIVE David Oliver Unproductive activity and NHS consultants

With constrained public money, a slowly rising volume of clinical community services aren’t resourced growing focus arises on doctors’ activity. Appleby emphasised the or functioning. key role in reducing variation importance of considering “quality Into this analysis, I’d add a few in processes and outcomes and adjusted” productivity and the need more ingredients. Firstly, the era of improving value in healthcare, to differentiate elective, outpatient senior doctors doing ward rounds especially how money is spent care from acute, unselected care. He only twice a week, or being on call and what it delivers in outcomes We’re expected noted that, as care becomes more only from home, has gone. We’re that matter to patients and system to see patients complex, a crude calculation is expected to see patients more efficiencies. more frequently, unhelpful. frequently, earlier in admission, at Earlier this year John Appleby at weekends, Of course, doctors work in teams weekends, and during evenings. published an analysis in The BMJ and during and organisations, not as lone This skews the productivity calculus. comparing current and historical evenings. This practitioners. We depend inherently It’s surely the right thing, but its productivity of NHS consultants. The on the availability of decent IT impact on crude productivity is more skews the headline figures suggest that today’s and records, timely investigations, marginal. consultants are less productive productivity logistical support, adequately staffed Secondly, as a King’s Fund report than their predecessors in crude calculus multiprofessional teams, capacity on frontline care recently showed, terms of “volume of output versus (in theatres, intensive care, or hospital doctors can spend a lot of unit of input,” with consultant clinics), or the ability to get patients time battling the poor logistics I’ve expansion unmatched by the more flowing through the system when highlighted. And endemic rota gaps

434 10 June 2017 | the bmj addiction services, or they fall out of treatment during transitions between BMJ OPINION Daniel Grant service providers through tendering Humanising healthcare processes every three years. This continual and unnecessary churn Being a doctor should be about being human, and yet it of service providers is inefficient, is one of the most dehumanising jobs of all. ineffective, and costly. We always talk about the doctor-patient relationship— Cutting community based the need to work with, relate to, and help the person in addictions services has transferred front of us. We can empower patients to ensure that they the burden of patients with drug and have the maximum quality of life for as long as possible. alcohol dependence on to already We can, but we don’t. pressurised emergency departments As a junior doctor, I’m frustrated. I work in an and general psychiatry. The 15 074 environment that suffocates my ability to treat hospital admissions in England for individuals. I spend 95% of my time with the computer illicit drug poisoning is an increase instead of the patient. I identify them by their bed

JOHN BIRDSALL/ALAMY JOHN of 6% on the previous year—and number or by their illness, I check their results remotely, which impact on the effectiveness is a staggering 51% higher than in and, at best, I have a brief clinical chat with them and and safety of patient care. To meet the 2005-06. hold their hand. needs of people with drug and alcohol Cuts at a local level make savings— Medicine has moved away from personal problems, we must return the number but what is the real cost? Our care towards depersonalised guidelines of addictions psychiatry training posts previously well functioning treatment in England to 60. system has been downgraded by a There are many reasons for this, but, fundamentally, In addition, NICE approved, short term strategy to save money. medicine has moved away from personal care towards evidence based harm reduction This is a false economy. If we want depersonalised guidelines, academic elitism, and treatments are under attack by the to tackle the rise in drugs related bureaucratic complexities. Most of this isn’t our fault, government. This has resulted in some deaths, there must be at least 60 and I know that most doctors share these frustrations, local authorities limiting how long addiction psychiatry training posts in but it is never too late to strive for change. I’d start by patients can remain on methadone England and there must be no further looking at three things. treatment, and “payment by results” cuts to addiction services by local Firstly, the role of doctors must change. If we continue contracts have removed the incentive authorities. to have a hierarchical system whereby newly qualified for addiction treatment services to Colin Drummond is professor of addictions doctors barely use a single skill they’ve accrued at take on patients with complex needs psychiatry, Institute of Psychiatry, Psychology, medical school, then we’re doing something wrong. who are likely to need longer and more and Neuroscience, King’s College London If the majority of a junior doctor’s job is doing tasks intensive treatment. As a consequence [email protected] that you don’t need a medical degree to do, then we’re this group is either unable to access Cite this as: BMJ 2017;357:j2704 wasting a generation’s skills. We need to be using our resources correctly, both in terms of technology and staff, so that we can free up doctors to spend more time ACUTE PERSPECTIVE David Oliver with the people they are treating. Secondly, the medical school bubble—full of type A, Unproductive activity and NHS consultants in acute medical specialties don’t or professional development. But highly strung, high achieving, multitalented people—is help. does every bit of it really add value an unhealthy environment. Being a doctor is all about Thirdly, compared with the start of or merely detract from face to face communication, so why don’t we focus more on drama, my consultant career 20 years ago, patient care? rhetoric, and philosophy? We often champion “well we’re drowning in e-correspondence Maybe productivity isn’t all that rounded” people and pluck them from school into and paperwork. Consultants had matters anyway. Staff morale is medicine, where we then bash them into a square barely any of this administrative crucial to clinical quality, recruitment, hole and knock the creativity and burden when we each had personal retention, and organisational individuality out of them. In a medical secretaries and no hospital performance. Doctors should be discipline that needs to be more email. encouraged to do wider work for about communication and empathy, Perhaps more importantly, the the NHS, in leadership, policy, this is a disaster. exponential growth of time spent education, training, and research. Thirdly, the environment needs to on documentation for revalidation, Senior professionals in key roles are change, not just for the sake of healthcare staff and their appraisal, external regulatory not production line automatons. low morale, but for patients. They can feel dehumanised standards, trainees’ e-portfolio Discussing them as if they were because we make them feel like machines on a conveyor assessments, mortality reviews, doesn’t help them to help patients. belt, when they should be treated as individuals. If we’re allowed to communicate properly and engage mandatory training, incident David Oliver is a consultant in geriatrics and reporting, and investigation is acute general medicine, Berkshire the creative aspects of our nature, then we can begin to out of hand. Clearly, we shouldn’t [email protected] change what it means to be a doctor. be complacent about patient Follow David on Twitter, @mancunianmedic Daniel Grant is an F2 working at Luton and Dunstable Hospital safety, educational supervision, Cite this as: BMJ 2017;357:j2693

the bmj | 10 June 2017 435 ANALYSIS Integrating approaches to care during the Syrian refugee influx in Lebanon How countries can build resilient health systems Hardy national services begin by measuring critical capacities ahead of any crisis say Margaret E Kruk and colleagues

he 2014 west African capacity, and investment to build Ebola epidemic shone a resilient health systems that can harsh light on the health withstand shocks while maintaining systems of Guinea, routine functions.10 The issue of how Liberia, and Sierra global bodies can support countries TLeone. While decades of domestic in withstanding future health shocks and international investment had is played out in the election of contributed to substantial progress WHO’s director general with several on the Millennium Development candidates making health system Goals,1 2 health systems remained resilience part of their campaigns. Crises do system resilience has been defined weak and were unable to cope with Based on recent literature, this not respect and widely discussed, there is debate the epidemic. paper defines health system resilience geopolitical about whether the concept has Routine care of the population also as “the capacity of health actors, anything new to add to discussions 1‑4 boundaries deteriorated during the outbreak. institutions, and populations to and so on health system strengthening, and Surveillance systems did not function prepare for and effectively respond to how resilience can best be built and effectively, allowing Ebola to spread crises; maintain core functions when resilience measured. within and between the countries. a crisis hits; and, informed by lessons requires Resilient health systems are aware, Global institutions were slow to learnt during the crisis, reorganise if “smart integrated, diverse, self regulating, respond, squandering an opportunity conditions require it.”12 dependency” and adaptive. These do not arise in a to stem its course.5‑7 Health system resilience is relevant vacuum: they require a foundation Since then, experts have pointed in all countries facing health shocks— of local and national leadership, a to political and technical deficiencies whether sudden (Ebola, earthquakes, committed health workforce, sufficient in multilateral organisations in terror attacks, refugees), slower infrastructure, and global support. tackling health crises.8‑11 These moving (new pathogens such as Zika The last point is worth emphasising: reports have noted that the first line becoming endemic or epidemiologic resilience is not self sufficiency. of defence against future pandemics transition), or the more chronic Crises do not respect geopolitical is an effective national health stresses (drug shortages, loss of key boundaries and so resilience requires system. They have also called for health personnel, smaller outbreaks thoughtful interconnectedness or better measurement of public health of endemic diseases). While health “smart dependency.”

Transforms operations to KEY MESSAGES: improve function Coordinates between government, Acts on evidence and National health systems are the first line of global, and private actors • feedback defence against health crises Works across sectors Encourages flexible Involves communities Integrated Adaptive response to t situation • Health systems today are rigid and slow to adapt; they must become more resilient to effectively respond to crises and maintain core services Health system Resilience requires planning and investment Self • Tracks population Aware resilience in slow variables (for instance, health workers, health threats regulating Isolates health threats Maps system strengths Minimises disruption managers, information systems) and fast variables and weaknesses to essential services (such as isolation wards, protective equipment, Knows available resources Diverse Can access reserve surveillance). It requires methodical building of capacity collaboration and trust with communities ahead Addresses range of health problems of crises Provides quality services that meet population needs • The resilience index proposed (see full article on bmj.com) is designed to help countries assess National leadership and policy • Public health and health system infrastructure Committed workforce • Global coordination and support whether their systems can withstand future shocks Resilient health system framework12

436 10 June 2017 | the bmj Integrating approaches to care during the Syrian refugee influx in Lebanon Since the beginning of the Syrian steering committee to streamline surveillance system improved civil war in 2011, Lebanon has relief funding and encourage the ability to detect emerging had an unprecedented influx transparency and accountability diseases, contributing to the of refugees, increasing its across international and national quick response to polio threats.42 population by 1.5 million, or health actors.39 Despite early successes 30%.34 The Syrian crisis persists Primary healthcare grew in primary care, access to today, placing continuing strain to be the central platform for Lebanon’s secondary and tertiary on Lebanon’s health system. the response. In 2015, the healthcare systems continues to Lebanon’s health system has government and its multi-sectoral be a challenge for refugees.40 41 demonstrated resilience by partners (including UNHCR, Recent estimates suggest that rapidly mobilising and expanding UNDP, World Bank, and NGOs) approximately 26% of the refugee its diverse primary care capacity in established 20 public health population needs secondary the public and private sectors. centres and directly supported healthcare; however 23% of those Initial refugee health 100 private health centres, are unable to access it, primarily relief focused on short term increasing primary care capacity because of high fees (71%).43 assistance delivered by by 40%.40 Services include Financial assistance is limited to multiple organisations.37 38 The non-communicable disease specific conditions and requires fragmentation of early relief screening, nutrition services, co-payment, which contributes to efforts motivated the ministry and mental health support.40 41 substantial financial burdens for 40‑44 MOHAMED AZAKIR/REUTERS MOHAMED of public health to establish a Additions to the epidemiological refugees.

The concept of resilient health systems helps bridge disparate health and Communicating with communities While the construct of resilience has development agendas—such as during Liberia’s Ebola crisis been widely used in diverse fields, universal health coverage, the Global At the peak of the 2014 Ebola including ecology, engineering, Health Security Agenda, and the epidemic, Liberia reported 300 to 400 new cases each week and and psychology, it is relatively Sustainable Development Goals— had the highest incidence of Ebola new to health.13‑17 With a plethora lending fresh impetus to the need 25‑28 deaths of the affected west African of frameworks and catchphrases to invest in health systems. It nations.45 Meanwhile, non-Ebola crowding the global health lexicon, identifies the immediate and longer patients were neglected—health there are legitimate questions about term payoffs of well functioning, facilities lacked testing and the value added by the concept. We responsive, and adaptable systems isolation capacity and thus turned identify three contributions to the and highlights the unacceptable costs away patients who appeared health systems field. of inaction. By containing outbreaks, sick.46 Some communities resisted First, resilience emphasises the returning to baseline function more surveillance and disease control efforts, believing Ebola functions health systems need (figure) quickly, and mitigating other shocks, was introduced by the government and foreign institutions 46‑48 to respond and adapt to health shocks, resilient health systems can contribute to profit from emergency response activities. Trust was further eroded by inadequate responses from Ebola task introducing a dynamic dimension to economic stability.29 The recognition forces and help hotlines when neighbours fell ill.47 into more static health system that health systems are the front line Gradually, Ebola treatment units opened and health models, which can help the system for dealing with the next big threat to facilities resumed services. At the same time, the health cope with surges in demand and global health security amplifies the ministry and partner NGOs launched a series of public adapt to changing epidemiology and urgency of strengthening them and health messages starting with “Ebola kills,” to emphasise population expectations of care.18 draws in new actors and ideas.10 the epidemic’s gravity.49 Second, the concept contributes The increasing focus on resilience in This approach backfired. Communities reasoned that if useful ideas to health systems from global health has, however, prompted Ebola was fatal then affected people should avoid treatment 49 other sectors. Solutions for supply criticisms of the concept. One is that it units and instead wait to die at home, supported by family. chains and logistics to respond to is an imposed, technocratic solution Public messages gradually evolved to “the earlier you report Ebola, the more likely you are to survive.” Traditional surges in demand from other fields that obscures the socioeconomic and leaders were enlisted to support community training in all may be relevant.19 20 Building trust and political factors that lead to inadequate 88 counties and spread advice in local dialects.50 promoting meaningful community responses to shocks. These factors To improve the effectiveness of the epidemic response, engagement have been studied in may include unfavourable trade terms, communities were directly engaged in surveillance. In West other fields, such as environmental weak citizen engagement, and chronic Point, Monrovia’s largest slum, community and traditional sustainability and political science, health system deficiencies.30‑33 leaders were assembled to discuss concerns and propose but have not been well used in health There are also worries about short a locally driven solution for Ebola surveillance.50 51 A systems science.21‑23 Resilience draws term timeframes when problems are system for active case finding developed. Leaders recruited on complex systems notions identified multifactorial, and a paradoxical push volunteers to complete ministry led surveillance training, as important in health but rarely acted for national self reliance when threats which eventually led to the deployment of 152 active case 51 upon, such as the interconnectedness cross borders.31 finders and 15 psychosocial support workers. These helped identify potential Ebola cases, reduce caregiver of health and non-health actors and While these concerns highlight the transmission, and promote burials by trained “safe and the importance of feedback loops.24 potential for resilience to be used as dignified” burial teams. Finally, the concept of resilience shorthand for a narrow preparedness the bmj | 10 June 2017 437 agenda, they do not represent the where a range of large health shocks Margaret E Kruk, Future research should consider how meaning of health system resilience contributed to improved health system associate professor the elements of resilience perform as intended here. Building resilience resilience: chronic system dysfunction of global health, when adopted before the event. is much more than preparedness; it aggravated by a population influx in Harvard TH Chan The value of having diverse involves investment in institutions, Lebanon; sudden and severe infectious School of Public healthcare providers that can preconditions (like an effective health disease outbreak in Liberia; and Health, Boston, US coordinate with each other is seen in workforce) and other “slow variables.” repeated, anticipated disaster shocks mkruk@hsph. the case of Lebanon, which is now harvard.edu Communities should not have in Indonesia. hosting 1.8 million refugees from Emilia J Ling; Asaf to shoulder crises alone; instead Awareness is the capacity to detect Syria, increasing its population by Bitton; Melani 34 meaningful government engagement and interpret local warning signs Cammett; Karen over 30%. To meet this challenge, is needed to ensure responsive health and quickly call for support. Liberia’s Cavanaugh; Mickey the ministry of health has expanded services that people trust and want to initial paralysis during the Ebola Chopra; Fadi primary care to tackle the multiple use.12 Imposed technocratic solutions epidemic was partly caused by poor el-Jardali; Rose needs of refugees and citizens. This has will not bring about needed change, understanding, at all levels, of the Jallah Macauley; been done in part through consultation and the arrangements needed to disease’s severity. Self regulation Mwihaki Kimura and contracting with private sector, promote resilience have to emerge is the ability to isolate threats and Muraguri; Shiro including faith based, providers; an from the country’s context. Value maintain core functions under stress. Konuma; Robert example of integration among diverse judgments about what constitutes While Ebola treatment units are a Marten; Frederick health actors who in the past may not Martineau; Michael resilience for whom should be made classic example of self regulation (in have worked together. Myers; Kumanan explicit. Ordinary people may lack Liberia’s case, these came too late), Integration also draws attention to Rasanathan; Enrique the power to shape the health system Lebanon’s emergency vaccination and Ruelas; Agnès the key mediating role that broader response or hold it to account; the surveillance efforts, and Indonesia’s Soucat; Anung state-society relations play during process of building resilience should regional crisis mitigation centres Sugihantono; Heiko crises. Involving communities in foster that power. Building resilience can also be seen as homoeostatic Warnken crafting a crisis response depends should be integrated with existing innovations for containing threats. Full author details and on strengthening government efforts to strengthen health systems Indonesia’s case also shows the references on bmj.com accountability. Stronger mechanisms Cite this as: BMJ and its success should be judged on value of learning and adaptation: in 2017;357:j2323 for state-society partnerships allow equitable health gains rather than the anticipation of catastrophic weather governments to weave the experience, security of wealthy nations. events crisis mitigation centres were expectations, and capabilities of created following poor coordination affected people into the containment Resilience in action after tsunamis. In each of these cases, strategy for a more powerful and We present three case studies, in which most elements of resilience emerged empathetic response. Identifying ways several of the authors were involved, after a crisis rather than ahead of it. to work effectively with local leaders was a critical lesson from Liberia. Improving self regulation during natural disasters in Indonesia Community leaders were critical in Spread across three major Aceh was the site of recent battles to Yogyakarta to support the case finding, community mobilisation, geologic fault lines, Indonesia with the Free Aceh Movement, a National Disaster Management and other control measures. experiences periodic guerrilla separatist group.55 56 Agency emergency efforts.57 earthquakes and tsunamis. Each When aid arrived, provision was While 67 of 115 health centres Conclusion recent disaster has tested the chaotic with duplication of efforts in Yogyakarta were damaged or Before the failure of health systems country’s health system and led in some areas and service gaps severely destroyed, domestic during the Ebola outbreak is forgotten, to progressive adaptation. in others. It took two weeks to health teams were quickly we need to consider how to make The 2004 Indian Ocean tsunami establish a disaster coordination mobilised to provide emergency them more resistant to crises and more devastated the province of Aceh.52 centre, and nearly a month for the relief.58 59 The response to this flexible in their response. The concept Overnight, 106 health facilities Aceh health system to resume earthquake—both more efficient of resilience adds dynamism and were damaged or destroyed, function. and more locally driven—was and more than half of the health Two years later during the informed by lessons learnt from urgency to the longstanding work of workforce was displaced or 2006 Yogyakarta earthquake, Aceh and the absence of conflict health system strengthening and gives killed.53 54 The government the response was remarkably in the area. an opportunity to learn from other struggled to organise a response different. Hours after the Learning from these sectors. Country experiences as varied and assistance was further earthquake the president experiences, Indonesia as Lebanon, Liberia, and Indonesia

DYLAN MARTINEZ/REUTERS DYLAN delayed by security concerns: temporarily relocated his office established nine regional crisis demonstrate how resilience can be mitigation centres in 2009.60 built after crises. Proposed measures Located in disaster prone areas, of health system resilience can these centres are proactively improve our assessment of countries’ equipped with staff, vehicles, progress in building resilience and and emergency supplies, and indicate areas for action. We hope perform community outreach implementation of these ideas can with health facilities, teaching energise policymakers and ultimately basic first aid and natural disaster response.61 62 benefit families and communities in times of crisis and beyond.

438 10 June 2017 | the bmj LETTERS Selected from rapid responses on bmj.com. See www.bmj.com/rapid-responses

PATIENT ACCESS TO RECORDS insightful for clinicians to Patient experience should doubt their diagnosis based on history and examination be recorded alone. This is the rationale Simply giving patients access to for having differential their records is pointless apart diagnoses, especially when from showing openness and managing a progressively older transparency (Editor’s Choice, demographic. 6 May). Patients assume that Terms such as “routine their records are detailed and bloods” detract from their include a verbatim record of their purpose as a basic screening conversations with clinicians, but tool for potentially serious the reality is much more mundane. LLOYD ROSE pathology. Attention to I found this out recently when LETTER OF THE WEEK informatics is required to avoid I was granted access to my GP unnecessary repetition of Human trafficking and interpreters records, which consisted mainly blood tests, but a routine panel of appointment entries that gave The What Your Patient Is Thinking article (22 April) was a good insight should be considered holistic only a partial perspective. into how clinicians can communicate sensitively and effectively medicine, not a psychological If we want to involve patients through family translators. But we must bear in mind that a small support blanket. electronically, then we must minority of patients bring someone along to translate who isn’t who Keith Siau, gastroenterology ST6, provide some real value to both they say they are or does not have the patient’s best interests at Dudley patients and the healthcare heart. Cite this as: BMJ 2017;357:j2675 system. Feedback from patients Human trafficking is a vast but mostly hidden crime, and often on health outcomes and patient in healthcare settings we miss an opportunity to help someone Doctors misunderstand diaries might give doctors a because we don’t speak to them on their own. Many thousands of predictive value better perspective on the realities men, women, and children in the UK are currently being exploited in Doctors poorly understand of being a patient and the conditions of modern slavery. They may be foreign nationals or UK predictive value. An old study consequences of treatment. This natives. showed that 25 routine tests could improve healthcare delivery. Trafficked people suffer from severe psychological and physical done on healthy volunteers had Currently we partially record harm. Their traffickers control them in various ways, including debt only a 28% chance of all being only the clinician’s experience; bondage, coercion and lies, threats to the person or their family, normal. Doctors were asked: we need to add the patient’s violence, and cultivating a dependency on the trafficker for food, “If a test for a condition with 1 experience so that we can know accommodation, and other needs. in 1000 prevalence has a false which treatments achieve the Although trafficked people come into contact with health services positive rate of 5%, what is the best outcomes. (particularly maternity departments, emergency departments, and chance that a positive result Peter D Singleton, management general practice), some are not being recognised. Traffickers are likely means I have the condition?” consultant, Cambridge to come into the consultation and translate for the patient or remain Most doctors answered 95%, Cite this as: BMJ 2017;357:j2673 in the room so that the trafficked person is too afraid to disclose. but the answer is 1.9%. Most Healthcare professionals need more training about recognising the positive results don’t mean that Consider the vulnerable signs of human trafficking and the safe use of interpreters. the patient is ill, and results patient Toby Bonvoisin, fourth year medical student, Sheffield are meaningless unless we The advantages of sharing Cite this as: BMJ 2017;357:j2671 understand their predictive records with patients probably value. outweigh the potential increase discussion on contraception ROUTINE BLOOD TESTS The golden rule of in workload (Editor’s Choice, would be kept secret. preoperative assessment is Routine bloods screen for 6 May). For centuries, patients could not to order tests unless we But I am concerned about be confident that what they said serious pathology understand what an abnormal with whom these records might to their doctor would remain Faulkner et al say that routine result means and how it would be involuntarily shared. It is not confidential, and doctors would blood tests are a clinician’s influence management. A hard to imagine a woman being rightly fend off prying others “psychological support good example is clotting forced to log on by an abusive who may not have their best blanket” (Observations, 6 screens, which have an husband to reveal what was said interests at heart. We need to May). But clinical assessments extremely low predictive value in her last appointment or forced find ways we can preserve this, if vary between doctors, so in asymptomatic patients—so to reveal her past history, which we decide to go down the route investigations are often the only don’t do them. might include confidential of providing full access. objective information available. Katherine Teale, clinical lead gynaecological or mental health Brian McKinstry, professor of primary In a society that is preoperative assessment clinics, information. Likewise the young care e-health, Edinburgh increasingly internet savvy Salford teenager who thought her Cite this as: BMJ 2017;357:j2674 and litigious, it is healthy and Cite this as: BMJ 2017;357:j2701 the bmj | 10 June 2017 439 Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

OBITUARIES David Anthony Andrewes Clifford Brewer Dewi Davies General practitioner Senior consultant Consultant chest and social researcher surgeon Liverpool Royal physician (b 1921; (b 1930; q Barts, London, Infirmary (b 1913; q Guy’s Hospital, London, 1954; DObst RCOG), q Liverpool 1935; FRCS), 1945; MD, FRCP Lond), d 9 February 2017 d 29 April 2017 d 10 April 2017 David Anthony Andrewes Clifford Brewer served In 1955, Dewi Davies joined West End Road with the Territorial Army was appointed Practice, Southampton, in France, the Middle as physician in 1963, while also working with the new East, and Normandy with a field surgical superintendent at Ransom Sanatorium department of general practice at Southampton unit. After the war he returned to Liverpool and consultant respiratory physician to University. In 1973 he was appointed to found as lecturer in surgery and was appointed to Mansfield Hospital. At the sanatorium—a 182 a practice at Stirchley in Telford New Town, the staff of the Royal Infirmary, the Liverpool bed unit that was dedicated to pulmonary where he designed the health centre and Homoeopathic Hospital, and the St Helens tuberculosis—he was the singlehanded built the team he needed to achieve his vision Hospital. He was clinical lecturer to the physician superintendent from 1955 to 1973. of the best possible holistic care for 15 000 university and the dental school, was an He and his family lived on site, so he was able patients. He developed innovative systems examiner in surgery for the RCS and several to oversee patients at all times. He later wrote to file A4 notes by family address, and an northern universities, and established a a short history of the hospital, which contains age-sex register on embossed addressograph breast clinic at the Royal Infirmary. Brewer an excellent description of the treatment of plates. The systems allowed him to achieve served on the council of the Medical pulmonary tuberculosis in the late 1950s and remarkable immunisation and prevention Institution and other committees, but his 60s. In 1973 he moved to Nottingham City rates in a deprived area, attracting national main interest lay in club life. He was a founder Hospital to form a firm with the new academic attention. After retiring to Hampshire in 1989, member of the Antiquarian Horological department of therapeutics. He retired David and his wife, Diane, remained involved Society and wrote two books on antique from the NHS in 1981. He will be missed by in social research and published a series of clocks for Country Life publications. He was all who knew him. He leaves Ann and four studies into older people’s problems. He leaves married to Marjorie Hirst, and they had five children, eight grandchildren, and five great Diane, four sons, and four grandchildren. children. grandchildren. Quentin Shaw Bill Brewer David Banks, Ann Davies, Ann Booth Cite this as: BMJ 2017;357:j2406 Cite this as: BMJ 2017;357:j2415 Cite this as: BMJ 2017;357:j2418

Gillon Caldwell Ferguson Charles Henry James Swan David J Wilkinson Consultant physician Consultant physician Consultant radiologist Northampton General and gastroenterologist York District Hospital Hospital (b 1936; (b 1937; q Birmingham (b 1939; q Mary’s q St Andrews 1960; 1961; MD), died from Hospital, London, 1965; FRCP Lond, FRCP Ed), died a complication of DMRD Eng, FRCR, FFR), from multiorgan failure the myelodysplastic died from a malignant complicating sepsis on syndrome on 9 February brain tumour on 20 March 2017 2017 16 October 2016 Gillon Caldwell Ferguson initially read classics Charles Henry James Swan was appointed David J Wilkinson trained in radiology and at St Andrews and graduated with first class consultant physician and gastroenterologist married Hazel Harrison, a fellow medical honours. After medical training posts in at the then North Staffordshire Hospital student. The couple moved to York in Scotland he worked at the Royal Brompton Centre in 1972. He was the first specialist 1974. David contributed enormously to the Hospital before being appointed as consultant gastroenterologist at this very large district development of the new x-ray department. physician with an interest in chest medicine general hospital. Having established a He also worked at the Friarage Hospital, at Northampton General Hospital in 1970, gastrointestinal endoscopy service in North Northallerton, and Selby Memorial Hospital. where he introduced fibreoptic brochoscopy, Staffs, he set up the first hands-on endoscopy David obtained his pilot’s licence and flew respiratory function testing, and asthma training course for trainees from across the UK frequently. In retirement, he studied the history nurses. He retired in 2001. His interests in 1978. The format of this course is still used as of early horse racing in Yorkshire and the origins included English and Scottish literature, the basis for gastrointestinal endoscopy training of the thoroughbred, for which he was awarded classical music, the visual arts, and Latin and in the UK and abroad. Charles held office and an MA. Hazel predeceased him in 2013. David Greek texts. He wrote a history of the Waverley, received awards in professional societies, and, was diagnosed with a malignant brain tumour the last surviving paddle steamer on the Clyde, in retirement, he became the medical director at in 2015. Shortly before his death, he married and was elected honorary purser. He leaves his the local hospice. He leaves his widow, Ann; two Patricia Soanes. He leaves two daughters from wife and two daughters. children; and four grandchildren. his first marriage and three granddaughters. John Birkhead Jonathan R B Green Robert Porter Cite this as: BMJ 2017;357:j2403 Cite this as: BMJ 2017;357:j2420 Cite this as: BMJ 2017;357:j2422

440 10 June 2017 | the bmj Ingeborg Rapoport Neonatologist who fled Nazi Germany and was awarded a PhD at the age of 102

Ingeborg Rapoport (b 1912; q Hamburg born in rapid succession. But their University, Germany, 1937, and Women’s leftwing political activities began to Medical College of Pennsylvania, draw unwanted attention. In 1950, US, 1942), died 23 March 2017 while both were in Zurich at a medical conference, Samuel Rapoport learnt In 2015 three professors from the that he had been subpoenaed to testify University of Hamburg travelled to in Washington, DC, before the House Berlin and were welcomed into the Un-American Activities Committee home of Ingeborg Rapoport. After the chaired by the infamous Senator professors were seated in her living Joseph McCarthy. Samuel started room they began firing a steady stream looking for work in Europe, while of difficult questions at the 102 year Inge, pregnant with their fourth child, old, to test her knowledge of diphtheria. returned to the US to collect their three Rapoport, known by friends as Inge, children and then return to Europe to was undergoing an oral examination start a new life. to defend her doctoral thesis, a thesis that she had completed in 1938 and Move to East Berlin submitted to her professor at Hamburg The University of Vienna, Samuel University. Although she had studied Rapoport’s alma mater, declined In 2015 A couple of years ago a colleague medicine and graduated in 1937, she to offer him a position, apparently Ingeborg of Inge’s son told the story about her was not allowed to defend the thesis in because of pressure from the US Rapoport 1938 degree to Uwe Koch-Gromus, an oral examination after Nazi officials government. Other institutes across defended dean of Medical Center Eppendorf at learnt that her mother was Jewish. Europe also shunned him. Finally, her doctoral Hamburg University. Officials at the he accepted an offer from Humboldt thesis, which university were eager to rectify the A new life in the US University in East Berlin to become she had injustice but faced legal obstacles. In 1938 Rapoport had been allowed to professor and the director of the So they devised a new strategy and practise medicine at a Jewish hospital. Institute for Physiological Chemistry completed set a date for an oral examination on But she and her mother sensed the at Charité hospital. The family who and diphtheria, giving Rapoport time to danger emerging in Germany. In late loved the US moved to communist East submitted study developments in the subject 1938 Rapoport fled to start a new life in Germany. They thrived there and grew in 1938, and since 1938. the US. Her medical qualification from fond of their new home. finally gained Because of failing eyesight, she Germany was not recognised in the US, Inge Rapoport practised medicine her doctorate could not read or use a computer. so in 1940 she enrolled at Women’s and was affiliated with Charité. In So friends and relatives scoured Medical College of Pennsylvania in 1959 she was awarded habilitation, the internet, collecting information Philadelphia and qualified in 1942. and in 1964 was named professor on scientific advancements and She then trained in paediatrics at Johns of paediatrics. In 1969 she was the reporting their findings over the Hopkins University in Baltimore before founding head of the new department telephone. She worked hard, and moving to the Children’s Hospital at the of neonatology. She retired in 1973 but after the oral examination the University of Cincinnati, Ohio, in 1944. continued conducting research into professors approved her doctoral Eventually she was named head of the the 1980s. degree. She travelled to Hamburg outpatient department and became In 1989 the government of East a few weeks later and received involved in research. She also fully Germany disintegrated, and the the degree in a ceremony, the embraced the communist movement in previously closed borders with oldest person ever to be awarded the US. western Europe were thrown a doctorate. She went through the open. The next year, East Germany difficult process, she said, as a matter Communism disappeared after reunification with of principle and for the millions who In 1946 Inge married her colleague West Germany. In the following years suffered under the Nazi regime. Samuel Mitja Rapoport, a renowned Rapoport held firmly to her socialist Rapoport’s husband died in 2004. Ukraine born physician and biochemist beliefs and remained fond of East She leaves two daughters; two sons; who had grown up in Vienna (read Germany. “I still think it was the best nine grandchildren; and 13 great obituary: http://www.bmj.com/ society I have seen, despite its faults grandchildren. content/329/7461/353.1). The couple . . . the dedication of physicians to Ned Stafford, Hamburg enjoyed life in Cincinnati and felt at their patients was untouched by [email protected] home in the US. They had four children money.” Cite this as: BMJ 2017;357:j2247 the bmj | 10 June 2017 441 DIGITAL HIGHLIGHTS MOST READ ONLINE Suicides among junior doctors BMJ Podcast in the NHS (see p 423) Linking BMJ j Death rate now rising in UK’s health and poorest infants BMJ j environmental David Oliver: Should practical quality improvement have parity research of esteem with evidence based This week The BMJ’s Navjoyt Ladher medicine? talks to Andy Haines, professor of BMJ j public health and primary care, about Diagnosis and management of a new initiative that links e orts inflammatory bowel disease to study health and environmental because many of the changes that we are in children sustainability. In the extract below, making in the world’s environment will Haines discusses the historical barriers have long term e ects: for example, more BMJ j that have prevented people from than % of the carbon dioxide we put Development and grasping and acting on the threats into the environment today will remain validation of QRISK3 risk posed by environmental change. there for a thousand years or more. So this prediction algorithms is something we are bequeathing to future to estimate future risk of “There are a number of conceptual generations, and that’s a big conceptual cardiovascular disease challenges. One is that we’ve tended step for people to take to try to understand to use rather awed metrics of human that the implications of their actions are not BMJ j progress, so when you listen to the political just relevant to wellbeing today but also well discourse it’s all about economic growth into the future. and increasing GDP, but we know that’s “The other conceptual challenge is that Free resources on actually quite a poor re ection of human we were all brought up in a silo mentality, the Zika virus progress. It doesn’t take into account, for so we were trained in a particular clinical If you want to find out more about the example, the damage that we’re doing to discipline or a particular scienti c Zika virus and to answer questions your the environment, the adverse e ects on discipline. It’s important to have that kind patients may have about its transmission, health of pollution, and so on. And so we of rigour, but it’s also important to be able you can take a look at our need to develop better metrics of human to see the bigger picture and to respect other Zika page at bmj.com/ progress and, of course, we would argue forms of knowledge and other disciplines freezikaresources, which that human health and wellbeing need and to learn to work together.” contains free resources to be placed right at the centre of this Listen to the full podcast at bmjco/ from across BMJ. agenda . . . We need to be looking forward future_earth

FROM THE ARCHIVE “A darkness giving bill for the majority” In the June issue of The BMJ in times are bad for our system, and (Br Med J ; : ), John the shifting of the hours of work is Milne took the opportunity to rail bad for the work. Medical men are against the proposal of daylight well acquainted with the results of saving time being introduced in the experiments bearing on these points, UK. He contested that “it is a selfish, the inference from which is that, should wicked, and ill considered project, the bill come into force, for a certain which, if carried out, will affect the period twice a year the efficiency of nation with moral, financial, and the worker would be somewhat physical trouble.” damped.” Poor John Milne must have “Habits cannot be trifled with,” he felt fairly dismayed when, five years said. “We may change them, but the later, the Summer Time Act change takes time. Meals at irregular established British Summer Time.

442 10 June 2017 | the bmj