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We medicalise normal physiology (and a large ‘ proportion of NHS staff) to little benefit NO HOLDS BARRED Margaret McCartney Let’s concentrate on dehydration

emember—healthy whose „ nancial pro„ t and pile of plastic pee is  to €,  to ‚ empties are fuelled by the fear that, if we you must hydrate!” So aren’t running clear urine, something is goes a rhyming couplet inherently wrong with us. “R from the Think Kidneys The bottom line is this: where’s the website, the online presence of the evidence that telling people to monitor Transforming Participation in Chronic the colour of their urine and saying that Kidney Disease programme. It comes they’re in a pathological state results in with a colour chart, not unlike those better health outcomes? Common sense available in shops selling paint, ranging in medicine needs evidence—because we from the oƒ -white shade  (good) to frequently, and with good intentions, get shade ‚, which I’d describe as orange it wrong, even while seeming sensible. with a hint of rust (severely dehydrated). Then there are “sick day rules.” These are a Scottish I suspect that the normal colour of most doctors’ pee Patient Safety initiative for patients to have a credit when at work—if they get to the loo at all—will range card sized infographic advising them to stop using from “dehydrated” to “severely dehydrated” (that is, angiotensin converting enzyme (ACE) inhibitors, from mellow yellow to that classic dark orange). But anti-in ammatories, and diuretics during intercurrent is this actually pathological? Dehydration is surely by illness, to prevent acute kidney injury. This sounded de„ nition pathological and would need blood tests to very sensible when it was initiated a couple of years determine it: a physiological adjustment of our renal ago. However, my initial support has wavered because output shouldn’t be classed as dehydration but as a body no good evidence shows that this will improve mortality that needs uid to continue functioning normally. or morbidity. Human physiology is amazing: drink more, and I should have asked for better evidence „ rst. A" er we pee out more urine; drink less, and our kidneys all, we thought that steroids would help head injury, concentrate it. This ballet is orchestrated through our that caring for a simulation baby would reduce osmoreceptors and baroreceptors, by antidiuretic, teenage pregnancy, and that vertebroplasty would angiotensin, and aldosterone hormones, and by the treat painful osteoporotic fractures, when they did sensation of thirst, which everyone remembers from nothing of the sort. tutorials in medical school. So, when does physiology The human body is mainly incredible. Professional become pathology? intervention needs evidence. Can we please have free All sorts of considerations apply when people have a access to tap water and the time to drink it—but also a speci„ c diagnosis, are ill, or are in hospital and cannot proper randomised controlled trial of well intentioned respond to the natural call of thirst. They may need help safety initiatives before they’re rolled out? to drink, or they may be on deliberate uid restrictions. Margaret McCartney is a general practitioner , Glasgow But we medicalise normal physiology (and a large [email protected] proportion of NHS staƒ ) to little bene„ t. We must also Follow Margaret on Twitter, @mgtmccartney think of those poor people in the bottled water industry, Cite this as: BMJ !"#$;%&':j()(!

the bmj | 21 October 2017 105 ETHICS MAN Daniel Sokol Lessons fromthe frontline Lawsuits are miserable for doctor defendants but can lead to better, safer practice

n the summer of €€ I was sitting in an Oxford cafe with a professor of medical ethics. I had just  nished a masters degree Iin the history of medicine and, intrigued by the dubious conduct of some doctors in the past, was has been an outlet for those lessons. Do not skip or for interview panels, whether they contemplating a career in medical Here are further re! ections from the rush through are selecting medical students or ethics. “What do you want to do?” past two months. surgical consultants, should be: does this asked the professor. “I want to help I represented a medical student checklists. person have insight? doctors,” I replied. And so started my in a  tness to practise hearing. The Do not stray Cosmetic surgery journey in medical ethics. chief concern was his lack of insight beyond the Fi‚ een years later, now working as into his rudeness towards others. scope of On occasion I advise on cosmetic a barrister, I sue doctors. Insight can be de ned as the ability surgery cases. I attended a course on the original The way to reconcile these two to understand intellectually and the topic last month, in which the facts is that lawsuits, though emotionally why a behaviour is consent case study, a  ctitious one blending miserable aƒ airs, can lead to better, wrong. Without this ability, learning the stories of several patients, was a safer practice. But this only occurs if is sti! ed and poor practise goes schoolteacher who underwent breast lessons are learnt, and this column unchecked. A compulsory question augmentation.

ACUTE PERSPECTIVE David Oliver ChallengingthevictimnarrativearoundNHSdoctors In July, I posted some tweets arguing If more doctors really are feeling of  nite public resources, as well as that doctors still have public respect, this way it may damage recruitment, pressure from a range of stakeholders high professional status, secure and morale, and retention and reduce well beyond medical professionals, relatively well paid careers, and a engagement in medical leadership not least from patients and voters. great deal of hard power and so‚ and patient advocacy, with Doctors will never get everything we in! uence. I said doctors shouldn’t consequences for patient care. want or call every shot. It’s the same describe themselves as hapless, In any case, none of these for the military, police,  re service, impotent victims of the state. Plenty examples proves that the profession prisons, and schools. of doctors agreed with me. And In a politically is powerless or has earned victim Pay? The whole public sector has plenty disagreed vehemently. accountable status. Feelings run high and taken an austerity hit. We do better Years of below-in! ation pay rises, system, shouldn’t be dismissed, but I’d than most and have relatively more the mistreatment of whistleblowers, doctors will challenge the hyperbole. security, career progression, pension and the government’s demoralising never get to NHS doctors work in a tax entitlements, and paid leave. attitude to junior doctors during last call every shot funded, politically accountable Public respect? Doctors and the year’s contract stand-oƒ were all cited system—a principle that most of NHS still repeatedly top polls about as evidence of our disempowerment. us still strongly support. But this trust in professionals, despite some They certainly contribute to doctors’ comes with consequences. As a horribly disrespectful attitudes we sense of being less in! uential than public service the NHS is in! uenced can all encounter. Online reaction to we once were—or were expecting to by macroeconomics, government TV hospital documentaries has been be when we entered training. allocation, and trade-oƒ s in the use incredibly supportive—o‚ en awed.

106 21 October 2017 | the bmj During the operation one of the In the knee case the surgeon said implants was dropped and, with no nothing about the mishap to the BMJ OPINION Mary McCarthy spare implant available, the surgeon patient until she asked some weeks decided to insert two larger ones. later. She was distraught and lost It’stimeforGPsto The operation was a success, but the faith in the surgeon. The lesson: be berecognisedasthe patient was distraught. So obvious honest when you make a mistake, specialiststheyare was the change that she became the however daunting the prospect. You For many years general practitioners have been butt of teenage jokes at her school, will be surprised how o" en patients arguing that they are specialists in general practice fell into depression, and quit. forgive. Remember also the legal duty and want to be recognised as such. of candour. Many see their European colleagues recognised Nickel allergy Finally, last weekend I had as specialists in family medicine: € out of  EU Coincidentally, the next week the misfortune of attending an states recognise general practice as a specialty. In fact, I received a new case involving emergency walk-in centre with an eye European GPs are surprised to find that the UK, which a patient who underwent a knee problem. Sitting there, I witnessed the is widely regarded as the founder of modern general replacement operation. She was depressing sight of sick and injured practice, does not acknowledge its own GPs as expert allergic to nickel and had asked for a people walking in, some propped up specialists. nickel-free product. In the operation against a worried helper, others with And it’s not just in Europe. Australia, Canada, and the surgeon removed the old knee, bloodied tissues packed into their the US also recognise the specialty. A Canadian doctor once told me that in his country consultants opened the packet for the new knee, noses, and others pale as ghosts. were considered “doctors of restricted scope of and to his horror discovered that it They looked so despondent that the practice,” whereas GPs were “doctors of unrestricted contained nickel. Faced with a large very experience sunk my spirits. scope of practice.” defect cavity, he thought he had no When my turn came, the doctor was The GMC—despite having two registers, one for choice but to implant the knee. The cheerful, diagnosed conjunctivitis in specialists and one patient developed complications. an instant, and prescribed some eye for GPs—still lists The lessons: do not skip or drops. I can now see perfectly. The general practice as rush through surgical checklists. lesson, all too easily forgotten in these a specialty on its Remember, if the patient consents litigious times: medicine is a noble website. Universities to one thing (a certain cup size or vocation admired and appreciated and medical schools have chairs of a nickel-free knee) you should not by all, including clinical negligence general practice, and do something else unless there is a lawyers and other wicked folk. there are relevant medical emergency and asking the Daniel Sokol is a medical ethicist and professors of the patient is impossible. In short, do barrister , London discipline. General practice fails to not stray beyond the scope of the daniel.sokol@talk!.com If it looks like a attract young doctors as original consent. Cite this as: BMJ !"#$;%&':j()!( duck, swims like a they believe it has less duck, and quacks status than hospital posts like a duck, then it is a duck. General practice looks like a specialty, behaves like a specialty, has all the attributes of a specialty, and Power? We control curriculums service changes, their line managers is a specialty in many other countries—it should be recognised as a specialty in the UK. and exams (yes, the GMC and Health are generally fellow doctors. It is widely acknowledged that general practice is in Education England have a statutory BMA doctors were in# uential at crisis, with overworked, demoralised, and underfunded stake, but they employ senior medics every turn of the contract stand-o% . GPs who are increasingly retiring early or moving too). We are training supervisors Their tactical decisions were central abroad. We are failing to attract young doctors into the and examiners. We make clinical to how events played out. profession because they believe it has less status than decisions that determine how most Of course, doctors have legitimate hospital posts and is a career with few rewards for the non-pay NHS resources are spent. concerns about the NHS's future, as skills it demands. We develop and lead the research, well as our own working lives and Recognising general practice as a specialty would raise evidence base, guidelines, and conditions. And we o" en disapprove its profile, confer long overdue status on a beleaguered quality standards for best practice. of decisions made or imposed in our profession, and acknowledge the skills and expertise needed to deal with patients with undifferentiated We lead clinical audit and quality name. This doesn’t make us hapless illnesses or multiple morbidities. improvement programmes to help victims. We have to be realistic GPs have a long and rigorous training path to become implement it. Our specialist societies about what we can achieve, but we specialists in general practice and family medicine. and colleges provide clinical and must also use our considerable hard The fact that they are not recognised as such is an policy in# uence in their $ elds. power, so" in# uence, and status to anachronistic anomaly, which the government would do In every service some doctors preserve and improve patient care. well to acknowledge. double up as managers, from heads David Oliver is a consultant in geriatrics and It is within their power to correct this and it is a of department to medical directors, acute general medicine , Berkshire measure that would give fresh heart to the UK’s hard and they foster the culture—good davidoliver"#@googlemail.com pressed GPs. or bad. If doctors feel bullied, or Follow David on Twitter, @mancunianmedic Mary McCarthy is a GP in Shrewsbury unsupported or don’t like certain Cite this as: BMJ !"#$;%&':j(%"( the bmj | 21 October 2017 107 LETTERS Selected from rapid responses on bmj.com. See www.bmj.com/rapid-responses

INFECTIVE!ENDOCARDITIS inject drugs, at least in the LETTER!OF!THE!WEEK Risk is low after developed world. Remission of The effects of continued dental procedures type 2 diabetes injecting on life course and health Cahill and colleagues endorse MALCOLMWILLETT needs are poorly understood. routinely offering antibiotic McCombie and Primary and other healthcare prophylaxis to people at high risk colleagues discuss services might provide a valuable of infective endocarditis when the remission of type * opportunity to screen for health they undergo invasive dental diabetes (Analysis, %& problems potentially associated procedures (Uncertainties, ! September). When I was with injecting drug use or ageing. September). They quote their given the diagnosis of Services developed for people own work to support this but type * diabetes about five who inject drugs should be low do not acknowledge that their years ago, I decided threshold and client centred, findings were challenged during to lose weight by and this may become especially development of the current dieting. important as users age. The NICE guideline. I lost %+ kg and now stay between /% kg and /* kg. My BMI effects of opioid substitution They note that “high risk” is *0.+. My blood pressure has only once reached %+$//$ mm treatment on cardiovascular patients should be reassured Hg and is usually <%*$/<2$ mm Hg. My cholesterol has been function are largely unknown, that they have an “extremely low raised for at least 0$ years, and I have had a coronary artery and high rates of smoking risk” of infective endocarditis bypass graft, a pacemaker, and transcatheter aortic valve remain a concern. after dental procedures—even implantation. I am 22, and I walk two miles a day. As people who inject drugs without antibiotic prophylaxis. I have found that the amount of food I need is much less age their presentations to No studies show whether than would be regarded as modest. Although the urge to eat primary and other care for reducing the incidence of is less intense now, I am hungry most days. People forget that chronic health problems are bacteraemia with antibiotic when you reach your target weight you can’t go back to your likely to increase. Services that prophylaxis reduces the previous intake. can tackle these presentations incidence of infective I find the driving force to “relapse” is hunger. This powerful may reduce presentations to endocarditis. The number drive is not only uncomfortable but provokes anxiety. Having costly tertiary settings. needed to treat would be very specialised in addiction, I came to recognise that my problems Peter Higgs, senior lecturer, Melbourne high—we estimate that several with food are closely allied to addiction. I applied what I Paul Dietze , professor, Melbourne thousand patients would need to had learnt from my patients to manage my urge to eat. The Cite this as: BMJ "#$%;&'(:j)%&+ be treated to prevent one case of difference is that I cannot be a total abstainer from food. I am infective endocarditis. like a patient maintained on methadone. GOOGLE!DEPRESSION!TEST The research community David Marjot, retired consultant psychiatrist , Weybridge Online screening needs to design better Cite this as: BMJ "#$%;&'(:j)%"+ is inappropriate epidemiological research and to propose better preventive The BMJ ’s series and should prophylaxis for invasive dentistry Duckworth and Gilbody debate strategies. Focusing solely on be welcomed. but also to investigate other novel whether Google should offer exposure to invasive dental Baker and Alderson reiterate preventive strategies. an online screening test for procedures may distract from the caveats that we outlined Thomas J Cahill , cardiology specialist depression—namely, the patient that research effort. in our article. But we think that registrar , Oxford health questionnaire ! (PHQ-!) Mark Dayer , consultant cardiologist , Mark Baker , director, London decisions about antibiotic Taunton (Head to Head, %& September). Philip Alderson, consultant clinical prophylaxis should be devolved Bernard Prendergast, consultant But PHQ-! is not a screening adviser , London to individual patients and not cardiologist , London tool for depression, rather it is Cite this as: BMJ "#$%;&'(:j)%&& taken nationally. This approach, Martin Thornhill, professor of used to monitor the severity of translational research in dentistry , supported by European and depression and response to Authors’ reply She* eld American guidelines, enables Cite this as: BMJ "#$%;&'(:j)%&) treatment. Using it as an online Baker and Alderson emphasise those at highest risk to make screening tool is inappropriate. data supporting the decision decisions about their care SUBSTANCE!MISUSE It can also be inaccurate. made by NICE to withdraw with support from general Injecting drug use Positive responses indicating antibiotic prophylaxis for practitioners, cardiologists, continues in older age depression can be the result patients at risk of infective and dentists. of hypothyroidism, anaemia, endocarditis in the UK We agree that the rising Rao and Roche note the global or other chronic undiagnosed (Uncertainties, ! September). incidence of infective rise in number of people aged disease. The potential for harm Differing interpretations of endocarditis is concerning and over #$ who have substance through overdiagnosis or wrong best practice in the context that research funding is required. misuse problems (Editorial, diagnosis is inevitable. of limited data are the essence Furthermore, research needs not %& September). This rise The possibility of of the uncertainty that underlies only to clarify the role of antibiotic also applies to people who inappropriate drug advertising

108 21 October 2017 | the bmj direct to patients via Google is and their children’s existential FRAILTY!AND!EXPECTATIONS improved communication by also worrying. Other unintended difficulties is why Hannah’s all staff caring for frail patients consequences may occur, as a character threw adults in the Taking responsibility for and a campaign to inform the result of Google using algorithms show into a panic. unrealistic expectations public about outcomes for this related to previous searches. Marco Scalvini, lecturer , London Oliver mentions relatives’ failure group of people. The limitations and harms of Flandina Rigamonti, psychodynamic to grasp the imminence of death Communication is screening are underappreciated. psychotherapist and counsellor , London in frail elderly patients (Acute the responsibility of all Cite this as: BMJ "#$%;&'(:j)%)& Perhaps all adverts for Perspective, ! September). professionals: medical and screening should come “Edutainment” to We as a profession are mainly non-medical, in primary and with disclaimers explaining reduce the risk of suicide responsible through having secondary care. Too often we whether they meet Wilson and overplayed what can be achieved look to each other rather than Jungner’s criteria for an effective Arendt et al argue for medically. We also need to act. screening programme. strengthening guidance on accept responsibility for our A publicity campaign is Avril Danczak, GP , Manchester suicide and the media (Editorial, contribution to the increasing needed to ensure that the Cite this as: BMJ "#$%;&'(:j)%&- ! September). In addition to these frailty and sometimes distress information we know as policy efforts, health promotion after our heroic efforts in treating professionals about outlook SUICIDE!ON!TELEVISION can use the media as a powerful interim disorders. becomes known by all of Why we must defend tool to reduce suicide. society so that decision making suicide in fiction One of us (TU) has produced is informed and smoother. Think You Can Shrink? —a Andrew Thorns, consultant in Arendt et al suggest that !" reality TV style web series. The palliative medicine, Canterbury Reasons Why violates guidelines design strategically leveraged Cite this as: BMJ "#$%;&'(:j)%-# on portraying suicide in the media entertainment and the power “Progressive dwindling” (Editorial, ! September). of media to encourage viewers and end of life care However, viewers are not to seek help for mental health called to sympathise for problems in the hope of improved Oliver uses the term progressive Hannah, the teenager at health outcomes for men. Actors dwindling to describe the the heart of the drama, but portray suicidal depression and progressive and accelerating Frank discussions are needed on the instead invited to reflect on the other mental health problems. Lay resuscitation status of elderly people functional decline that may problems of teenagers in the age people who think they are good occur at the end of life in very of social media. at giving advice are contestants. Frail elderly people should old people (Acute Perspective, Rather than sanitise fiction Viewers learn about depression, not be admitted to care or ! September). Others have that tackles suicide and opens suicidal ideation, and how to nursing homes without fairly referred to this process as a dialogue with those most in communicate with others to frank discussions about terminal decline or terminal need, we should use its stories to encourage them to get help. resuscitation status. Dying drop. demand the government invest Our proof of concept study should be discussed with the Empirical evidence of more in mental health services for showed the “edutainment” patient and family on discharge terminal decline has been young people and on information design works, with viewers being when prognosis is poor and reported for cognitive and counselling about self harm more likely to seek help or know future admission probable, functioning and subjective and suicide in schools. what to say to someone who is particularly for those coming health measures. Using Parents, educators, and suicidal after watching. towards the end of life. It is a electronic health records in therapists cannot delegate their Thomas Ungar, associate professor , charitable way of pre-empting people aged 2$ years and over role to screenwriters or producers. Toronto inappropriate treatment by the we found a substantial terminal Stephanie Knaak, assistant professor , decline in blood pressure in the They need to talk to children and Calgary next medical team. young people openly, not censor Cameron Norman, principal and When death has been final two years of life that was what they read or view. Perhaps president , Toronto distressing because families have not observed in patients who the failure to confront their own Cite this as: BMJ "#$%;&'(:j)%)" pushed for unrealistic care they did not die. need to be told about the part Distinguishing changes they played if we are to change in health due to aging from behaviour long term. those due to dying is difficult. Simon Kenwright, retired physician , Researchers and clinicians Stowting should aim to determine Cite this as: BMJ "#$%;&'(:j)%-+ whether these processes Wanted: communication are distinguishable to improve end of life care for and a public campaign older people. Overexpectation in frailty by Rathi Ravindrarajah, research relatives and patients (Acute associate , London Martin Gulliford, professor of public Perspective, ! September) can health , London Mental health groups criticised the TV series 13 Reasons Why be tackled only by two actions: Cite this as: BMJ "#$%;&'(:j)%%" the bmj | 21 October 2017 109 ANALYSIS P roviding support and opportunities for physical activity can help older adults maintain independence and lessen the costly burden of social care, argue Scarlett McNally and colleagues

ocial care has received substantial media coverage in recent months. There is now acknowledgment of S the direct link between the parlous state of the NHS and the social care crisis. ! Most social and political commentators focus on cuts in public funding of social care, shortages of sta" , the increasingly fragile # nancial state of care home providers, and knock-on consequences for the NHS. The blame is usually placed on the rising numbers of older people, as if the requirement for social care was an unavoidable consequence of ageing. Thankfully, the need for social care is not inevitable. The UK National Institute for Health and Regular! physical exercise# Care Excellence made it clear in $%!& that “disability, dementia and frailty $ the ‘miracle cure’ to ageing can be prevented or delayed.” This remarkable statement received little publicity at the time. ages to be active. Concerted action by diabetes, dementia, heart disease, and A person’s need for care and national and local organisations is also recurrence of some cancers. * - 0 support, whether provided by unpaid required to provide infrastructure and Many high pro# le examples exist of family carers or professional carers options, especially for those who need healthy older people, but we usually paid for personally or by the local most help. assume that is this is down to luck. authority, arises when someone is no The sometimes drastic loss of ability There are massive social inequalities longer able to manage vital activities that many older people experience in length of healthy life,1 with better of daily living such as washing, is not an inevitable part of ageing. nutrition and more exercise being two dressing, and feeding themselves. Ageing is a normal biological process important causes. * A healthy old age is For illustration, for some people, the that leads to a decline in vision, more likely to result from experiencing ability to get to the toilet in time is hearing, skin elasticity, immune lower risks of preventable disease or a threshold marking the di" erence function, and resilience—the ability frailty than from luck. between having carers visit twice a to bounce back.+ The common decline day and requiring live-in or residential in # tness that occurs with age is Effect of disease care. The cost of care increases di" erent, starting around (% years The older the age group studied, the # vefold as this threshold is crossed. ( of age and accelerating more rapidly more disease is found, but this is not a A residential care placement costs an a/ er age +&. & This decline in # tness is consequence of ageing in itself—many average of )($ *%% a year ( and may be made worse if a person moves into a diseases are caused by environment required for months, years, or decades. “dangerous” occupation—that is, one and lifestyle. Forty per cent of people Ensuring that as many people that involves sitting. The car, the desk aged +% have a long term condition, as possible maintain the ability to job, and the internet have transformed and the prevalence goes up !%% each manage vital activities of daily living work. A sedentary lifestyle is one decade, with an increasing proportion requires a cultural change so that it of the top four causes of ill health of people having multiple diseases!% !! becomes normal to expect people of all in the UK, contributing to type $ as the e" ects of environmental and

110 21 October 2017 | the bmj KEY MESSAGES • Regular exercise can help older people increase ! tness levels to that of a person #$ years younger • Fitness loss increases the risk of needing social care • People should try to stay ! t enough to be able to get to the toilet in time% Crossing this threshold increases social care costs ! vefold • Environments and expectations need to change to make exercise possible for middle aged and older people& including open spaces and facilities for active travel

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IN PICTURESIN LTD/CORBISW/GETTY IMAGES a decade” (based on data from Cooper et al) behavioural risk factors accumulate. The attitude conditions you have the more you need improvements in older people’s Small changes in habits—for example, that exercise to improve the four aspects of # tness: “up and go” times when exercise cycling to work, can reduce the e" ect is for the strength, stamina, suppleness, and ranging from low to moderate aerobic of sedentary behaviour.!$ young while skill. Strength and balance training (walking) to high intensity progressive Fitness o/ en worsens with the onset older people reduce the risk of falls. !+ Furthermore, resistance training was started as an of disease because of an indirect social should be evidence is growing that recovery intervention; there was a clear dose impact. For example, caring relatives of these four attributes of # tness e" ect, and those who were the most encouraged to !1 and professionals, who are o/ en risk relax needs to improves cognitive ability and reduces frail bene# ted the most. averse, may do things for the person the risk of dementia, not only in The prevailing attitude that exercise rather than encouraging them to do be challenged midlife but also in the 4%s and 0%s. !& !* is for the young while older people things for themselves. The physical, mental, and social should be encouraged to relax needs Genetics are relatively unimportant bene# ts of exercise can help enable to be challenged. Physical activity is in determining modern diseases; less people to live more independently and de# ned as any movement produced by than $%% of the risk is genetic, on more autonomously. + skeletal muscles that results in energy average across a range of diseases.!( The good news is that at any age expenditure, including gardening The need for social care is determined and with any combination of health and walking. $% Exercise is a subset more by a loss of # tness than directly problems, exercise provides, in the of physical activity that is planned, by disease and multiple morbidity. words of an important report from the structured, and repetitive. $% Academy of Medical Royal Colleges, A person’s physical # tness can be Keeping fit “the miracle cure.”* Exercise may measured and includes attributes The e" ects of ageing and of loss of reverse the decline and keep a person that are health related (eg, cardiac # tness are commonly confused. above the threshold for needing endurance) or skill related (eg, The loss of ability that results from increased care. strength). $% The UK chief medical inactivity may lead to a person People in their 4%s with below o7 cer’s guidelines recommend !&% requiring social care. average ability (measured as “chair minutes a week of moderate physical People with long term conditions rise” time) who improve this by activity plus twice weekly strength and those who experience pain o/ en $&%, to the average speed of those in and balance training for adults of all mistakenly believe that exercise their *%s, experience a reversal of a ages.4 Any physical activity for at least will make things worse, rather decade of decline (# gure).!0 A recent !% minutes that gets someone slightly than understanding that the more meta-analysis showed signi# cant out of breath contributes to the !&% the bmj | 21 October 2017 111 minute weekly minimum target and misconceptions about how to reverse as well as strength and balance there is a dose-response e" ect.& - 0 The declines in ability and # tness* !1 and training to increase muscle strength Japanese Orthopaedic Association not realise the scale of improvement and “get up and go” times. recommends regular !% minute bursts possible.* - $4 They should advise all Need is a function of service of brisk walking and sets of squats to patients, including those with long organisation as well as ability; if too prevent “the locomotor syndrome” term conditions, to start an activity and much is invested in polypharmacy and in older people caused by inactivity build up frequency, intensity, or time * ; passive care, activity and rehabilitation and contributing to a “heightened practical details can help maintain services may be overlooked. risk of care dependency.” $! The World exercise—for example, exercise For people who fear reduced Health Organization’s analysis of prescriptions, follow-up, knowledge independence, the solution is not to interventions that work for older adults of local opportunities, and advising hope for a quick exit from this world include “physical activity interventions people to share their goals and activity but to do enough activity every day and in a group setting using an existing sessions with family and friends.* - $4 with every diagnosis. The attitudes of social structure or meeting place.”$$ health and care professionals need to Local environment and policy change too. Functional decline and the Support a positive approach Structural changes are necessary in need for social care are not inevitable One major change needed is to the built environment to encourage consequences of ageing. A quarter of challenge and reset the beliefs about people, especially older adults, women and $%% of men in the UK what happens to us as we grow older, to become and remain active. report doing no activity at all in a week, to know that it is possible to combat Environments that are “walkable” let alone the recommended minimum some e" ects not by a drug or potion or and places that promote active travel Scarlett McNally, !&% minutes to maintain health. 0 consultant elixir of life but by increasing activity— have been shown to increase rates orthopaedic surgeon , physical, mental, and social. + !* of physical activity. Practicalities Reducing costs Eastbourne District Encouraging research suggests include even pavements, open spaces, General Hospital Local authorities spend )0.0bn a year (% (! the key to reducing the incidence of tables and seating in public places, scarlett.mcnally@ on care for the over *&s in England, dementia is unlikely to be a new drug safe cycle lanes, and restrictions on nhs.net and a further )!%bn is spent on but keeping healthy and feeling well car use. Several frameworks exist to David Nunan, senior formal care services by self funding in the short term—namely, increasing support this in the UK, including work researcher , Centre individuals. (! Furthermore, there are activity, stopping smoking, good on Active Design $0 and Transport for for Evidence-Based # ve million informal carers in the nutrition, and sparing use of alcohol. !& London’s Healthy Streets approach.$1 Medicine, Nuffield UK.* (! If local authority, self funding, Gyms, walking groups, gardening, Department of Primary and informal care is included, the cooking clubs, and volunteering have Reducing social care need Care Health Sciences, total cost of social care is more than all been shown to work in improving People need social care when they are University of Oxford )!%%bn, which is similar to the annual the health and wellbeing of people at unable to perform some activities of Anna Dixon, chief amount the UK spends on the NHS.(% - ($ executive , Centre for all ages with long term conditions. !0 daily living in their environment. The The lifetime costs of care di" er Ageing Better, London Models of social prescribing can be WHO report on ageing di" erentiates massively between individuals. Mahiben Maruthappu, successful.$( two useful concepts: “intrinsic The value to society of even modest health executive , Cera, capacity” as the composite of all the London improvements in # tness could be Healthcare can support activity physical and mental capacities of an several billion pounds a year, since the Kenny Butler, health Health services can aggravate the individual and “functional ability,” and wellbeing lead , mean care needs of a person almost problem and increase the need which includes intrinsic capacity UKactive, London double between age *& and 4&, and !! -($ for social care. People admitted to but additionally how the individual Muir Gray, public triple between age *& and 0&. + hospital o/ en experience a rapid interacts with their environment. health doctor , Oxford We need individuals to understand decline in function. Patients are o/ en Action is needed on both fronts—for University Hospitals their role in cutting social care demand encouraged to stay in bed or in the example, adaptations to environments NHS Trust by being active. National and local chair next to the bed and not to go to organisations must act to encourage the toilet without assistance because opportunities for people to be active, of a fear of falls, which are reported as building this into our environments, adverse incidents for the hospital. transport, and schedules. The gap Arora describes this loss of ability between the best possible level of during acute illness and hospital ability and actual ability can be admission as the “deconditioning reduced at any age, $* no matter how syndrome” $+ ; inpatients spend more many long term conditions the person than 0%% of their time in bed and more may have.!1 The rise in ability may not than *%% reduce their mobility. $& This only restore the person to the ability can be combated by multidisciplinary they enjoyed !% years earlier, it may focus on rehabilitation and make the crucial di" erence between maintaining activity. $+ living well at home or being dependent Care should not be passive. on social or residential care. ADRIANDENNIS/AFP/GETTY IMAGES Health professionals may have Older people taking regular exercise could save the UK billions Cite this as: BMJ #$!%;&'*:j+,$*

112 21 October 2017 | the bmj OBITUARY Ruth!Pfau !DAHW" German nun who settled in Pakistan and led ! ght against leprosy

Ruth Pfau (b !"#"; q University of Marburg, Germany, !"$%), was admitted to hospital after a dizzy spell and died on !& August #&!' GERMANLEPROSY ANDTUBERCULOSIS RELIEF ASSOCIATION In !"#$ Ruth Pfau, a Catholic nun Touched by Early life By !"#0 the centre was treating who was also a gynaecologist and what she saw Ruth Katharina Martha Pfau was born +'$$ patients each month. A building obstetrician, le% Germany to serve in a leprosy on " September !"+" in Leipzig to in the heart of Karachi was donated, in India. But during a stopover in care project, Protestant parents. When she was !- triggering vehement opposition, Pakistan to pick up her visa, her plans she decided Allied planes bombed the city, and her including from some in the medical changed drastically. As she recalled to remain in family’s home was severely damaged. community. Despite the opposition many years later, God intervened, and A% er the war ended, Leipzig became Pfau and her team transformed the Karachi and Pfau remained based in Pakistan for part of East Germany. In !"-/ Pfau * ed building into a modern hospital the rest of her life. Instead of providing devote her life and joined her father in West Germany. named the Marie Adelaide Leprosy gynaecological care and delivering to fighting In !"-" she started studying Centre. Under Pfau’s leadership it babies, she fought leprosy. Through the disease medicine at Mainz University. She was became the centre for ( ghting leprosy, her e& orts more than '$ $$$ patients baptised in !"'0 as an evangelical cooperating with local governments were treated, and in !""# leprosy in Protestant, but later—a% er transferring to set up treatment and control units. Pakistan was declared “under control” to Marburg University—converted to In !"1" Pfau became federal adviser by WHO. She continued to monitor Catholicism. on leprosy to Pakistan’s Ministry of and treat the disease, and also to ( ght Health and Social Welfare, and in !"// tuberculosis and other diseases of Faith she was granted Pakistani citizenship. poverty. As a university student Pfau had She was the author of nearly a dozen boyfriends, one of whom proposed books about her work and her faith. State funeral marriage. Pfau later recalled that she Pakistan’s government honoured had eagerly anticipated the proposal. Ruth Pfau Foundation Pfau with a state funeral and ordered But when it ( nally came, she declined. In !""# Pfau and the DAHW founded the national * ag to * y at half mast. She said she had “received a calling the Ruth Pfau Foundation. In Leipzig Her funeral mass was held at St from God,” adding: “When you receive a secondary public school—focusing Patrick’s Cathedral in Karachi, and such a calling, you cannot turn it on healthcare and social work—was she was laid to rest in the city’s down, for it is not you who has made named a% er her. The list of Pfau’s Christian cemetery. The !"$$ bed the choice. God has chosen you for honours is long and includes Civil Hospital Karachi was renamed Himself.” Pakistan’s highest civilian award, the Dr Ruth K M Pfau Hospital in her Pfau started training in internal Hilal-e-Pakistan. honour. medicine in Cologne and in !"'1 she At the end of May +$!1, Pfau In !"#$ Pfau was a member of joined the order she remained with stopped her professional duties, the Catholic order the Society of for the rest of her life. In !"'" she allowing her to make her eternal Daughters of the Heart of Mary. Nuns completed gynaecology and obstetrics vow to the Society of Daughters of based at the order’s community in training in Bonn and in !"#$ le% the Heart of Mary. Her last message, Karachi took Pfau to visit a leprosy Germany for India—only to change her which was videotaped, concerned the care project they had started four plans in Karachi. state of the world and was made from years earlier. The dispensary had A% er committing to the leprosy her sickbed. “I am still convinced,” no electricity or running water and project, Pfau reorganised the dispensary she said, with some e& ort, “that there was in one of Karachi’s worst slums. in line with modern medicine. In !"#! is only one way out from our current Pfau was touched by the sight of one she travelled to southern India for di5 culties and that is that we learn patient crawling to the dispensary training in the management of leprosy. again to love each other. That is so on his hands and knees through dirt In the same year the project began simple. And so di5 cult.” and slime. She decided to remain in receiving ( nancial support from the Ned Stafford , Hamburg Karachi and devote her life to caring German Leprosy and Tuberculosis [email protected] for and treating people with leprosy. Relief Association (DAHW). Cite this as: BMJ #&!';*$+:j-!&- the bmj | 21 October 2017 113 BMJ.COM HIGHLIGHTS NHSstaffandtheflujab MOST READ ONLINE @tissington . Others failed to Comparison of see what the problem was: postoperative outcomes “I see immunosuppressed among patients treated patients every day of the week— by male and female duty of care to them includes surgeons washing my hands and BMJ !"#$%&'(j)%** having the 1 u jab,” said Lesley @tapisdesouris . Which pain Konrad Kangru @WhitGP , a medications are doctor from Australia, waded effective for sciatica into the debate to o0 er this (radicular leg pain)? perspective from a country BMJ !"#$%&'(j) )+ The BMJ recently reported tactics of a nanny state: “An that’s just coming out of its that, this winter, NHS sta0 who imposed vaccine to go with winter and which reported refuse the 1 u vaccine will have the contract,” said Henry Stam a heavy 1 u season, leading to tell their employer why (see @Stam_EM ; “Doesn’t sit to warnings the UK will too. Most read online), reigniting well that employers bully “Seriously guys? If #In1 uenza the longstanding debate about employees into a treatment,” vax @NHSEngland is o0 ering healthcare workers’ obligation observed Christopher Scott includes our rotten Aus ‘A’ to be vaccinated. @Christopher_CSS ; “I , nd this strain for !"#4 you’d be mad to For some readers on Twitter, rather sinister. Am I right to?” forego it.” Follow the debate on this looked like the intimidation wondered Prof Pat Tissington Twitter @bmj_latest Margaret McCartney: PODCAST Promising miracle diet fixes isn’t fair on Doesasurgeon’s anyone sexaffectpatient BMJ !"#$%&+(j) * NHS staff who refuse flu outcomes? vaccine this winter will have to give reasons A recent study ( BMJ !"#$;%&':j)%**) found as we all know, has traditionally been a male BMJ !"#$%&'(j)#** that patients treated by female surgeons have dominated specialty. There is a real ongoing slightly lower death rates in the , rst few weeks movement for gender equality in this , eld and David Oliver: How much a- er their operation than patients treated by a study such as this . . . can provide real world information should male surgeons. In a linked podcast, two of the data and help to dispel some of the biases and patients’ families authors of that paper discuss their , ndings and myths that exist.” expect on acute wards? put them into context. They say that this is an Listentothepodcastat BMJ !"#$%&'(j) '& important question to study because “surgery, http(//bit,ly/surgeon_sex

FROM THE ARCHIVE Divorceandincurableinsanity Eighty years ago, the Matrimonial years, and few will maintain that for divorce on the that “not every Causes Act €‚ introduced it has not on balance been very ground of insanity may permanently new grounds for divorce, with beneficial. A survey recently . . . be presented by either spouse insane spouse desertion without cause, cruelty, [showed that] the number of cases on the ground that the other is comes within the Act.” The and incurable insanity becoming in which the insanity ground is incurably of unsound mind and article called for the removal legal justifications. This last raised is small—only about a has been continuously under of “these and other incidental reason was regularly covered hundred and fifty a year out of care and treatment for at least defects,” but in € € the Divorce in The BMJ over the following seven thousand. Petitions on the five years immediately before the Reform Act removed the idea of years and in €ƒ„ the journal ground of desertion are much date of the petition.” Yet “‘care having to prove some fault in a published a retrospective more numerous.” and treatment’ is very precisely partner at all, allowing couples to article on this new law (Br Med J However, the article pointed defined,” observes the author, divorce on the grounds that their €ƒ„;„:€„). “The Act has now out that in some respects the law “in terms that sound strange to marriage had irretrievably broken been administered for about four needing amending. “A petition a medical ear,” and which mean down.

114 21 October 2017 | the bmj