comment “The events at Gosport are probably less likely two decades on” DAVID OLIVER “There's always a third presence in the consultation—my computer” HELEN SALISBURY PLUS Sugar tax and lobbying by fizzy drink companies; hospital patients' boredom THE BOTTOM LINE Partha Kar Stan Lee’s lessons for the NHS ast month the world lost Stan Lee, the falter when it comes to delivery. In the X-Men series, great comic book creator. I was one of created in the 1960s to highlight prejudice against many who mourned his loss. As a child certain groups, “mutants” are accepted rather than I loved the colourful panels and stories shunned, and their capabilities are recognised. The of heroism in comic books, and as I’ve release of the Black Panther film in 2018 showed Lgrown older I’ve become aware of some important life many children that being a superhero wasn’t about lessons they’ve taught me. Those lessons—around being white—it was about their skills and qualities. management, leadership, and equality—are ever In terms of gender, studios aren’t merely paying lip more important as the NHS faces an uphill struggle to service to diversity when they give prominent female maintain staff morale. title roles to Wonder Woman or Captain Marvel: For one thing, comic books help us understand our these women are central figures who become leaders colleagues by creating vivid characters who personify because of their abilities. specific personality types. Personality types have been People say that life imitates art. The NHS would mapped, eruditely but controversially, by Myers- certainly be a better place if we could learn how to Briggs scores and other measures. But comic book work together and use the skills of the whole team, characters can help us to understand these types and like the superheroes we know and imagine how they would act in different situations. admire. We’ve all met someone who stands up for what’s Partha Kar is consultant in diabetes and right and whose reluctance to shift on principles endocrinology, Portsmouth Hospitals frustrates others, just as it does with Superman and NHS Trust [email protected] Captain America. And we’ve all met the show-off who Cite this as: BMJ 2018;363:k5037 struggles to fit into a team but still fights the good fight, just as Batman and Iron Man do. Beyond this, comic book stories are full of big egos Certain burying hatchets—people recognising their own circumstances weaknesses and collaborating for the sake of a team, need someone such as the Avengers or the Justice League. And yet, else some other how many times has integration in the NHS faltered character— at a presentation meeting, simply because different to step personalities can’t work together? Thinking about how fictional characters overcome forward their differences has helped me in my work. When and take the creating a model of integrated care in Portsmouth and lead building consensus in my role at NHS England I was aware that certain circumstances needed someone else—some other character—to step forward and take the lead. It was about the team achieving the goal. Similarly, the NHS may have introduced mandatory courses on equality and diversity, but these often the bmj | 8 December 2018 399 OBSERVATIONS Douglas Kamerow The shopping trolley attack: how industry is fighting against sugar taxes Lobbying by US fizzy drink makers to ban city levies on all groceries—not just on sweetened drinks—has had mixed results ugar sweetened beverages waging successful campaigns against Financial support provide empty calories that cities that proposed taxes on sugar Laws prohibiting taxes on groceries of any succeed in two ways: they make sweetened drinks, blocking the passage kind have already been passed in Michigan, great profits for manufacturers, of such laws. Since then, however, cities Arizona, and California. And referendums and they fatten adults and such as Philadelphia, San Francisco, and against taxes on sugary drinks took place in Schildren who drink them. Seattle have passed laws despite industry November in Washington and Oregon. These Dozens of countries around the world opposition. ballot initiatives had solid financial support and a few US cities have instituted taxes Manufacturers needed a new strategy, from the grocery and fizzy drink industries. on sales of such drinks to discourage and they came up with an aggressive plan: One committee that was registered to support consumption and to raise funds for lobby for statewide legislation or ballot Washington’s initiative—benignly named government health initiatives. Research initiatives forbidding cities and counties “Yes! To Affordable Groceries”—raised and is starting to accumulate showing that from taxing any grocery items at all. No need spent $20m (£15.6m) on the campaign, more these excise taxes (often the equivalent of to mention sugary drinks; instead, market than 99% of which was from four donors: a penny or two per ounce at the wholesale these initiatives to consumers as checks on Coca-Cola, PepsiCo, Keurig-Dr Pepper, and level) reduce sales of sugary drinks and “tax-happy politicians.” Everyone is against Red Bull. Their opponents, the Healthy Kids increase sales of those without sugar, such higher taxes, right? Who would want their Coalition, spent less than $16 000. as bottled water. groceries taxed—even if there were actually What did $20m buy in Washington? When I last wrote about this, in 2010, no plans to tax any groceries except those Television advertisements with plaintive three US beverage manufacturers were containing a sugary beverage? shoppers saying, “We should not be taxed on BMJ OPINION Jeremy Smith For doctors and nurses, and far between, and What’s so frustrating is hospital wards must surely those available quickly that the distractions I sought The malady of boredom feel like intense microcosms lost their sheen. Even are so obvious: books; bright of the life-death experience. getting visitors becomes walls (instead of municipal I came Yet for patients enduring stressful as you rack your greens or yellows); and to know long term stays in hospital, mind for something, the absolute necessity of boredom the gruelling cocktail of pain anything at all, to recount of having cards, letters, and on an and boredom, loneliness your endless inactivity. photographs from family intimate basis and fear, and the numbing Bafflingly, the mental and friends to put up on minutiae of ward routine can health professionals walls. Too often, hospitals strip a mind of all but its most (psychotherapists, make no provisions for these primal functions. counsellors) assigned to preoccupations, or even Jeremy Smith is Three years ago I spent oversee the wellbeing of actively strip them away. an Oxford based almost 11 months in hospital those enduring long term One patient I knew had a journalist and because of a spinal injury hospital stays never seemed hand drawn card made by broadcaster. In and, consequently, I came willing to ask, “Are you his young daughter removed 2015, he suffered a to know boredom on an bored?” It’s as if being bored without warning from his spinal injury and was intimate basis. was somehow unworthy of bedside while he was in hospital for 11 months Distractions were few clinical appraisal. awaiting an x ray; needless to 400 8 December 2018 | the bmj what we eat. We need to eat to survive, and if we have to cut back on what we eat, that’s not ACUTE PERSPECTIVE David Oliver going to be good—especially for the elderly.” Other spots starred farmers and housewives Preventing a repeat of Gosport urging the viewer to vote for the tax ban “before local governments can put taxes on n the wake of this June’s or measurement of their any of our groceries.” Cynical, but effective. inquiry report on the performance. In Oregon, opponents of the ballot initiative sometimes preventable Jane Barton, the doctor who raised more money than in Washington, or needlessly distressing featured most prominently in thanks in part to a $1.5m contribution deaths of 451 patients at the Gosport inquiry, worked as from former New York City mayor Michael IGosport War Memorial Hospital in a clinical assistant. Her case Bloomberg. They were still outspent by the the 1990s, a Commons statement raises an issue of training and group backing the measure, “Yes! Keep Our in November by the health supervision for doctors in such Groceries Tax Free,” supported by the soda secretary set out policies aiming roles, and accountabilities for the companies and supermarket chains. to prevent a repeat and to improve supervising consultants if based How did the elections turn out? Split healthcare safety. on another site. decision. Washington approved the ban on I welcome such government The inquiry also found that grocery taxes by 56% to 44%, though the attention, but the devil is in the several patients who were not ALAMY result does not overturn existing city beverage detail. Ultimately, the only way to terminally ill were labelled as Most of taxes, such as Seattle’s. Oregon voters improve safety and prevent more dying or given very large doses the £15.6m defeated the proposal, by 57% to 43%. scandals is through the culture and of opioids. This in turn raises the This issue has wider ramifications for the solutions of local organisations. issue of doctors’ confidence in spent in rights of local municipalities to tax citizens. Reports on other mass care failings accurately recognising the dying Washington Similar initiatives have worked in 43 states have shown that external regulation phase and discussing it openly came from for guns: pre-emptive laws banning gun can be late in recognising them.