this week SCOTTISH GPs page 296 • LANGUAGE TESTS page 298 • MEASLES page 299

Alcohol link to is “robust”

Chronic heavy drinking should be The study’s lead author, Michaël The study of French patients recognised as a major risk factor for Schwarzinger, from the Translational found that use dementia, especially early onset Health Economics Network, said, “The disorders were the strongest modifiable risk for dementia dementia, say researchers. Doctors should link between dementia and alcohol use screen patients for heaving drinking and disorders needs further research but is likely offer brief interventions to help reduce a result of alcohol leading to permanent alcohol consumption if necessary, they structural and functional brain damage. wrote in Lancet Public Health. “Alcohol use disorders also increase The study found that of 31.6 million the risk of high blood pressure, diabetes, people over 20 discharged from French stroke, atrial fibrillation, and heart failure, hospitals between 2008 and 2013 more which may in turn increase the risk of than 1.1 million had a diagnosis of some vascular dementia. Lastly, heavy drinking is form of dementia. Around 3% of dementia associated with smoking, depression, and cases were attributable to alcohol related low educational attainment, which are also LATEST ONLINE brain damage, and other alcohol use risk factors for dementia.” disorders were recorded in almost 5% of In a linked commentary, Clive Ballard, • Surgeon is dementia cases. The association was even from the University of Exeter Medical suspended for nine stronger in early onset dementia: 57% of School, said that the study was “immensely months for working people with this diagnosis also had an important and highlights the potential of without insurance alcohol use disorder. alcohol use disorders, and possibly alcohol for 12 days The World Health Organization defines consumption, as modifiable risk factors for • OxyContin maker chronic heavy drinking as consuming dementia prevention. stops marketing more than 60 g of pure alcohol a day for “In our view, this evidence is robust opioids as report men (six small glasses of wine) and more and we should move forward with details payments than 40 g a day for women. clear public health messages about the to pain advocacy groups Overall, alcohol use disorders were relationship between both alcohol use the strongest modifiable risk factor for disorders and alcohol consumption, • Surgeons urge dementia, with an adjusted hazard ratio of respectively, and dementia.” NHS England to ban minimum 3.34 (95% confidence interval 3.28 to 3.41) Jacqui Wise, London waiting times for women and 3.36 (3.31 to 3.41) for men. Cite this as: BMJ 2018;360:k814 the bmj | 24 February 2018 295 SEVEN DAYS IN GPs resign from BMA in Scottish contract row A group of GPs in Scotland are resigning from the BMA in protest at a new contract that they claim will have a “devastating” effect on patients in rural areas. A majority of GPs who voted accepted the contract, but 28% rejected it. The strongest opposition came from doctors in rural and deprived areas, on the grounds that the new funding formula shifts money to urban practices with elderly patients. The BMA responded to the criticisms by establishing a working group, but in an open letter to BMA leaders, 10 GPs said its response was not adequate. The GPs, three of whom have been BMA members for at least 25 years, said the decision to resign was taken “because we believe there has been a serious breach of trust between the SGPC [Scottish general practitioners committee] and its electorate.” Cathy Welch, an Arran GP and one of the signatories, responded to the vote on bmj.com, warning the contract would make recruitment and retention in rural areas even harder. Alan McDevitt, chair of SGPC, said, “The new GP contract was given clear backing by the profession. It is always regrettable when any doctor chooses to end their BMA membership, and I hope that in time they will reconsider. ”

Gareth Iacobucci, The BMJ Cite this as: BMJ 2018;360:k805

Litigation Ireland seeks membership gun violence as a serious public Government to cap costs of of discount group health threat by restricting sales clinical negligence claims Ireland’s health minister, Simon of assault weapons, improving A group of government, NHS, Harris, sent a letter asking to reporting laws, and closing gaps and legal experts will work to begin negotiations to join the in background checks. introduce a cap on the amount BeNeLuxA group, an association that lawyers can recover in of four small European nations Research news clinical negligence cases, the that club together to negotiate Brain injuries are found in Department of Health and better prices for new and US diplomatic staff in Cuba rate was three times as high as Social Care announced. The costly medicines. The group Neuroimaging and clinical tests in real life (22% v 7%) and that proposed cap would apply to all currently comprises Austria, showed evidence of sustained most (71%) of its patients went cases up to £25 000 and could Belgium, Luxembourg, and the brain injury in a group of 24 US straight from emergency care to save the NHS £45m a year, it Netherlands, although France government staff previously the operating theatre, whereas said. Claims, including legal is also reportedly considering working in Havana, Cuba. They only one in four (25%) does so in bills, had cost the NHS £1.6bn membership. In the future, said had all reported exposure to real life. Unrealistic expectations in 2016-17. Harris, member nations may unusual auditory and sensory of healthcare may be important also pool expertise and post- phenomena in their homes in an era in which patient Drug pricing marketing data. or hotel rooms while in Cuba. satisfaction is a key component NICE recommends Writing in JAMA, the researchers of quality initiatives and tivozanib after price deal Gun control said that the staff showed performance related pay, said NICE recommended tivozanib US doctors repeat call for persistent cognitive, vestibular, the authors in the journal Trauma as an option for treating adults action after latest shooting and oculomotor dysfunction, Surgery & Acute Care Open. with previously untreated The American College of sleep impairment, and advanced renal cell carcinoma, Physicians expressed its growing headaches. The findings “raised Brief exercising cuts death after the manufacturer agreed a frustration at the lack of action concern for a novel mechanism risk in older men discount to bring the cost lower on firearms policy after the of a possible acquired brain Clocking up just a few minutes than for existing treatments 30th mass shooting and injury from a directional at a time of any level of physical even though the appraisal 18th school shooting in exposure of undetermined activity, rather than the committee found it “likely to 2018, after 17 people died etiology,” they wrote. recommended 10 minute bouts, be less effective.” The final and 14 were injured is linked to a lower risk of death in appraisal determination at a high school in TV may distort older men as long as they reach said, “The estimated costs Parkland, Florida, expectations the target of 150 minutes a week, savings are high enough to on 15 February. The An analysis of suggested a study in the British compensate for the estimated doctors repeated the television Journal of Sports Medicine. Each lower effectiveness.” The their 2015 hospital drama additional 30 minutes a day decision reverses previous draft demand Grey’s Anatomy of light activity, such as gentle guidance that recommended to deal (above right) gardening, was associated with a against the NHS using the drug. with found that its death 17% lower risk of death.

296 24 February 2018 | the bmj SIXTY SECONDS MEDICINE ON . . . MALNUTRITION MEDICAL ANOTHER AFRICAN FAMINE? POLICE No, much closer to home—in UK hospitals, 74% in fact. The Telegraph’s recent headline 49% summed things up: “Record numbers of patients are dying malnourished in NHS hospitals with almost one case a day.” Charities slammed the latest figures as “shocking,” urging hospitals to do more to ensure that vulnerable elderly patients TEACHERS receive help with eating and drinking. WHAT’S BEHIND THE HEADLINES? 49% Malnutrition was the underlying cause or a contributory factor in 351 deaths in NHS hospitals in England and Wales last year in Public opinion and difficulties eating, cooking, figures from the Office for National Statistics. Medical staff are most and dressing. INFANT It was listed as the underlying cause in 66 trusted professionals deaths, an increase from 59 in the previous Medical workers are the most Health inequalities DEATHS year and the highest of the past decade. trustworthy professional group, Life expectancy gap widens a survey of 2000 British adults between rich and poor The UK is WHY NOW? found. In the YouGov poll, 74% The difference in life expectancy The information was requested by the said that medical staff would between rich and poor people 30th of 184 shadow health secretary, Jonathan Ashworth, in a written question to the secretary of state provide trustworthy information, in the UK is widening, a report countries in new for health and social care. followed by teachers and police found. Research by the Longevity global rankings, officers (both 49%), librarians Science Panel using 2015 data with one baby in IS THE NHS AT FAULT? (46%), and lawyers (39%). found that, on average, boys Neglect is not to blame, said Myer Glickman 285 dying in 2017 Politicians came last, with born in the most affluent areas from the Office for National Statistics. backing from 2% of respondents. of the country will outlive boys before they were a Although the number of deaths in hospital The poll was commissioned by born in the poorest by 8.4 years. month old. Japan involving malnutrition is small, there CILIP, the library and information The panel called for “coordinated ranks top (1 in has been a general increase since 2001, association. policy initiatives across health, 1111) and Pakistan increasing from an age standardised rate of 0.58 to 0.88 per 100 000 in 2016. But more work, welfare, pension and bottom (1 in 22) Rheumatology housing to improve outcomes patients arrive at hospital with malnutrition. And analysis of death certificates shows Hydroxychloroquine and for all.” (Unicef) hand osteoarthritis malnutrition usually accompanies several other diagnoses, with pneumonia, frailty, and Hydroxychloroquine is no Job losses chronic heart disease particularly common. more effective than placebo Medical defence advisers in reducing the symptoms of face redundancy SO WHAT IS THE CAUSE? hand osteoarthritis, a study in The Medical Protection Society is Where malnutrition was a the Annals of Internal Medicine considering making several of its contributory factor in a death, found. The UK researchers said medically qualified legal advisers causes varied widely and that their findings did not support redundant and replacing them included conditions affecting the current practice of using with other “experts” to speed the patient’s ability to eat or off-label hydroxychloroquine in up its response to queries. Rob absorb nutrients. More than patients with hand osteoarthritis, Hendry, its medical director, said, one in 10 (13%) cases were attributed to alcoholic liver which affects 4-31% of over 70s “Members would benefit from disease or chronic alcoholism, and can cause significant pain having doctors, lawyers, case and a similar number involved advisers, and managers all in one dementia or Alzheimer’s disease. “The team, focused on getting the best mortality data and hospital admissions both outcome for them.” He said that if show that malnutrition doesn’t often occur the proposals were implemented on its own,” said Glickman. “At least part the staff reduction would be of the increase is from an increase in these “limited,” although he could not other illnesses, probably associated with the provide numbers. The society ageing of the population as a whole.” employs 49 doctors as advisers. Cite this as: BMJ 2018;360:k799 Susan Mayor, London Cite this as: BMJ 2018;360:k789

the bmj | 24 February 2018 297 FIVE MINUTES WITH . . . Many CCGs are not passing Ceri Butler The academic talks to Abi Rimmer on extra mental health cash about the GMC’s decision to accept Many clinical commissioning groups failing to meet the government’s the Occupational English Test as in England are failing to increase parity of esteem funding proof of a doctor’s language skills spending on mental health in line commitment, which requires CCGs with national policy commitments, a to increase mental health spending report from the BMA has found. in real terms by at least the same The government has made proportion as overall budgets. ince I began working with repeated commitments to increase refugee doctors in 2003, the funding for mental health services “No obvious uplift” most significant barrier to over recent years. But in light of “Despite some geographical working in the NHS that they concerns that the money is not variation, there appears to be no have faced has undoubtedly reaching the frontline, the BMA obvious uplift in overall mental been“ the IELTS S (International English Language examined recent spending trends health spending in recent years,” the Test System). It can take a refugee doctor across England. report said. anywhere between two and four years to pass Using data obtained from freedom The report found that many CCGs the test, in addition to the amount of time that of information requests, it found are failing to increase spending they have already spent out of practice. that half of CCGs plan to decrease on child and adolescent mental “IELTS is something that we use in the their spending on mental health health services, and echoed a university system to assess people’s ability to services this year. As a result, the recent warning from child health speak and write English at an academic level. BMA said a significant number are experts that extra funding in this There is a question about the appropriateness of using the test for doctors. “If people wanted to do a masters or a PhD GP suspended for altering dead in addition to their clinical qualifications patient’s notes after missing DVT then perhaps having A GP has been suspended from the UK made a further undated change on an academic English medical register for 12 months after 5 June, adding “pain around knee,” language test is he missed deep vein thrombosis in a “?dependent oedema,” and “r/v appropriate. More often patient’s leg and altered her notes after [review] earlier if any further swelling than not, however, you are her death four days later. or SOB” [shortness of breath]. testing doctors against a WE NEED TO TAKE A MORE Fardeen Haque, from South Shields, system they will never use. HOLISITIC faced a Crown Court trial on a charge “Respected clinician” “What IELTS doesn’t test APPROACH of attempting to pervert the course of A medical practitioners tribunal is whether or not a doctor TO HOW WE justice but was acquitted. found that the first two amendments can communicate. We know COMMUNICATE Haque first saw Patient A on 1 March accurately reflected what Haque that how a doctor converses IN THE NHS 2013 and provisionally diagnosed a had noted during the consultation, in English in a clinical Baker’s cyst, a swelling at the back of but were misleading because they setting is important further down the line. the knee. Four days later the patient were not accurately dated. The final “My gut instinct is that having a test like the collapsed and was taken to hospital amendment was held to be dishonest, Occupational English Test (OET), which is based but died on the way. as it created an inaccurate and on a clinical setting, is better as a measure misleading record of the consultation. of a doctor’s ability. The OET gives us the Edited notes The GMC had asked the tribunal opportunity to approach language in a way that A postmortem examination on to strike Haque off the register, is appropriate for a healthcare setting. 16 March found massive bilateral although its counsel acknowledged “We need to take a more holistic approach coiled thromboemboli of some age that he was a respected clinician. and look at how we communicate and work and residual thrombi of some age in The tribunal had concerns about in the NHS, and how that is different from the the calf veins of the left leg. the credibility of some of Haque’s systems that these doctors have already worked Haque edited his consultation evidence, said the tribunal chair, in. These sorts of things need to be tackled early note on 6 March, adding “pain Nicola Murphy. But in deciding on in a doctor’s progress towards getting back on weight bearing” and “joint line to suspend him the tribunal into practice, and not wait until after they have tenderness,” without noting the had given weight to “the volume passed the IELTS test.” Ceri Butler is a doctoral student in primary care and population date of the changes. On 4 June, after of high quality references and health, University College London the postmortem report, he added testimonials” provided. Abi Rimmer, The BMJ “swelling around ankle,” again Clare Dyer, The BMJ Cite this as: BMJ 2018;360:k806 without dating the change. He Cite this as: BMJ 2018;360:k778

298 24 February 2018 | the bmj provision remains far from optimal” Many CCGs are not passing because of the very low baseline from which the expansion of services on extra mental health cash started, and the services’ historical under-resourcing.

“Escalating demand” Gary Wannan, deputy chair of the BMA UK consultants committee and a child and adolescent psychiatrist, said, “These findings are further evidence that funding for mental health services is failing to get Consultant psychiatrist Gary Wannan (above) says a plan of action is needed to ensure funds reach services through to the frontline at a time of escalating demand. area is being diverted “to spend on care than on IAPT (Increasing Access “It’s time to “It’s time to end the smoke and other priorities.” to Psychological Therapies) services end the smoke mirrors of mental health funding, Elsewhere, the analysis showed delivered in primary care. and mirrors put in an effective plan of action to that only 28% of CCGs and 50% of The report noted that ringfenced of mental get funding through, and ensure mental health trusts are increasing funding commitments to the heath funding” services have sufficient resources to real terms spending on psychological provision of perinatal mental meet the rising demand that we see

therapies. Most (83% of CCGs health services in England had every day.” and 64% of trusts) spent more on led to “tangible improvements” in Gareth Iacobucci, The BMJ psychological therapies in secondary this area. But it warned that “service Cite this as: BMJ 2018;360:k815

coverage, consistently low and 35 lives lost in 2017 “Tragedy” of measles deaths coverage among marginalised alone, are a tragedy we simply in Europe is unacceptable groups, interruptions in vaccine cannot accept.” supply, or underperforming She added: “Elimination of A total of 21 315 cases of seen in Romania (5562), Italy surveillance systems, WHO said. both measles and rubella is a measles and 35 deaths were (5006), and Ukraine (4767). The UK was among the priority goal that all European recorded in Europe in 2017—a Vaccination rates (second dose) countries with a large outbreak countries have firmly committed 400% increase on the previous in these countries were 76%, with 282 cases last year, as to, and a cornerstone for year, when there was a record 83%, and 31% respectively for were Greece (967), Germany achieving the health related low of 5273 cases, World Health 2016, the most recent year for (927), Serbia (702), Tajikistan sustainable development goals. Organization figures show. which figures are available. (649), France (520), the This short term setback cannot Large outbreaks of measles Russian Federation (408), deter us from our commitment to (100 or more cases) have Declines in coverage Belgium (369), Bulgaria (167), be the generation that frees our affected 15 of the 53 countries These countries have been Spain (152), Czech Republic children from these diseases.” in the WHO European region, affected in recent years by (146), and Switzerland (105), WHO said that countries were with the highest numbers declines in routine immunisation although many of these were in tackling outbreaks by raising decline by the close of 2017. public awareness, immunising MEASLESMeasles vaccine VACCINE (2nd dose) (SECOND coverage, DOSE) European COVERAGE, countries (% )EUROPEAN COUNTRIES (%) healthcare professionals and 100 Unvaccinated children other adults at particular risk, Zsuzsanna Jakab, WHO regional tackling challenges in access, UK Italy director for Europe, said: and improving supply planning 80 Romania “Every new person affected by and logistics. measles in Europe reminds us Eleven health ministers were 60 that unvaccinated children due to meet on 20 February and adults remain at risk to discuss how to achieve the of catching the disease and goals of the European Vaccine 40 spreading it to others who may Action Plan by 2020. Ukraine not be able to get vaccinated. Zosia Kmietowicz, The BMJ 20 Over 20 000 cases of measles, Cite this as: BMJ 2018;360:k795

0 MEASLES: more than 20 000 2005 2010 2015 cases, and 35 lives lost in 2017 alone, are “a tragedy we Data source: http://apps.who.int/immunization_monitoring/globalsummary/timeseries/ tswucoveragemcv2.html simply cannot accept”

the bmj | 24 February 2018 299 Strikes had a “significant impact” on services but did not increase deaths

Strike action taken by junior in 31 651 fewer admissions, doctors in England in 2016 did 173 462 fewer outpatient not lead to an increase in patient appointments, and 23 895 deaths, researchers have found. fewer emergency department However, the four periods of attendances compared with strike action, in protest against expected volumes for similar a new contract, did result in weeks. A total of 294 844 fewer hospital admissions, outpatient appointments were fewer emergency department cancelled by trusts, an increase attendances, and an increase of 52% compared with the in cancelled appointments, expected number. the study, published in BMJ Open, found. Emergency departments The researchers compared During all strike days, 3209 hospital episode statistics for patients died in hospital during the four periods—12 January, emergency admissions, 98 10 February, 9-10 March, and patients died during elective 26-27 April—with normal weeks admissions, and 356 died in immediately before and after emergency departments. each strike. The study said that the Overall, the strikes resulted number of recorded hospital

NEWS ANALYSIS In or out? The transplantation conundrum Is an opt-out scheme the way to increase organ donations in England, asks Nigel Hawkes

ngland is proposing at NHSBT. Online consultations opt out, reducing the potential The introduction of the system to adopt an “opt- normally attract only a few pool of donors. in Wales meant organ donation out” system for hundred responses. But she said that opting out had been widely discussed, and organ donation with Respondents were not asked would not prevent doctors from this alone may have been enough no clear evidence their opinion on the virtues of approaching families and asking to improve consent rates. In Ethat it will increase donation an opt-out system but rather whether the potential donor had England consent rates had risen rates, says a leading transplant on how such a system should perhaps had a change of mind. without opt-out, from 58% to surgeon who is also a non- be introduced. The government “We will always speak to the 65% in the past three years. executive director of NHS Blood argues that opt-out would better families,” she said. “The decision The past decade had seen a and Transplant (NHSBT). reflect public opinion, which to opt out might have been taken 75% rise in donors in England Keith Rigg, consultant strongly favours organ donation. 20 years before, so people might and 56% more transplants, he transplant surgeon at It sees opt-out as “shifting have changed their minds.” said. The waiting list had fallen Nottingham University Hospitals the balance in favour of organ The calculation in the model from 8000 in 2010 to 6270. NHS Trust, told a briefing at the donation.” rests on the assumption that These improvements were Science Media Centre in London consent rates would rise in an attributable to strategies devised that he was an opt-out sceptic. Families' right of refusal opt-out system, from the 65% by NHSBT and launched in 2008, “It’s often seen as a solution to NHSBT’s modelling suggests recorded in England in 2017 to which focused on improvements the organ shortage, but there are that a “soft” opt-out system, around 70%. In Wales, which in identifyinG potential donors many other factors that muddy where families retain the right of adopted an opt-out system at the and in streamlining the system the waters,” he said. refusal, would have increased end of 2015, the consent rate in for consulting families and The consultation was launched the number of donors in England 2017 was 72.1%. harvesting organs. in December and closes on in 2017 by 9%—an extra 100 But Rigg noted that consent “We’re delivering now, but 6 March. It has attracted more donors—and the number of rates in many parts of England more needs to be done,” said than 11 000 responses—a huge transplants by 7%, an extra 228. are as high as in Wales, and he Rigg. “Will opt-out be the answer? number, said Claire Williment, Williment predicts that three warned against assuming that It’s unlikely it will, on its own. head of transplant development million people would choose to opt-out had made any difference. There will be a significant costs

300 24 February 2018 | the bmj deaths did not appear to change appointments to protect higher GMC pushes for automatic Strikes had a “significant impact” on significantly during the strike risk services. periods compared with what They said that future work in erasure for doctors found was expected. “We found no the area should focus on how services but did not increase deaths measurable effect on mortality the strikes affected waiting guilty of serious crimes within the dates analysed, times and whether quality of although deaths from poor care care was negatively affected The GMC is seeking power to strike off doctors from the UK are likely to have an associated in the period immediately medical register without a hearing if they are convicted of a delay,” the study added. following the strikes. serious criminal offence. Researchers said future work A BMA spokesperson If such a power had existed when the trainee paediatrician should focus on how strikes said: “The decision to take Hadiza Bawa-Garba was convicted of gross negligence industrial action was based on manslaughter, she would not have been able to present evidence affected waiting times genuine concerns about the of serious systemic failures to a medical practitioners tribunal. There was some regional impact of proposed changes The tribunal took account of these when deciding to suspend variation in the strikes’ impact on patient care. her for 12 months, a decision that was overturned by the High on patient care. Yorkshire and “In recent weeks, we’ve seen Court after a GMC appeal. the Humber, London, and the large numbers of patients being In its response to a government consultation on East Midlands saw the biggest affected by the cancellation of professional regulation reform, the GMC asked drops in recorded elective operations because the health for the change to its fitness to practise rules admissions, while emergency service is unable to cope with to “better support public protection and admissions were most affected demand. This highlights the confidence and reduce the impact on in the South West and the West scale of the pressure the NHS patients and witnesses.” Midlands. is operating under, which was The move, which would require The researchers said the a key concern of junior doctors secondary legislation, is opposed findings suggest that NHS during the dispute.” by the defence bodies that represent trusts responded effectively Abi Rimmer, The BMJ doctors accused of criminal offences or by cancelling outpatient Cite this as: BMJ 2018;360:k782 regulatory failings. Rob Hendry, medical director of ROB HENDRY, MPS “IT IS FOR NEWS ANALYSIS the Medical Protection Society, which represented Bawa-Garba, wrote in a letter CRIMINAL COURTS TO statistics are so far inconclusive. to a doctor concerned about her case, “We In or out? The transplantation conundrum DETERMINE In 2016-17, the first full year are deeply concerned about a scenario A SENTENCE” Is an opt-out scheme the way to increase organ donations in England, asks Nigel Hawkes of the opt-out system, 135 where the GMC is given powers to ‘presume transplants from deceased erasure.’ We are firmly opposed to any such powers. donors took place, down 33 “In our representations to government, we have stressed it from the year before. The first is for the criminal courts to determine a defendant’s guilt or three quarters of 2017-18 saw innocence. It is for the criminal courts to determine a sentence.” 101 such transplants. Unlike Caroline Fryar, head of advisory services at the Medical England, the number of patients Defence Union, agreed. “The MDU would strongly oppose any in Wales awaiting a transplant such proposal. Any decisions, especially any decisions that has increased since 2014. could end a doctor’s medical career, must be made using a fair and transparent procedure and that includes a hearing.” Hard opt-out Anthea Martin, joint head of medical division at the Medical In 2016-17, 13 of 33 families, and Dental Defence Union of Scotland, said her organisation where deemed consent applied, agreed the GMC should have power to dispense with a hearing in in adopting it, and it’s vitally refused to agree to organ cases where suspension was proposed, the doctor agreed, and important the existing strategies donation. Such refusals could the outcome satisfied public and professional interests. But she are continued and properly be bypassed by a “hard” opt-out added, “We would be concerned about a move to mandatory funded.” system, where families do not erasure without a fair hearing.” International comparisons have the right to be consulted. A A GMC spokesperson said, “Our proposal would be to apply can be read in different ways, possibility in the consultation, the measure only to cases where a doctor had been convicted of he added. The top three but unlikely to be adopted. a very serious criminal offence—such as rape, murder, or child countries for donors per million This week the Dutch abuse. In some cases doctors have asked us to remove them from population (Spain, Belgium, parliament narrowly passed a the register following a conviction, but we are not able to do this. and Portugal) all have opt-out law for an opt-out system. The Instead, we have to go through the process of a hearing, which systems but all say that this is law, similar to that in Belgium takes time, costs money, and may add to victims’ distress. the result of good infrastructure, and Spain, will come into force “We would expect there to be a thorough consultation on not the law. in July 2020. what offences would be covered and how the issue would work The closest parallel to Nigel Hawkes, London in practice.” England is Wales, where the Cite this as: BMJ 2018;360:k744 Clare Dyer, The BMJ Cite this as: BMJ 2018;360:k755

the bmj | 24 February 2018 301 THE BIG PICTURE The art of giving life

Move over Warhol, Rosalind Aughwane is the new name in pop art, thanks to this set of highly colourised photographs. Aughwane’s “Placental Pop-Art” montage won second place in the Weird and Wonderful category of the fifth annual photographic competition run by the Engineering and Physical Sciences Research Council. Taken during her research at the centre for medical image computing at University College London, the photos show how placentas are fantastically diverse in shape and appearance. Each one in the montage successfully supported a new life. The images show automatically segmented chorionic vascular trees obtained from high resolution photography, taken for research into how tree structures relate to successful placental function. The competition judges said: “the simple colour palette reflects how diversity can arise while providing this vitally important life-creating role.” The competition received more than 100 entries from researchers in receipt of EPSRC funding. See all the winning photographs at www.epsrc.ac.uk Alison Shepherd, The BMJ Cite this as: BMJ 2018;360:k824

302 24 February 2018 | the bmj the bmj

| 24 February 2018

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DR ROSALIND AUGHWANE/UNIVERSITY COLLEGE LONDON EDITORIAL Failing health of the United States The role of challenging life conditions and the policies behind them

ife expectancy in the US  discrimination, and higher all cause OECD aggregate . has fallen for the second  mortality—have not experienced a year in a row.1 This is United States surge in drug deaths or suicides. alarming because life  Over the three decades in which . Lexpectancy has risen  survival advances slowed, educational for much of the past century in performance weakened, social divides developed countries, including the widened, middle class incomes US. The decline in US health relative  stagnated, and poverty rates exceeded to other countries, however, is not  those of most rich countries.3 The US is 11 new; it has been unfolding for decades Life expectancy at birth (years) rich, but its wealth is not inclusive. Its            (figure). In 1960, Americans had the social contract is weaker than in other Year highest life expectancy, 2.4 years countries—those in need have less Life expectancy at birth in the US and the Organisation higher than the average for countries for Economic Cooperation and Development, 1995-20152 access to social services, healthcare, in the Organisation for Economic or the prevention and treatment of Cooperation and Development (OECD). Vietnam war. The country is belatedly mental illness and addiction. The But the US started losing ground in the scrambling to reduce access (with, for “American dream” is increasingly out 1980s. US life expectancy fell below example, prescription drug monitoring of reach, as social mobility declines the OECD average in 1998, plateaued and drug take back programmes), and fewer children face a better future in 2012, and is now 1.5 years lower improve emergency responses to than their parents.12 than the OECD average.2 reverse overdoses (such as naloxone In theory, policy makers jolted by the A joint panel of the National programmes), and enhance access to shortening lifespan of Americans would Research Council and Institute of effective addiction treatment (such as hasten to correct these conditions. Medicine investigated the US health medication assisted treatment). They would promote education, boost disadvantage in 2013.3 It found that support for children and families, Americans had poorer health in many Public health crisis increase wages and economic domains, including birth outcomes, But the opioid epidemic is part of opportunity for the working class, injuries, homicides, adolescent an even larger public health crisis: invest in distressed communities, and pregnancy, HIV/AIDS, obesity, death rates from alcohol abuse strengthen healthcare and behavioural diabetes, and heart disease. It also and suicides have also been rising. health systems. But the pro-business found that many factors contribute Between 1999 and 2014, the suicide policy agenda favoured by elected to the health disadvantage; for rate rose by 24%.6 These “deaths officials rarely prioritises these needs. example, Americans are more likely of despair,” as some have called On the contrary, recent legislation and to engage in unhealthy behaviours them, disproportionately affect regulations may prolong or intensify (such as heavy caloric intake, drug white Americans, especially adults the economic burden on the middle misuse, and firearm ownership), live aged 25-59 years, those with limited class and weaken access to healthcare in cities designed for cars rather than education, and women.7 The sharpest and safety net programmes. pedestrians or cyclists, have weaker rises are occurring in rural counties, Ironically, leaders are outspoken social welfare supports, and lack often in regions with longstanding about ending the opioid epidemic and universal health insurance. social and economic challenges.8 9 bemoan spiralling and unsustainable The panel reported high death Why white Americans are dying healthcare costs. Solutions to both— rates in the US from drugs, a problem at higher rates from drugs, alcohol, which involve investment to support that has grown over time. Between and suicides is unclear, complex, struggling families and communities 2000 and 2014, the rate of fatal drug and not explained by opioids alone. and thereby improve public health—are overdoses rose by 137%, a crisis Possibilities include the collapse of often rejected, usually by leaders with fuelled by the growing use of highly industries and the local economies competing self interests or ideological addictive opioid drugs.4 In 2015 they supported, the erosion of social objections. The consequences of alone, more than 64 000 Americans cohesion and greater social isolation, these choices are dire: not only more 5 The “American died from drug overdoses, exceeding economic hardship, and distress dream” is deaths and illness but also escalating the number of US casualties in the among white workers over losing the increasingly healthcare costs, a sicker workforce, security their parents once enjoyed.9 10 and a less competitive economy. Future Steven H Woolf, director, Center on Society out of reach, and Health, Virginia Commonwealth By contrast, greater resilience might generations may pay the greatest price. as social University [email protected] explain why black Americans—who Cite this as: BMJ 2018;360:k496 mobility Laudan Aron, senior fellow, Urban have contended with longstanding Find the full version with references at Institute, Washington, DC structural disadvantages, declines http://dx.doi.org/10.1136/bmj.k496

304 24 February 2018 | the bmj EDITORIAL : another bitter pill Participants affected by dementia deserve greater involvement and recognition in future trials

his has already been dementia has been on the “magic a disheartening year bullet” of an effective disease for research into drug modifying drug. However, an treatments for dementia estimated 47 million people in and Alzheimer’s disease, the world have dementia, and Tespecially for people affected by improvement in distressing symptoms dementia. Negative results have is a priority for them.6 Much hope was been posted for phase III clinical therefore pinned on 5-HT6 antagonists trials of two 5-hydroxytryptamine-6 providing a new effective class of receptor (5-HT6) antagonists for drugs for symptomatic treatment. the symptomatic treatment of Phase II human studies found moderate dementia,1 2 as well as for that idalopirdine led to a small a trial of an amyloid β antibody as improvement in cognition in a Expectations Dementia Australia) they are still a disease modifying treatment in subgroup of participants taking must remain willing to be involved in clinical mild dementia.3 Pfizer announced .7 Subgroup analyses should realistic while trials, understanding that progress that it will end its neuroscience and always be treated with caution, and we conduct depends entirely on their voluntary related dementia investments in previous trials based on hopeful hints an open contribution. drug development, removing a major in subgroups of early phase studies debate on the industry partner from the field.4 have failed.8 Even so, plausible Trial ready cohorts ethical issues biological mechanisms may explain Collaborative research organisations Negative drug trials why acting on both neurotransmitter are harnessing this willingness These developments follow a long systems might be effective,9 although to establish “trial ready” cohorts: period of negative drug trials in it was also noted that idalopirdine, registries of people who have dementia. In recent decades the as a cytochrome P450 inhibitor, may undergone investigations such as failure rate has been nearly 100%,5 simply be increasing the blood levels cognitive testing and biomarkers, who and the only registered medicines of co-administered donepezil.10 may be at higher risk of developing are the cholinesterase inhibitors and Phase III clinical trials were dementia and are willing to take , which at best generate undertaken to determine whether part in clinical trials. This raises modest symptomatic improvement in idalopirdine can improve cognition substantial ethical issues such as the cognitive testing among some patients in people with Alzheimer’s disease status of consent obtained well in and for only a limited period. who currently take cholinesterase advance of any trial, when disease Drug development has often been inhibitors, mostly donepezil.1 These progression might later change associated with great excitement multinational studies enrolled 2525 participants’ or their carers’ wishes.11 generated by the so called participants with mild to moderate People with dementia make it breakthroughs seen in animal models Alzheimer’s dementia and compared clear they should be included in the of dementia, followed by uncertain three doses of idalopirdine and design and implementation of trials results in early human studies and placebo over 24 weeks. and that there should be greater then the certainty of negative results The results of these high quality, incentives to take part. But everyone from phase III studies. But it has definitive studies were recently must be represented, including been a rollercoaster of hype and published and were entirely negative.1 older people with comorbidities and disappointment for people with The authors noted that the positive frailty—the overwhelming majority dementia and their families, who are results from the phase II subgroup of people with dementia. dismayed, and may even grieve, when analysis had been achieved with Clinical trials to date suggest any a promising new treatment fails in a higher dose but, even so, they therapeutic advances are likely to high profile clinical trials. concluded that idalopirdine was be hard won and incremental.11 The major focus of research in ineffective. Likewise, negative results Expectations must remain realistic have been posted from a similar while we conduct an open debate David G Le Couteur, professor of geriatric medicine, Concord Hospital and University trial with another 5-HT6 antagonist, on the ethical issues, including of Sydney intepirdine. These trials indicate that the disclosure to asymptomatic [email protected] 5-HT6 antagonism is another blind individuals of a possible but uncertain Brace Bateman, dementia advocate, alley in treating dementia. risk of dementia. Dementia Australia, Melbourne Despite the long line of drug trial Cite this as: BMJ 2018;360:k753 failures, people affected by dementia Carol Brayne, professor of public health, Find the full version with references at Cambridge Institute of Public Health confirm (through bodies such as http://dx.doi.org/10.1136/bmj.k753 the bmj | 24 February 2018 305 PHARMACOVIGILANCE French patients take to the streets, and courts, to protest against new levothyroxine

housands of French Huge rise in is the same for both Lévothyrox thyroid patients have side effect versions, and that “particularly complained about high media attention and adverse effects after reports has strengthened surveillance” may have taking a modified led to angry increased reporting of side effects. Tversion of Merck’s Lévothyrox marches (levothyroxine). Change in excipients Since the drug was reformulated and legal France was the first country to last year, patients have reported charges, introduce Merck’s new formulation problems including fatigue, memory finds of levothyroxine in March 2017, to loss, palpitations, weight gain, Barbara reduce variability in dosing. The dizziness, and nausea, prompting active ingredient did not change, 318 077 signatories to a petition Casassus only the excipients: it removed demanding Merck return to the lactose and added mannitol and previous formulation. Merck has citric acid. not decided whether to launch Data published by the French Lévothyrox in the UK. national drug safety agency (ANSM) that soon she developed low mood, The concerns of patients have on 30 January show that 67% of hair loss, headaches, and cramp. led to an emergency parliamentary the 1745 patients who submitted “I only learnt about the change inquiry and the initiation of a detailed complaints about the in July, when it was all over the criminal investigation by the public new version between the end of media,” she said. “I tried two prosecutor for Marseilles, while the March and November 2017 had other options [of levothyroxine], French health minister has asked normal levels of thyroid stimulating but they did not work either, so I Merck to continue providing the old hormone (TSH), which suggests that started buying the old version from formulation temporarily. they were receiving the right dose. Lebanon in November, and a month Meanwhile several groups of “There is no explanation for later was almost back to normal. My patients are taking legal action. this,” the agency’s deputy director TSH level didn’t budge during that “Merck intends to continue to general, Christelle Ratignier- period.” cooperate fully . . . and will provide “The report Carbonneil, told The BMJ. “The “We have yet to see the 2012 the investigating judges with has raised even question must be examined in depth pharmacovigilance report that all necessary documents and and will be looked at by the French justified the change in the first more questions information,” its spokesman Endocrinology Society.” place,” adds her husband. Matthias Reinig told The BMJ. than it has Symptoms improved for 65% of Ratignier-Carbonneil told The The European Medicines Agency is answered” the 1745 patients who switched BMJ that the public prosecutor in unfazed by recent events, however. Alain-Michel to a competitor drug or Merck’s Marseilles, Xavier Tarabeux, has It said that the pattern of side effects Ceretti old version. “The report has raised refused to allow ANSM to publish even more questions than it has the 2012 report while his office is answered,” says Alain-Michel investigating the drug. However, the Ceretti, president of France Assos newspaper Le Parisien published a Santé, which represents 80 leaked extract on 30 January, noting patients’ associations. only 23 cases of side effects from Lévothyrox between November 2009 Buying the old version from Lebanon and December 2011. Tarabeux did Ceretti’s wife Béatrice has not respond to The BMJ. hypothyroidism and switched to “Why would the ANSM take action the new Lévothyrox formulation in for 23 people out of the three million April 2017. She had understood that patients taking the drug at the time, Merck had changed only the colour but not for the thousands who are of the packet. But she told The BMJ suffering now?” asks Ceretti.

306 24 February 2018 | the bmj LAWSUITS OVER LEVOTHYROXINE The lawyer Marie-Odile Bertella-Geffroy has filed criminal charges, including for endangering lives, on behalf of 1200 patients. These include members of the French Association of Thyroid Patients (AFMT), some of whom say they are buying the old formulation from abroad. Another association, Vivre sans thyroîde (Living without a thyroid), asked the law firm MySMARTcab to seek an “emergency expertise procedure,” which was due to be heard in Paris on 23 February. It wants full information about the reasons for the switch and the composition of the new version. MySMARTcab has filed a civil claim demanding compensation from Merck of €10 000 (£9000) for each of 4115 patients. It offered to represent patients through its website in return for a small fee. More than 10 000 signed up, but only 4115 provided the necessary paperwork. The case will be heard in Lyons on 1 October. ROMAIN LAFABREGUE/AFP ROMAIN

Reasons for reformulation French as to other countries’ experience reaction is “paranoid,” as he put it “In 2012, we asked Merck to narrow demonstrators in reformulations of synthetic to The BMJ, and can be explained the variation of the active ingredient gather outside a thyroxine, including problems in by poor communication, thyroid factory that makes from 90%-110% to 95%-105%,” New Zealand a decade ago and fluctuations, and the nocebo effect. Merck products Ratignier-Carbonneil explained. last November to Takeda Belgium’s smooth transition Five endocrinologists endorsed This is because “laboratory tests protest against to its new formulation in 2015. the nocebo theory in the newspaper had shown instability and uneven the new version Le Monde at the end of December. shelf life.” of Lévothyrox Side effects The latest data have not changed Simultaneously changing the In France, 17 310 patients reported Bergmann’s mind, and “do not excipients made sense because of the potential side effects between March warrant further scientific studies.” global problem of lactose intolerance, and November 2017: 0.75% of Bergmann was one of the experts according to Merck’s chief medical the estimated 2.3 million people— questioned in an emergency inquiry officer, Steven Hildemann. about 90% of them women—taking led by the parliamentarian Jean-Pierre The company did all it could to Lévothyrox. The total has dropped Door, who concluded on 31 October ensure a seamless transition in from three million, partly because of that “there is no health crisis, only a France, Hildemann says, including new rivals and purchases of the old media crisis.” informing the ANSM and patient formulation abroad. In September, the French organisations. Under ANSM The previous formulation also actress Anny Duperey, who has supervision, Merck sent some had side effects, but the drug hypothyroidism, sent a furious 400 000 letters and emails to health agency’s January 2018 report open letter to health minister Agnès professionals announcing the change says that the scale with the new Buzyn, denouncing the switch as a and advising doctors to test TSH levels formulation is “unprecedented [and] “shameful scandal.” in patients at risk, such as pregnant totally unexpected.” Buzyn dismissed the problem women and people with cancer. The agency examined 339 serious initially but eventually asked Merck Despite the large communication cases reported between September to provide the old version in France effort, many patients say they didn’t and November last year, including temporarily, announced competitors know about the change. several deaths. “In none of the cases would enter the market, and Prelaunch tests showed can we formally include or exclude established a committee to devise new bioequivalence with the previous Lévothyrox,” the report said. ways of informing professionals and formulation. But Ratignier- But Jean-François Bergmann, a patients about drugs changes. Carbonneil says that her agency pharmacologist and head of internal Barbara Casassus, freelance journalist, Paris should have paid more attention to medicine at Lariboisière Hospital [email protected] complaints on social media as well in Paris, is convinced that patients’ Cite this as: BMJ 2018;360:k714 the bmj | 24 February 2018 307 new breed of TECHNOLOGY doctor is stalking UK hospitals and clinics—young, tech Doctors turn entrepreneur to savvy, and frustrated Awith clunky NHS processes, these try to modernise the NHS “doctorpreneurs” are setting up technology companies in an Frustrated by outdated systems and clunky processes, attempt to make the health service run more smoothly. medics are developing their own apps in the hope It is impossible to say how many of finding solutions, reportsAnne Gulland doctors are tinkering away on their laptops trying to develop an app, but Kit Latham, a former NHS emergency medicine doctor and cofounder of Dr Focused, whose products include an online rostering system, believes that doctors are becoming increasingly frustrated with the outdated processes they are using at work. “Every time they book a holiday or buy travel tickets doctors are confronted with tech that’s well designed, easy to use, and doesn’t waste their time. But when they’re at work they’re confronted with tech that is out of date and makes their job harder,” he says. Latham is a perfect example of the new breed: a digital native who worked as a systems administrator in his teens. He did a masters in technology entrepreneurship at University College London and decided to develop an exception reporting app (to record when your work has varied from your schedule) with his company cofounders. This app has now been downloaded by doctors in 74 hospitals. He now wants to create a whole digital back office for doctors, bringing all their paperwork into one place. “We built the app with the brief of making exception reporting as fast as possible: people can now do their exception report in 19 seconds. This got us into rostering—rostering is the lynchpin of the hospital but often it doesn’t work properly,” Latham says.

Adoption hurdle Lots of people have expressed an interest in the product, but trying to turn that interest into a sale is the hard bit, he says. “A hospital’s sales cycle takes about two years. One hospital said to us that even if it used our software for free we would

MALCOLM WILLETT MALCOLM have to get past four committees

308 24 February 2018 | the bmj and it would take a minimum of “You may have We offer fellows the support of eight months. created a lovely mentors, relationships with other “There are lots of legitimate app, but what we peers, and introductions.” concerns around the privacy of need are end-to-end Tailor says individuals who join people’s data but we have conned solutions that solve the NIA are expected to share their ourselves into thinking that using real problems” learning and report on progress. tech that’s 40 years old is a risk-free They do not give up any intellectual James Somauroo, strategy. It’s not,” he adds. property, and profit goes back to the Digital Health London Whether or not Dr Focused is Accelerator innovator. Tailor adds, “Innovations the answer to the NHS’s rostering must have evidence to demonstrate problems, getting the NHS to take in practice significantly greater up an innovation is definitely quality outcomes for significantly difficult. The NHS’s travails with new NHS. For entrepreneurs to get onto lower cost. technology are well documented— the programme, set up in 2015, “Being on the NIA does not the aborted National Programme they must have—in geek speak—a offer innovators a preferred NHS for IT was described by members of minimum viable product. That is, supplier status,” she says, but 964 parliament as a fiasco and ended up the product must have been tried organisations across the NHS in costing the taxpayer £10bn. and tested and be ready to be England are using NIA innovations. Rebekah Tailor is communications delivered at scale. These are not just tech based and engagement manager for Tailor says, “It takes something and include models of care and NHS Innovation Accelerator like 17 years for an innovation to products, such as a pair of fixed angle (NIA), a programme supporting be adopted throughout the whole episiotomy scissors. entrepreneurs and clinicians to NHS. The point of our programme spread innovation throughout the is to accelerate that adoption. Anti-innovation? James Somauroo, an anaesthetist DOCTORPRENEUR CASE STUDY: QUIT GENIUS by training, is programme director of the Digital Health London When they were in their fourth thought their idea of an app says Ahmed. “We were doing Accelerator, a project similar to year of medical school at based smoking cessation tool exams but at the same time NIA but focused on the capital. It Imperial College, London, had potential and spent every trying to raise investment from is a partnership between London’s Maroof Ahmed, Yusuf night and weekend of their key people. But we managed three academic health science Sherwani, and Sarim Siddiqui final year at medical school to find a way around it and it networks and the charities of Guy’s did a research project looking working on Quit Genius. The worked out. One of the reasons at how gamification—the use app, which uses tailored I go back to talk to students and St Thomas’ and the Chelsea of gaming elements such as cognitive behavioural therapy is to promote a culture of and Westminster hospitals. It’s challenges and rewards— (CBT) to help smokers quit enterprise within medicine,” supported by the mayor of London. could help smokers quit. and stay non-smokers, was he says. Somauroo rejects the idea that the “As students we saw doctors launched on iOS last summer NHS is anti-innovation. talking to patients about quitting and on Android in November. Leaving medicine? “There are people in the NHS who smoking but [the patients] were The students built the initial Although they are pleased are open to innovation, and there given no help,” says Ahmed. prototype themselves. with the app’s success so far, are problems in the system that need “Around 70% of smokers “It went through a process of they want to take it further solving. The NHS is spending a lot of want to quit, but only around iteration and improvement, and and, with their parent company money on systems and processes that 3% are successful and only then about 12 months ago we Digital Therapeutics, look at are inefficient. It is under pressure 6% are offered any access to secured a large funding round ways of using app based CBT behavioural support,” he says. and it took off from there,” says for other addictions. They are in terms of time and resources and When the research project Ahmed. They now have a team also looking at promoting the is not in a position to buy things that was finished the students of experienced developers, app to businesses as part of are nice to have,” he says. designers, and psychologists staff health and wellbeing Doctors who want to innovate who are helping to improve the packages. need to have a robust business app and launch new features. Ahmed and his cofounders model, which shows how their Trying to launch a business have decided to delay innovation will drive up quality and while in their final year of foundation training while they reduce costs, he says. “You may have medical school was difficult, concentrate on the business— created a lovely app, but what we but they will return to practice need are end-to-end solutions that one day, he insists. “I go back to talk to “We don’t see this as leaving solve real problems.” students to promote medicine. You go to medical And frontline clinicians are in an a culture of enterprise school to make an impact on ideal position to provide solutions, within medicine” people’s lives—with this app he says. “You only need to go to Maroof Ahmed, we could have an impact on hospital or the doctors’ mess to hear Quit Genius the lives of millions,” he says. people moaning about systems. What’s changed is that access to the bmj | 24 February 2018 309 DOCTORPRENEUR CASE STUDY: MY LOCUM MANAGER Surina Chibber, a locum GP in London, had just had her second baby when she started filling in her tax return. Coping with two small children while trying to sort out her paperwork was difficult, and she thought that there had to be an easier way to do it. “I felt I needed some kind of tool that was useful, intuitive, and would save me time,” she says. With her husband Matt Beddoe, a “Doctors are confronted with “I’m trying to create a really general practice partner, they decided to build tech that is out of date and makes good company that improves software that would help locums manage their their job harder the care patients get” business administration and paperwork. “When we had the initial idea we coded a Kit Latham, Dr Focused Felix Jackson, medDigital Star Wars trivia app to learn about coding, functionality, and how the app store works. We technology is so much easier and 10 years and is the founder of medical launched it as an experiment and it did really people can code an app from their communication company medDigital, well,” she said. bedroom.” says there is a feeling that making Beddoe built all the wireframes—the Latham believes doctors have a money from the NHS is somehow blueprint for the software—and then the responsibility to get involved in the grubby. All doctors get paid salaries, couple joined forces with a tech company. tech world. “We have two choices— but that’s different, he says. They launched the site two and a half years either we take on that responsibility “I’m a fan of health workers, and I ago, continually testing and refining it, with and learn as a profession, or we want to help health and care workers feedback from users. abdicate that responsibility and let tech do their job better. There are a lot Locums pay for the site and it’s free for companies have a go. And they may get of people who believe that making practices. Once a locum is signed up it it right or they may not,” he says. money out of the NHS is an immoral brings all paperwork together, such as work But doctors don’t always get it right, act. I’m trying to create a really good scheduling, tax, and pensions, and includes either. Last October a doctorpreneur’s company that improves the care features such as automatic invoicing. idea to help solve NHS bed shortages hit patients get. I think it is okay for this “When you’ve been in the NHS for a long time the headlines. Dubbed “Carebnb,” the company to make money so we can do you sometimes develop a certain mindset CareRooms proposal aimed to free up this really well,” he says. that doesn’t let you do any creative thinking,” hospital beds by putting NHS patients Jackson says there are easier says Chibber. “When I was on maternity leave who no longer needed to be in hospital ways to make money than being an I started to read more widely and meet people in local spare rooms. entrepreneur. “You invest a lot of time doing different things. That led to me to start “Hosts,” to use Airbnb parlance, and energy into your idea [but] you thinking about improving things in the NHS.” would receive £50 a night in return for don’t know if it’s going to work. Every She still works as a locum and says combining this with her business means life providing a room, three meals a day, entrepreneur works very hard. is very busy but fulfilling. “For most of us it’s and “conversation where appropriate.” “I don’t want to be an entrepreneur an extension of what we did on our training— The story attracted lots of negative just making rich people richer. I want problem solving. We’re in an age where tech is press coverage, and within 24 hours to go out there and help patients and part of everything. Southend University Hospitals the people who care for them,” he “Being an entrepreneur is an opportunity to Foundation Trust, where the pilot was says. bring out your creative side, problem solve, initially based, poured cold water on Latham agrees that people are and have some fun.” the project, saying it had never been its suspicious, and he struggles with the intention to support it. “guilt” of having left the NHS and “It’s an extension of what we did on It is unclear what is happening to the wasting his expensive training. But our training—problem solving” project as neither the entrepreneurs he thinks attitudes are changing. Surina Chibber, My Locum Manager behind it nor NHS England, whose “I haven’t come up against anyone clinical entrepreneur fellowship saying ‘you’re a rapacious capitalist.’ scheme is backing the project, Without my training and experience responded to requests for comments. of practice I wouldn’t be able to see the problems that healthcare has,” he Private business fears says. Some of the criticism centred on the “I can square what I’m doing with uneasy relations between the NHS my conscience.” and the private sector. Felix Jackson, Anne Gulland, freelance journalist, London a former anaesthetist who has been [email protected] working in digital health for the past Cite this as: BMJ 2018;360:k685

310 24 February 2018 | the bmj