How Do We End the Culture of Fear? Little Boy, Jack Adcock, Is Remain a Pipe Dream Until We Create a Dead

comment‘

There must be a better way to investigate deaths. One that examines human factors and systemic problems. ‘That commands confidence and honesty NO HOLDS BARRED Margaret McCartney How do we end the culture of fear? little boy, Jack Adcock, is remain a pipe dream until we create a dead. This is horrendous, culture where human error is seen as and accounts of the normal, inevitable, and as a source of background to the case important learning.” Aclearly show mistakes As Bawa-Garba’s reflective notes and shortcomings that could and were used as evidence against her in should have been avoided. But how? court, such a culture is unlikely any Jack’s treatment included clinical time soon. And the words of Mr Justice mistakes and numerous systemic Ouseley, giving the leading judgment ones, particularly regarding staff on the case in the High Court, are of absence and IT systems. This was particular concern: “There was no the “Swiss cheese” model writ large suggestion, unwelcome and stressful and fatal: the holes in the system aligned and let though the failings around her were, and with the tragedy happen. workload she had, that this was something she had The overwhelming feeling among many doctors not been trained to cope with or was something reading accounts of the case background is, “There wholly out of the ordinary for a year 6 trainee, not but for the grace of God go I.” There’s no suggestion far off consultancy, to have to cope with, without that Hadiza Bawa-Garba was doing anything except making such serious errors.” This seems to imply working hard in different circumstances. that doctors can be trained to have limitless Will striking her off the medical register ensure that capabilities. None of us can be. a death like Jack’s can’t happen again? I don’t believe There must be a better way to investigate deaths— so. Professional regulation and accountability one that examines human factors and systemic are vital. So, too, is patient safety. But the way we problems, which insists on evidence based change administer the two are often at odds. and can also command the confidence of bereaved The regulation of doctors is an adversarial families, as well as honesty from the medical system that seeks to deliver blame and sanctions profession. to individuals. Blame and sanctions clearly have A culture of fear is looming, but it needn’t be this their place. But it’s taken a long time for us to way. Doctors, patients, and families should be able regard human factors as the problem in many to work together to make systems safer. We need to medical errors and safer systems as the solution— move forwards, but this judgment risks taking us as well as outstanding efforts by people such as far back. Martin Bromiley, who founded the Clinical Human Margaret McCartney, general practitioner, Glasgow Factors Group, a charitable trust that promotes [email protected] best practice around human factors. As the group Follow Margaret on Twitter: @mgtmccartney says, “A safer, more reliable and efficient NHS will Cite this as: BMJ 2018;360:k443

the bmj | 3 February 2018 191 PERSONAL VIEW Helgi Johannsson and William Rook Avoiding blame and liability is vital to creating a safer NHS Medical law needs to be urgently reformed to allow doctors to reflect and to maximise learning from every mistake that is made

ritish medicine has seen Written fatigue, and inadequate supervision much progress in the reflections are common contributory factors. development of an open can act as a and honest safety culture. sacrament of Overstretched system We report and investigate penance—an The death of Jack Adcock, for which Bincidents; develop action plans to Hadiza Bawa-Garba was convicted prevent repetition; and spread learning open, honest of gross negligence manslaughter, wider by discussion with colleagues, reflection in a is a tragedy. He received poor care not only within the hospital but at place of safety from Bawa-Garba. He also received conferences, in medical literature, poor care from an overstretched and even on social media. We include system that meant that Bawa-Garba our patients in this process—we are was covering for several colleagues, open with them, not only about what including the consultant in charge of happened, but also what we are doing the unit. She had to work in difficult to prevent it happening again. circumstances, with an IT failure Doctors are human and make and a junior team. There are enough mistakes. Preventing errors is at contributory factors to make any the forefront of our practice and doctor shudder and be thankful that reflecting on our mistakes makes it didn’t happen on their watch. us better doctors. When a mistake Medical training is rigorous and happens it is almost never because taxing—it attracts high performing of one person and there are always people who are constantly trying to circumstances that contribute to the do better and to learn. When we make error. Short staffing, high workload, mistakes, the pain of those mistakes

ACUTE PERSPECTIVE David Oliver Should NHS doctors work in unsafe conditions? The case of Hadiza Bawa-Garba As is now well documented, Garba’s erasure, this case has far highlights a very specific issue with on the day that Jack Adcock died, reaching implications for an open no useful answer as yet. Bawa-Garba had just returned from reporting and learning culture. Where In 2016 the GMC made it clear in maternity leave and was working does this leave us? public advice that, if doctors believed in an unfamiliar unit, with an Commentaries on common law have that their workload, staffing, or off-site consultant. She was also suggested that system factors won’t supervision was unsafe, they had a covering staffing shortages, battling protect individuals from negligence professional obligation to report this IT systems, and supervising junior claims. The judgment in Bawa-Garba’s up the line and to have a clear paper However doctors new to paediatrics. appeal against her conviction and the trail of the concerns they had flagged. broken the The court decided, nonetheless, subsequent High Court ruling show But the GMC stopped short of system, that she (not her hospital or the wider that, however broken the system telling doctors to down tools if those doctors still NHS) was personally and criminally around doctors, they still risk being conditions put their patients’ or risk being held culpable. This led, after the GMC’s held personally culpable for failings. their own health at risk. The new personally decision to take its own Medical When Charlie Massey, GMC chief junior doctors’ contract, meanwhile, culpable for Practitioners Tribunal Service to executive, was confronted on the contains a clause that in “occasional failings the High Court, to Bawa-Garba Radio 4 Today programme about emergencies and exceptional (who had a previously unblemished whether doctors should refuse to circumstances” they may be asked record) being struck off the register. work in unsafe conditions, he evaded and expected to take on additional Whatever the rights and wrongs of the question. He spoke instead about duties and responsibilities. the criminal conviction and Bawa- their duty to flag any staffing and

192 3 February 2018 | the bmj can be unbearable. We search our Branch became operational last BMJ OPINION Richard Smith souls, blame ourselves, feel an year and its core mission is “to enormous sense of guilt. We talk to improve safety through effective and The continuing corruption colleagues as a form of counselling, independent investigations that don’t we reflect on what happened. Written apportion blame or liability.” of medical language reflections show our supervisors A doctor friend sends me a link and directors that we have learnt Conditions of work to a piece he has written for the from an incident, and also help us This is vital to learning from errors Guardian. I praise the simplicity come to terms with what happened. and creating a safer NHS, yet the law and clarity of the language and To a doctor, this process can act as and the GMC only look at a person’s suggest that, next time he sends a a sacrament of penance—an open, actions and do not take account of the piece to an academic journal, he honest reflection in a place of safety. conditions that person was practising uses the same language. “But will in. We feel that medical law has not the editors accept it?” he asks me. A step backwards undergone the same transformation I’d like to think that they’d prefer Bawa-Garba did exactly as the GMC as medical practice has regarding it, but I fear that his anxiety may be asks and reflected honestly on her liability and error. The law requires right. Why on earth should that be? performance. These reflections, urgent reform to prevent practitioners Almost everything, I believe, can be expressed in provided as evidence of learning from taking the full blame for system errors language that everybody can understand, and authors a critical incident, were then used and to allow us to maximise learning often use complex language because they don’t fully against her as proof of poor practice. from each incident. understand what they are trying to say. “Good prose,” This is concerning, and a step The death of Jack Adcock is a said George Orwell, “is like a window pane”: you see backwards for safety. Should doctors tragedy, but the way the investigation straight through it to what the author is trying to say. be fearful their reflections might be concentrated on individual failure, I accept that if writing for a technical audience then it used against them? Some may choose and used written reflections as makes sense to use their language. Doctors will know to make their writing vague to the evidence to strike Bawa-Garba off the what you mean by “glomerulonephritis,” and it wouldn’t point of being non-identifiable, or medical register, risks more lives by make sense when writing for doctors to explain what simply provide a note, confirmed by endangering the open, honest safety it is, especially as some doctors will have a whole a supervisor, that a reflective activity culture that is emerging in the UK. mountain of information about glomerulonephritis. But has taken place. This would inhibit there aren’t ideas in that mountain that could not be Helgi Johannsson, consultant anaesthetist, explained in simple language if the learning from other people's mistakes clinical director, Imperial College Healthcare Worst of that publicity and discussion allows. NHS Trust author wanted to. Too often, I suggest, academic all are The health secretary Jeremy Hunt’s William Rook, core trainee year 2, acute journals are filled with complex academics statement of concern after the ruling care common stem, anaesthesia, University language because authors are too who want is a welcome sign of support. The Hospitals Leicester NHS Trust lazy or too incompetent to write their writing Healthcare Safety Investigation Cite this as: BMJ 2018;360:k447 clearly or, worst of all, because to seem they want to make their writing grander ACUTE PERSPECTIVE David Oliver seem grander and more important. Michael O’Donnell, one of medicine’s best writers, Should NHS doctors work in unsafe conditions? workload problems and to document a If the GMC’s guidance is followed called this style of academic writing “decorated clear paper trail. Massey said that the we risk creating a vicious circle of municipal gothic.” Such writing, he said, “must be long, GMC’s High Court case was all about endless reports on unsafe staffing, tortuous, opaque, uninteresting, and possess a ‘built-in establishing a legal precedent that the consuming the time of doctors and quality of unreadability.’” Its main purpose, he argued, tribunal service couldn’t “go behind a managers, when the only solution was not to inform the reader but to ennoble the writer. criminal conviction” (although many is usually to put further pressure on O’Donnell identified two causes of “decorated doctors with criminal convictions existing staff to take on more duties municipal gothic.” One is that academic writers are not have remained registered). He played to cover gaps. It also leaves doctors concerned with readers but rather with extending their down any risks to the vast majority with a classic “rock and a hard list of publications. Real writing is about condensation of doctors, stating that striking off place” dilemma: refuse to work or of ideas, whereas academics often try to get as many and gross negligence manslaughter to cover extra shifts, to minimise the words as possible from a small amount of information. convictions were vanishingly rare. personal risk of legal sanction and The second cause, relevant to my friend, is that they On the same day, the GMC’s director breach of contract—or do the right believe there is “a norm out there to which they must for education and standards published thing for patients, colleagues, and conform.” They read the turgid prose in journals and a “Responding to your concerns” blog employers and risk a “there but for think that is the way they must write to be published. The best writing on writing that I know is Orwell’s reiterating the need for doctors to the grace of God” fate, like that of “Politics and the English Language.” His central highlight workload and staffing issues, Bawa-Garba? argument is that politics corrupts language. Good as well as risks to patient care or their David Oliver, consultant in geriatrics and acute writing is clear and simple, but politicians are usually own wellbeing. But it too ducked the general medicine, Berkshire concerned with making grand statements that have no big question of whether they should [email protected] substance because substance is commitment. refuse to work: they should apparently Follow David on Twitter: @mancunianmedic Richard Smith was editor of The BMJ until 2004 use their own judgment. Cite this as: BMJ 2018;360:k448

the bmj | 3 February 2018 193 When scientists refer to “insufficient HEAD TO HEAD evidence” they may naively help yes opponents of policy change Should action

Simon Capewell, professor , Public Health and and public health advocates; recruiting take priority Policy, Institute of Psychology Health and Society, stooges; substituting weak policies; and University of Liverpool [email protected] heaping cash on politicians. over more Paul Cairney, professor , University of Stirling Without strong public health advocacy, these tactics can be profoundly e ective. For Centuries of public health improvements example, tobacco use globally contributes to research on re ect actions not excuses. There are important more than six million premature deaths a year. reasons to act now, not wait for perfect evidence. However, the experience of tobacco policy public health? We know what causes most avoidable disease suggests that industry denial tactics can de ect and deaths: poverty, poor diet, tobacco, and e ective regulation and thus allow decades We have evidence on which to alcohol. And we know which evidence based of delay between the identi cation of solid act, and inaction costs lives, argue interventions work, so to wait for more evidence evidence and a proportionate policy response. is ethically unacceptable. Policy makers and We can learn useful lessons from previous Simon Capewell and Paul Cairney . clinicians need to act now, on a “balance of public health triumphs. All were predicated But Aileen Clarke says that our probabilities,” not wait for a mythical evidence on action, not excuses to await more evidence. understanding of behaviour leading “magic bullet” to remove all doubt. Consider a century of successes, including safe drinking water, sanitation, immunisation, to unhealthy choices is still lacking Politics, evidence, and ambiguity road safety, tobacco control, and pollution A focus on “insu cient evidence” o en regulation. Each was built on a foundation betrays a simplistic view of policy making, that of scienti c research. However, that evidence evidence is used merely to reduce uncertainty. was but the rst step on the SUPPORT pathway Politics is actually about using evidence to of cumulative policy change. SUPPORT reduce ambiguity. Evidence is important, but stands for: scienti c evidence emerges; policy change requires a powerful story and understanding spreads; professionals accept the ability to exploit windows of opportunity. the model; public and politicians become E ective political actors use evidence to draw aware and then supportive; opposition from attention to urgent problems, encourage vested interests is slowly overcome; regulation policy makers to understand them primarily is introduced; taxation is o en used to as epidemics, and create demand for evidence reinforce regulations. based solutions—for example, the recent smoke-free legislation and sugary drinks levy. Over-riding ethical duty A delayed response to evidence can be Does responsibility for tackling known damaging. For example, a cumulative meta- causes of preventable disease lie mainly with analysis published in provided ample individuals? No. We therefore suggest that our evidence that thrombolysis reduced deaths over-riding ethical duty is to use evidence to from heart attack by about %. However, maximise current and future health for our failure to consider this substantial evidence, communities. Health professionals must also compounded by medical conservatism, meant ensure that evidence based interventions are that thrombolysis was not widely used for piloted and evaluated before widespread use, two decades. Many patients were thus denied closely monitor their implementation and e ective treatment, likely resulting in about outcomes, and modify as necessary. avoidable deaths in the US. Systematic We have a duty of care to accelerate policy reviews alone may not be su cient to change reform through advocacy, not wait naively for practice; evidence based guidelines need to be the evidence to “speak for itself.” The prize is a developed and, crucially, implemented. regulatory framework that promotes a healthy When scientists refer to “insu cient environment and supports healthy behaviour. evidence” they may naively help opponents These urgent rules of evidence in action are of policy change. Corporations producing very di erent to the “wait and see” rules of harmful commodities such as tobacco, endless evidence production. alcohol, junk food, or sugary drinks routinely The huge burden of avoidable disease oppose regulation or taxation as they reduce is a scandal. “Insu cient evidence” is an pro ts. These merchants of doubt use MARSH excuse for dither and deaths. We have enough “denialism” tactics . MARSH stands for evidence; what we need is more action from misinformation; attack of evidence, scientists, policy makers, managers, and clinicians.

194 3 February 2018 | the bmj Why do the couch, the television, and the car sometimes appeal more than the no park, the gym, and the bicycle? Aileen Clarke, professor of public health and health at age - years arrive at school already services research , Warwick Medical School obese. Why do the couch, the television, and [email protected] the car sometimes appeal more than the park, the gym, and the bicycle? Proponents for action are clear about the For our future health and wellbeing, changes needed to improve public health: we we desperately need research to help us need to eat less, consume less sugar, and take understand our behaviour better. We know more exercise. The e ects of obesity, poor diet, precisely how much salt leads to what increase lack of physical activity, and overconsumption in blood pressure, with what cardiovascular of alcohol and zzy sugary drinks are plain, risk, but we still don’t really know why our they say. The research needed to improve taste for salt, sugar, and fat is so persistent. public health is done and dusted, and all we need to do is get on with things. Yet a central A new approach to research question remains. If the causes of ill health are Last year Public Health England reported that clear and all that is required is for us to take despite widespread publicity on the bene ts action, why hasn’t this happened? of exercise, six million adults in England Research shapes our understanding of health do not take even a single minute walk a and wellbeing. Research informs policy, and month. More worryingly, the increase in life policy interprets and informs research. Research expectancy in the UK has slowed, and women is key to understanding how individuals and are now spending more years in poor health. organisations, governments, and industries We need a new approach to research to improve behave. Research is vital to interpret the likely public health, a personal and social approach e ects of changes in our attitudes, cultures, and that does not just log declines in population societies, as well as in our politics, economics, indicators but which considers us as individuals and ultimately in our health and wellbeing. who make choices within our social contexts. Research needs to acknowledge “social, Understanding healthier choices economic, cultural and political factors.” Clearly, there is still research to do. How do Such “socially robust knowledge” gets under we continue to improve the health generating our skin, helping us to understand how environment so that people can make the we tick. Scienti c knowledge needs to be best choices to become healthier? And more produced that can speak to us as ordinary research is needed to understand how a person people. Researchers, for example, describe can make long term choices to sustain and refocusing research about preventing alcohol improve health, through his or her life. misuse from the aetiological to the practical. Public health research has tended to focus Understanding “social practices” and on the epidemiology and causes of diseases “settings and contexts” are key, they argue. such as heart disease, cancer, and stroke. However, behaviour change sciences are But insu cient attention has been paid to still young and relatively underfunded. In interventions that target the underlying causes its report on behaviour change, the House of reduced wellbeing and disability. We know of Lords science and technology select so much about the distribution and causes committee concluded that much is understood of obesity and diabetes, for example, but not about human behaviour but there is “relatively enough about what to do about them . little evidence on how to change the behaviour We know that a waist circumference of populations.” greater than cm for men and cm for Clearly we need more research in public women should prompt action, because health. Research is needed now to interpret of altered blood glucose metabolism and current knowledge and to develop socially subsequent diabetes. However, we do not robust and practical ways to change and yet have a reliable mechanism (apart from sustain our individual behaviour, to improve expensive surgery) to help people maintain our individual health, and thus to improve and limit their weight that really works on a the public health of our patients, families, long term basis. and communities. Meanwhile, % of US adults have Cite this as: BMJ ;:k prediabetes and % of older US adults have Listen to the authors debate the issue diabetes. And just under % of UK children in the podcast on bmjcom the bmj | 3 February 2018 195 Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

OBITUARIES

Achyutananda Sinha Geoffrey Vivian Feldman Vincent John Kielty Professor and consultant Consultant paediatrician General practitioner in ear, nose, and throat Manchester (b 1920; (b 1954; q London 1977; medicine (b 1927; q Manchester 1944; FRCS), died from cancer q Patna, India, 1949; DCH Eng; FRCP Ed, on 22 December 2017 MS, FRCS Eng), died FRCPCH), died from Vincent John Kielty was from heart failure on pneumonia on 31 the son of a general 29 December 2017 December 2017 practitioner. His main Achyutananda Sinha Geoffrey Vivian interests included worked in the UK between 1953 and 1956, Feldman was house physician at medicine and flying. He chose medicine as before spending a year in the US. In 1957 he Manchester Royal Infirmary and then his career, and after working as a surgeon, returned to India. He created a separate ear, served in the Royal Army Medical he went into general practice. His interest nose, and throat medicine department at Corps. He was subsequently appointed in flying never waned, and he held a private the All India Institute of Medical Sciences in supernumerary medical registrar at Royal pilot’s licence for some years while having New Delhi in 1959. He published extensively Manchester Children’s Hospital and later part ownership of a plane. In 2002 Vincent and was a revered teacher, past president of became lecturer in child health at the retired from general practice and gained the Indian Association of Otolaryngologists, University of Manchester. His last position his diploma in occupational medicine, and surgeon to the president of India. He was consultant paediatrician at the specialising in aviation medicine. In 2007 served as principal of Patna Medical College University of South Manchester Hospital he started his company, Examinair, and he and was director of health services in Bihar. and Wythenshawe Hospital. Feldman retired in 2016. He bought a motorhome, and He regularly visited the UK for meetings and was a member of the British Paediatric he and his wife, Sandra, took many trips in it conferences. He was married to Indu for 53 Association and Manchester Medical across the UK, with plans to take it abroad. years. For the last seven years he lived with his Society. Predeceased by his wife, Anne, he Unfortunately, this was not to be as Vincent sons in the UK. He leaves four children, seven died in Macclesfield Hospital and leaves was diagnosed with cancer in 2016. He leaves grandchildren, and 10 great grandchildren. his family. Sandra, and a son. Ajay Sinha, Arun Sinha, Ashok Sinha Lawrence Clark Gemma Bright Cite this as: BMJ 2018;360:k109 Cite this as: BMJ 2018;360:k228 Cite this as: BMJ 2018;360:k230 Moorthy Bagavatheswaran Peter Dennis Sprackling Sylvio Tamin Defence consultant General practitioner and Occupational physician adviser in paediatrics to Trent regional adviser in (b 1959; q Manchester the UK surgeon general general practice (b 1933; 1983; MFOM), died (b 1947; q Trivandrum, q Middlesex Hospital from a stroke on 28 Kerala, India, 1971; FRCP, Medical School, London, September 2017 FRCPCH), died from a 1958; FRCGP), died from Sylvio Tamin came to cerebral tumour on cerebrovascular disease Manchester from his 30 December 2017 on 5 September 2017 native Mauritius in On moving to the UK from his native Peter Dennis Sprackling was appointed 1978 to study medicine. He did his house India, Moorthy Bagavatheswaran began as part time lecturer in general practice jobs in Burnley and successfully applied for his lifelong affiliation with the UK Armed when the University of Nottingham Medical urology and subsequently the anaesthetic Forces and became the last of a regular School was founded in the early 1970s. rotation. Unsure of his career intentions, he cadre of paediatricians to serve in the He served on the local medical committee did numerous jobs, including conducting British Army. He worked at the Ministry and area and regional committees. In 1977 drug trials for Medeval, working as a locum of Defence Hospital Unit at Frimley Park he took up a formal role in postgraduate general practitioner and salaried partner at Hospital, Surrey, until retiring in 2012. As education as associate regional adviser in Partington Health Centre, and doing sessions well as providing a peripatetic service to general practice, helping to establish the as an examining medical practitioner for children whose parents were stationed in Nottingham vocational training scheme. He Atos before finally finding his true vocation Brunei, Cyprus, Germany, Gibraltar, Nepal, was active in the Trent faculty of the Royal in occupational medicine. He was working as and Kenya, he was the lead paediatric College of General Practitioners and was its an occupational doctor for Salford University cardiologist for Frimley Park. Moorthy was provost from 1991 to 1994. He retired as and Pennine Acute Hospitals NHS Trust when a keen sportsman and played hockey and regional adviser in 1993 and continued to in 2013 he was struck down by a devastating tennis to a high standard, and golf in later work half time in the practice until taking stroke. His wife, Jacqueline, cared for him at life. He was an examiner for the Royal College full retirement at 65. Peter leaves his widow; home for four years before he had a second of Paediatrics and Child Health from 2001. two children from his first marriage; two stroke, from which he never recovered. Sylvio Moorthy leaves his wife, Shobha. grandchildren; and his stepfamily. leaves Jacqueline and two daughters. David Ross John Temple Roger Ma-Fat Cite this as: BMJ 2018;360:k126 Cite this as: BMJ 2018;360:k129 Cite this as: BMJ 2018;360:k106

196 3 February 2018 | the bmj Pacheco Fernando spent 15 wonderful “Ferdie” years Pacheco basking in fame and Ringside physician for glory as Ali’s boxer Muhammad Ali ringside physician Fernando “Ferdie” Pacheco (b 1927; q University of Miami, Florida, USA, 1958), died after a prolonged illness on 16 November after a series of strokes

In 2002 Ferdie Pacheco met up with In 1977, a few months before As a member of Dundee’s corner an old friend, the legendary boxer his 36th birthday, Ali fought Ernie team, Pacheco worked the fights Muhammad Ali. Pacheco spent 15 Shavers, one of the hardest punchers around the globe of nearly a dozen wonderful years basking in fame and in boxing history. It was yet another world champion boxers and glory as Ali’s ringside physician until brutal fight of 15 rounds. Ali won in eventually became known as the their controversial—but amiable— a unanimous decision, but received “Fight Doctor.” But Pacheco’s service split in 1977. Pacheco had once said numerous thunderous punches from as corner man came to an end in that the young, 1.90 m tall, lightning Shavers. Pacheco had seen a medical 1977, when he left Ali’s camp. quick Ali had “the most perfect body report from another doctor, showing After the split, Pacheco used his long I’ve ever seen.” that Ali’s kidneys were no longer association with Ali as a springboard properly filtering blood, allowing for a lucrative career as a boxing analyst “You was right” blood into his urine. “So I went back for top TV networks, including Spanish But by 2002 those days were long to my office, sat down, and wrote language Univision. He retired from gone. Ali, 60 years old at the time, was Ali a letter saying his kidneys were his Miami medical practice in 1980. displaying the effects of Parkinson’s falling apart.” Pacheco was a highly accomplished disease. His once magnificent body Pacheco included a copy of the painter and an aficionado of was trembling. He could speak and kidney report in the letter and also history. He was also a prolific writer, walk only with great difficulty. As Ali sent duplicate letters by registered publishing nearly 20 books, many of and Pacheco embraced, the former mail to Ali’s manager; his long time them—not surprisingly—on boxing. boxer, in slurred speech, admitted to trainer, Angelo Dundee; and his wife. After Ali and Pacheco split, the his former doctor: “You was right.” “And I didn’t get an answer from any boxer subjected himself to four more Ali was referring to Pacheco’s of them,” Pacheco said. “Not one fights, three of which he lost. In pleas late in the boxer’s career that response. That’s when I decided December 1981—only weeks before he retire, pleas that Ali had ignored. enough is enough.” his 40th birthday—Ali fought for the Pacheco had become concerned that Pacheco left Ali’s camp. last time. He lost the fight, a pathetic Ali—over the age of 30 and past his effort that broke the hearts of millions prime—was showing signs of kidney Life and career around the world who loved him. damage and early symptoms of brain Fernando Pacheco was born on Three years later he was diagnosed damage. Pacheco later said that Ali 8 December 1927 in Tampa, Florida, with Parkinson’s disease. possibly could have avoided some with, as he described it, “deep The two men remained on of the health problems that later ancestral roots in Spain.” He decided friendly terms after the split, seeing plagued him had he retired after the he wanted to be a doctor while each other occasionally over the “Thrilla in Manila” spectacle in the working at his father’s pharmacy years. More than a decade after the Philippines in 1975. The brutal battle when he was a teenager. split, Pacheco said of Ali: “When of 15 rounds against Joe Frazier is As a young doctor he attended I see him at fights now, there’s no believed by many to be the greatest boxing matches in nearby Miami grudge. He says, ‘Doc, I made you boxing match ever. Beach. He met boxing promoter Chris famous.’ And I say, ‘Muhammad, Ali won, but his victory came at a Dundee, who asked Pacheco if he you’re absolutely right.’” heavy price. Pacheco was growing would treat his young boxers. Pacheco Pacheco leaves Luisita Sevilla, his concerned about the punishment agreed and subsequently met Chris’s wife of 47 years; their daughter; a son that Ali’s body was absorbing and younger brother, Angelo Dundee, and two daughters from a previous thought Ali should have quit at the the future trainer of Muhammad Ali. marriage that ended in divorce; and top. But Ali—encouraged by his huge Angelo liked Pacheco and named him two grandchildren. entourage and lured by millions as part of his three man corner team, Ned Stafford, Hamburg, Germany in prize money plus his love of the not only for Ali but also for his large [email protected] spotlight—kept on fighting. pool of other boxers. Cite this as: BMJ 2018;360:k117 the bmj | 3 February 2018 197 LETTERS Selected from rapid responses on bmj.com See www.bmj.com/rapid-responses

MENOPAUSAL SYMPTOMS £11 is saved on health costs LETTER OF THE WEEK Hair loss and the menopause alone. Improving access to This alarming policy will have GETTY IMAGES Hickey et al review non-hormonal eating disorder services consequences that the UK will treatments for menopausal be managing for many years This timely article on eating symptoms (Clinical Updates, to come. Contraception is vital disorders in children and young 25 November). But they do not for the health and wellbeing people reminds us that the interval discuss female pattern hair loss of women and the survival of between onset of illness and (FPHL), which many women modern society in its current access to specialist interventions experience around menopause. shape. It is cheap, effective, predicts outcome (Practice Pointer, The considerable psychological and well used. What Your Patient is Thinking, distress associated with hair loss Wealthy women may 9 December). The estimated delay from onset to accessing specialist is well recognised. Depression, access private services: where services is 42 months—patients present after about 36 months, and anxiety, low self esteem, and will women from deprived service providers are responsible for a further 6 months’ delay. NICE obsessional behaviour have been backgrounds turn? guidelines and promised NHS capital investment might tackle service commonly associated with FPHL. Sarah W Pillai, associate specialist, provider delays, but without earlier engagement with patients, Edgware Although the role of androgens compromised outcomes will continue. Cite this as: BMJ 2018;360:k285 and genetic susceptibility is Our charity offers online befriending services and in-house carer recognised in male pattern hair “LOW VALUE” DRUGS support groups for adolescent patients. Both provide support and loss, it is less well understood positive practical interventions and hopefully encourage patients to in FPHL. The majority of women NHS wants GPs to judge accept our in-house one to one and group peer support. with FPHL have neither clinical deserving patients Transition to university is a major trigger for new and relapsing nor biochemical features of Setting guidance on what not illness. Our eating disorder service for students at Nottingham hyperandrogenism. to prescribe would reduce universities seeks to identify and support such students and reduce Topical minoxidil is the only NHS costs, especially the the 20% of young people with eating disorders who withdraw from, licensed treatment for FPHL. prescription dispensing fees and 40% who interrupt, their university studies in the UK. Its mechanism of action is not (This Week, 9 December). But These services are provided by appropriately trained staff and known, but its efficacy for hair would it be easier to set up a volunteers, 75% of whom have lived experience of an eating disorder. regrowth is well documented national formulary on which “Being understood” by mentors is cited by people who use our in a systematic review and drugs are covered? If a patient’s services and their carers as a critical factor in encouraging their trust meta-analysis of randomised clinical and social conditions and willingness to engage in our services. controlled trials. Patients may warrant coverage for a non- not see an effect in the first four Antony Natt, retired GP, Derby formulary drug, the GP could Cite this as: BMJ 2018;360:k382 months of treatment, but should help the patient to apply for use it for at least 12 months special authority access. before concluding inefficacy. the social gradient, and they SEXUAL HEALTH SERVICES The NHS seems to want Amr Salam, dermatology registrar, interact. No adjustment method overstretched GPs to play London can calculate the proportional Cutting funding for judge and determine, in their Christos Tziotzios, dermatology reductions for each cause contraceptive provision time limited consultations, registrar, London David A Fenton, consultant separately, and what would be The BMJ’s investigation into which patients deserve an dermatologist, London the point? Marmot’s call to reduce sexual health services made NHS prescription. This further Cite this as: BMJ 2018;360:k245 unfair distribution of resources accurate but depressing reading recasts the role of GPs from

TRAFFIC POLLUTION and conditions of everyday life (Investigation, 2 December). I “gatekeepers” to “barrier continues to be almost ignored. was concerned to see very little builders.” Would GPs be legally Social determinants In the UK, around 60 000 reference to the concomitant covered if a patient experienced of low fetal growth babies are born prematurely cuts in contraceptive provision, an ongoing illness due to failure Smith et al show that traffic each year, and gestational age is which is a huge problem for to receive an NHS prescription? air pollution adversely affects strongly associated with neonatal public services, not only health. Instead, why not buy a fetal growth (Research, mortality and morbidities. Every unwanted pregnancy package of paracetamol at cost 9 December). The study adjusted Healthcare professionals must brings with it emotional, and have salaried primary care for confounding variables and lobby for universal social justice. relationship, and mental health pharmacists dispense and estimated that if exposure was Who better to advocate for future stresses, as well as economic counsel patients? This would reduced to zero the reduction in children destined for poor health strain for both the people save the NHS dispensing population morbidity would be from before their births? involved and local authorities. fees and improve patients’ 3%, which is the tip of the iceberg. Alain Braillon, senior consultant, Cutting money from understanding of medications. The most frequent avoidable Amiens, France contraceptive services does not Susan Bewley, professor of women’s Eugene Y H Yeung, medical doctor, causes of low fetal growth and health, London make economic sense. For every Lancaster preterm birth are associated with Cite this as: BMJ 2018;360:k399 £1 spent on contraceptive care, Cite this as: BMJ 2018;360:k404

198 3 February 2018 | the bmj