this week DOCTOR “LOAN SHARK” FACES JAIL page 2 • 60 SECONDS ON HAPPINESS page 3

Doctors not declaring drug firm fees

Only around half of doctors and other Thompson. However, NHS England Mike Thompson, chief healthcare professionals are putting their abandoned plans to force doctors to declare executive officer at the ABPI, names to payments and bene ts they the income they earned from outside the would like to see all UK doctors declaring their fees receive from drug companies in the register NHS a er doctors objected. and benefits from industry run by the industry’s trade association—far In the new analysis, RAND Europe found fewer than previously claimed. inconsistencies in how companies recorded A new analysis of data submitted to the data relating to healthcare professionals Association of the British Pharmaceutical who did not give their consent to publish Industry’s Disclosure UK database ( www. details of payments or bene ts in kind they disclosureuk.org.uk ) has found that just received, giving rise to the new  gures. % of doctors and other healthcare The General Medical Council does not professionals are allowing their names to have the power to make mandatory such appear alongside the fees and expenses disclosure by doctors, and a recent proposal they receive from drug companies, not the to make voluntary declarations was rejected % that was claimed in June  when by doctors. GMC chief executive, Charlie the scheme launched. Massey, said, “We strongly urge doctors LATEST ONLINE The database lists details of the fees involved in the pharmaceutical sector to Junior doctor and bene ts in kind paid by the industry participate fully in this scheme to ensure • who lacked basic to doctors, pharmacists, nurses, and patients’ con dence in the profession is knowledge and skills healthcare organisations. Only those that maintained.” is struck o give consent are identi ed. Commenting on the issue, the GP NHS England to Mike Thompson, chief executive o cer and BMJ columnist Margaret McCartney • publish national at the ABPI, said that he wanted % of said, “Without statutory declarations of guidance on low UK healthcare professionals to be open  nancial con icts of interest, it’s clear that value drugs about payments from drug companies. He voluntary registers contain signi cant gaps. Gastric acid said that NHS England’s new guidance on I hope that the House of Commons Health • suppressants declaring con icts of interest, launched last Committee asks the GMC why it didn’t associated with month, would help “make this a reality.” consider mandatory reporting.” increased risk NHS England’s guidance “advocates Ingrid Torjesen, London of C di disclosing on our database,” said Cite this as: BMJ ;:j the bmj | 1 April 2017 1 SEVEN DAYS IN Consultant must repay £525 000 or face jail A hospital consultant who became a loan shark to nursing staff and other colleagues has been ordered to repay £525 000 to his victims or face five years in jail. Arjan Savani (inset), 50, who worked in the emergency department at Central Middlesex and Northwick Park Hospitals in Harrow, northwest London, was sentenced last October to 10 months’ imprisonment, suspended for two years, and ordered to do 120 hours of unpaid work. Prosecutors said that Savani, who had pleaded guilty at Harrow Crown Court to two counts of illegal money lending, made 271 loans worth a total of over £1m to 90 people since 2011, charging interest rates of between 1.5% and 8% a month. After his conviction, prosecutors made a “proceeds of crime” application to seize his illegal gains. At a new court hearing he was ordered to pay back £525 000, the total amount he received in payments from his debtors. He has three months to come up with the money, or he will face a sentence of five years in prison. He has been suspended from practising and is under investigation by the General Medical Council. A fitness to practise hearing is expected but no date has been set.

DAILY MAIL/REX/SHUTTERSTOCK DAILY Clare Dyer, The BMJ Cite this as: BMJ 2017;356:j1532

GP funding was 22.9/1000 in 2014 and International health security compromised areas in BMA condemns lack of 47.1/1000 in 1969. The drop is Heat resistant rotavirus Borno state, northeastern Nigeria, resilience cash thought to be due to investment vaccine is “game changer” widely considered to be the only The BMA urged NHS England in sex education, improved A new vaccine against rotavirus— place in Africa where the virus to urgently deliver £16m access to contraception, and known as BRV-PV—is safe and maintains its grip. in resilience funding that it more young women staying in efficacious against severe promised to deploy to struggling education. Last month Justine gastroenteritis, showed a trial of Child obesity general practices by the end Greening (below left), the 4000 children aged under 2 in the Government’s plan needs of this financial year. The education secretary, said that Maradi region of Niger, published work, say MPs funding was due by the end of all secondary schools, including Sarah Wollaston, chair of the March as part of a four year, academies, private schools, and parliamentary health committee, £40m resilience package. But religious free schools, would have said that “vague statements” a BMA survey of local medical to offer sex education classes. about the progress of last year’s committees found that only government plan for tackling 60% of local commissioners Women’s health child obesity in England “are had identified and notified the GPs challenge claim that inadequate for the seriousness practices due to receive funding. they do not do enough and urgency of this major public And only 16 committees (40%) Helen Stokes-Lampard, chair in the New England Journal of health challenge.” The committee said that the promised funding of the Royal College of GPs, Medicine. Micaela Serafini, called on the government to stop had been made available. challenged the notion that medical director of Médecins discounts and price promotions (doi:10.1136/bmj.j1562) GPs do not take fibrosis and Sans Frontières, described the of unhealthy food and drink. endometriosis seriously after vaccine as a “game changer” (doi:10.1136/bmj.j1556) Teenage pregnancy a survey found that 62% of because it is heat stable and does Rate is lowest since women were not satisfied not require refrigeration, meaning Hospital finances records began with information they received that it can reach children in the Three more trusts enter The rate of about treatments. Some 40% most remote parts of the world, special measures conceptions in of respondents had had 10 or and it costs less than $2.50 (£2). St George’s University Hospitals women under more GP appointments before NHS Foundation Trust, Northern 18 in England being referred to a specialist. Mass immunisation aims to Lincolnshire and Goole NHS and Wales fell Stokes-Lampard emphasised that end polio in Africa Foundation Trust, and University to 21 in 1000 in endometriosis symptoms were More than 116 million children Hospitals of North Midlands 2015, the lowest broad, adding, “All of our patients in 16 countries in western and NHS Trust were put into financial since comparable should be treated with dignity central Africa will be immunised special measures by NHS figures and respect . . .whatever their against polio this week by a team Improvement. The three trusts were first symptoms, and whatever their of 190 000 volunteers to try to end have failed to keep up with their produced condition, their GP will always polio throughout the continent. agreed financial control totals and in 1969. take their condition seriously.” Last August four children were are forecasting a combined deficit The rate (doi:10.1136/bmj.j1533) paralysed by the disease in of £145m.

2 1 April 2017 | the bmj SIXTY SECONDS MEDICINE ON . . . Hepatitis C New drugs against HAPPINESS European patent of key hepatitis C are too I’M VERY HAPPY, GAZING OUT AT A costly, say charities drug is challenged FJORD, ENJOYING MY PICKLED HERRING Médecins Sans Frontières, Of course you are—you’re Norwegian. The Médecins du Monde, and civil World Happiness Report 2017 says that society organisations from 17 Norway is the happiest country in the world. countries filed simultaneous The US ranks 14th of 155 countries, the UK is patent challenges with 19th, and France is 31st. The poor old Central the European Patent Office African Republic is last. on Gilead’s hepatitis C drug IS IT TO DO WITH MY HERRING? sofosbuvir, in a bid to increase Well, the report doesn’t measure pickled access. Sofosbuvir is one of herring consumption specifically (unless a range of oral “direct acting I’ve missed something). It studies income, antivirals” to come to market healthy life expectancy, having someone to in the past four years and forms count on, generosity, freedom, and trust—the the backbone of most hepatitis last measured by the absence of corruption in C combinations. In Europe, business and government. Gilead charges as much as $59 000 (£47 000) for a 12 week hospital, regardless of distance, WHY IS NORWAY SO HAPPY? sofosbuvir treatment, but studies a study published in the NURSES A Norwegian man writing in puts his compatriots’ joie de vivre down to have shown that it costs less than European Heart Journal found. From September $1 a pill to produce. Key patents The researchers used data on having a log cabin in the mountains or by the sea—or both (he doesn’t mention herring but on sofosbuvir have already been 41 186 patients in Denmark to December last does mention berry picking and cosiness, revoked in China and Ukraine. who had experienced a cardiac year an average or hygge). The report takes a more prosaic arrest out of hospital, 3550 of nurses view: the country is happy not because of its Research news (9%) of whom were still alive 194 wealth but despite it. Norway invests in the Cutting salt could reduce 30 days later. Direct admission a month from future rather than on short term measures. urge to urinate at night to an invasive heart centre other EU countries “To do this successfully requires high levels Cutting salt intake could reduce rather than a local hospital was signed up to work of mutual trust, shared purpose, generosity the need to get up in the night to independently associated with in the UK, down and good governance,” said the report. urinate, showed a preliminary lower mortality (adjusted hazard SO, WHAT MAKES US MISERABLE? study presented at the European ratio 0.91 (95% confidence from Association of Urology congress interval 0.89 to 0.93)). 797 One revelation is that mental and physical in London. The Japanese study (doi:10.1136/bmj.j1572) in 2015 [Nursing ill health, unemployment, and poor included 321 men and women and Midwifery relationships lead to misery. Surveys of who experienced nocturia during Viagra Council] wellbeing in Australia, the UK, and the US found that poor mental health was the most sleep and had a high dietary Drug agency considers important factor. In poorer countries income salt intake (≥8 g/day in prescription status difference was more important, but poor men and ≥7 g/day Pfizer applied to the Medicines mental health was still high on the list. in women), 223 and Healthcare Products (69.5%) of whom Regulatory Agency to request WHAT ABOUT THE UK? reduced their salt that sildenafil (Viagra) for The Office for National intake from a mean erectile dysfunction is made Statistics measures of 10.7 g/day to available through pharmacies. wellbeing in the UK, 8.0 g/day, and whose The risks from sildenafil and although it surveys average night time frequency of intentional abuse are low, individuals rather than of urination reduced from 2.3 says the consultation, adding populations as in the times to 1.4 times (P<0.001). that making it available over World Happiness Report. (doi:10.1136/bmj.j1527) the counter would benefit men But the survey and the who are embarrassed to seek a happiness report both show that the UK is getting happier. Levels of wellbeing have Specialist centres are doctor’s advice. It could also help risen every year since 2011, when the ONS urged for cardiac arrest to identify men with heart disease surveys began. And 2017 is the first year the Patients have a better chance and reduce the risks associated UK has been in the top 20 since the report of survival after a cardiac arrest with buying counterfeit sildenafil began in 2012. Things can only get better . . . if they are taken immediately online. The consultation runs to a specialist heart centre until 18 April. Anne Gulland, London rather than the nearest general Cite this as: BMJ 2017;356:j1568 Cite this as: BMJ 2017;356:j1539

the bmj | 1 April 2017 3 FIVE MINUTES WITH . . . Kamila Hawthorne The vice chair of the RCGP discusses the college’s ambition for four years of GP specialty training

an Finlay, chair of the Shape of Training steering group, wrote to the college to say that it had rejected four year GP training and instead proposed a ‘three plus one’ model. This proposal was “I put to the RCGP council, which overwhelmingly Patient safety test will be part of rejected it. “Our understanding of three plus one is that it NHS staff appraisals from 2018 would be three years of training, as it is now, and that the ‘plus one’ would be a yearlong fellowship All NHS staff will have to sit an The announcement marks the latest after the certificate of completion of training (CCT). annual multiple choice test on phase of the health secretary’s Patient This would allow newly qualified GPs to do a little patient safety as part of a drive Power 2.0 plan, which he hopes will bit more in an area that interested them, so they by England’s health secretary, be the catalyst to create a “no blame” might, for example, become a GP with an extended Jeremy Hunt, to make the service learning culture in the NHS. Hunt role (the term now used for GPs with a ‘special “the world’s largest learning insisted that the measures would interest’). We pointed out to Ian Finlay in a reply organisation.” be “light touch” but would form an that the fellowship year is actually not pre-CCT The radical plans, unveiled in a important part of a “360 degree, 365 training and really what we were interested in was consultation document published days a year, 24-7, ultimate knowledge enhanced GP training. on 1 April, will require all NHS staff gaining experience.” “General practice has changed a lot in the past to sit the test as part of their He said, “I truly believe that 20 or 30 years, but the training, and the amount of annual appraisal from 2018. introducing this test will help us time given to training, hasn’t. We have now got a Ministers are understood to have achieve our ambitious target of lot more to do in general practice: a large number sounded out the production team making our NHS the safest healthcare of services have moved out of hospital and into behind the television quiz show system anywhere in the world. It primary care, and patients are discharged from Who Wants To Be A Millionaire? may not be ‘evidence based’ in the hospital much earlier. for advice on constructing traditional sense, but if you look at The population is getting the test. leading trusts like Salford Royal, and older, with increasing In its consultation document the Frimley, which are already delivering complexity of presentations Department of Health outlines a wonderful care, they would probably and multiple morbidities. list of sample questions that it may be delivering even more wonderful GPs are being brought into include in the final test. One mock care than they already are if they used positions of leadership and question asks: this test.” management with little or no But doctors’ leaders condemned formal training. “How much does poor care cost the proposals as bureaucratic, foolish, WE SEE A “We also see a greater the NHS financially?” and lacking in evidence. GREATER variety of illness than any The options are: Mark Porter, BMA chair, said, “The VARIETY OF other specialty, and yet we (a) more than good care; NHS is underfunded and services ILLNESS . . . AND have the shortest training (b) less than good care; are unable to keep up with rising YET WE HAVE time. I was pleased that our (c) the same as good care; or demand, but, instead of addressing THE SHORTEST council voted in favour of (d) don’t know. this, the government has chosen to TRAINING TIME enhanced GP training that implement what effectively amounts would entail both the extension of training to at least Another question asks: to a multiple choice trivia quiz.” four years and an improved quality of that training. “What is the name of the leading A spokesperson for the Centre for “The college is proposing to review and refresh US hospital often cited by Jeremy Quiz Based Medicine said, “Where its original offer of the four year extended training Hunt as a pioneer in the field of is the evidence base for this? This is and bring it up to date, because it’s now two or patient safety?” pure folly from a secretary of state three years since it was written, and these things The options are: who seems intent on imposing time can always be improved. So, that is the next step (a) Virginia Mason; wasting gimmicks and fads on the for us.” (b) Virginia Plain; medical profession.” Abi Rimmer, BMJ Careers (c) Virginia Woolf; or Gareth Iacobucci, The BMJ Cite this as: BMJ 2017;356:j1553 (d) Virginia Bottomley. Cite this as: BMJ 2017;356:j1542

4 1 April 2017 | the bmj The NHS isn’t getting the most out of its consultant workforce, not because they aren’t working hard enough but because of poor workforce planning, especially in the lack of nurses. Gareth Iacobucci reports on new research that analyses productivity across NHS hospitals, while John Appleby considers the pitfalls of measuring such activity.

CONSULTANT PRODUCTIVITY “Ineffective use of staff” blamed for fall in clinical activity of senior doctors

What makes for a The productivity of consultants working in found to have fewer nurses and support productive consultant? NHS acute care hospitals in England has staff working with consultants, a higher fallen by an average of 2.3% over the past number of delayed transfers of care, and Input to Health Resulting increase in Foundation model consultant productivity six years, new research has shown. pay rates that were less competitive for The think tank the Health Foundation, their area. 1% more Higher which conducted the research, attributed The researchers acknowledged that of workforce H impact are nurses 0.05–0.20%> 0.20% the fall to poor workforce planning. It their measure of consultant productivity highlighted a 22% rise in the number of was crude, as it did not adjust for quality 1% more of MediuHigherm workforce are M impact NHS consultants over the past six years, of output, but they added, “With the support sta 0.05–0.20%0.05–0.20% whereas the number of nurses rose by just magnitude of our results this will not 1%. affect the overall conclusions.” 1% fewer HigherLower delayed L impact Anita Charlesworth, director of research National policy decisions such as transfers of care 0.05–0.20%< 0.05% and economics at the Health Foundation cutting numbers of nurse training places and coauthor of the paper, said, while consultant numbers were rising, Skill mix “Consultant productivity has been falling, and three years of raids on capital budgets but not because staff aren’t working to bail out deficits, had also contributed to More 1% more 1 of workforce H nurses are nurses incredibly hard. NHS consultants work poor productivity, the analysis added. in a system, and if that system isn’t well The authors warned that the failure to

More 1% more of designed they can’t be productive. tackle ineffective use of staff was making it 2 support workforce are M sta support sta “Much better workforce planning increasingly difficult to reach the £22bn of is critical. Increasing the number of savings by 2020 set out in NHS England’s Regional variation consultants by a fifth without investing in Five Year Forward View, which means nurses is a prime example of short term increasing NHS productivity by 2%-3% Higher 1% higher cost savings undermining the essential a year. 3 NHS wages, v M wages local average task of improving long term productivity.” Keith Brent, chairman of the BMA’s The analysis looked at consultant Consultants Committee, said that Urban 1 point more urban, on productivity across 150 NHS acute consultants were working harder than 4 location M 5 point scale hospitals between 2009-10 and 2015-16. It compared cost weighted activity led by Hospital characteristics consultants, which rose by 1.8% a year NHS consultants through the six years, with the number of More 1% more work in a system, 5 specialist specialisation H full time equivalent consultants, which (ITI index) and if that system rose by just over 4%. isn’t well designed Not a No teaching The study concluded that the decline 6 teaching v teaching H they can’t be hospital hospital in productivity was due to “systemic problems,” meaning that the NHS was productive More 1% more not getting the most out of its consultant 7 private of total cost L nance is PFI* workforce. It noted that the output per full time equivalent consultant was 29% Fewer 1% fewer DToCs higher at the most productive hospital 8 delayed (delayed transfer L transfers of care) than at the least. Hospitals with the *PFI = Private Finance Initiative lowest consultant productivity were the bmj | 1 April 2017 5 DATA BRIEFING How productive are NHS consultants? On paper at least, the productivity of consultants is falling. But is one reason because the quality of their work is increasing, asks John Appleby? ever but were being let down by a system n the face of it, measuring the There is a second and rather fundamental “at breaking point.” He also emphasised productivity of the workers problem, which is not just specific to that “clinical activity is not the same as in an industry or business a publicly funded NHS or, indeed, to quality of care or patient outcome.” is straightforward. The healthcare but which exists for virtually all Brent said, “Consultants will always ONS Productivity Handbook industries, public, or private. treat patients as individuals, not as units Odefines productivity as simply the volume The problem is how to ensure outputs to be processed in ever greater quantity. of output per unit of input.1 Inputs (the are comparable over time. For producers This research highlights the shortage of number of workers) may increase over of mobile phones we can count the doctors and nurses in some areas and the time, but if the outputs (widgets) increase number of phones produced every year need for an NHS with the right mix of skill at a faster rate then productivity will have and call that their output. But it’s clear to deliver high quality care.” increased. On this basis, have NHS hospital that, although still a phone, Apple’s 2016 Jane Dacre, president of the Royal consultants been producing less, the same, iPhone 7 is somewhat different to Nokia’s College of Physicians, said, “Money or more widgets over the past few years? 1997 6110 mobile (though both cost alone will not solve this issue: workforce It turns out that dividing one number around the same). Over two decades the planning is crucial. (outputs) by another (inputs) to get a third power and capabilities of mobile phones “If we are to improve productivity (productivity) is somewhat have increased hugely. The 2016 mobile consultants need to be supported by harder in practice than the arithmetic phone product is not the same as its 1997 strong teams encompassing nurses, implies. counterpart. management, and support staff.” Over the past seven years, the good And the same is true for healthcare. Gareth Iacobucci, The BMJ news is that as consultant numbers have The attributes that patients’ value in the Cite this as: BMJ 2017;356:j1552 increased, so too has their elective activity things consultants’ produce (operations, (fig 1). The English NHS increased its attendances, etc) have changed over time, elective activity output by around 19% from mainly for the better—from time spent PRIVATE PROVIDERS TAKE 2 September 2009 to September 2016. But waiting to get treatment and experience of LARGER SLICE OF NHS CASH the bad news is that at the same time, the care, to the probabilities of experiencing • Spending by NHS trusts on private consultant workforce grew by around 22%.3 complications and the change in health sector and other non-NHS providers This means that the average productivity status as a result of treatment. rose by 18% between 2014-15 and per consultant has fallen by 3% since 2009 Adjusting the output of consultants 2015-16, from £810m to £960m (fig 2). to reflect changes in the quality of the • In the same year, NHS providers’ total But here’s the first problem with this “product” is not easy, but without budget grew by £800m, an increase of calculation: consultants’ output is not just it productivity can be seriously just 1.1% in real terms measured in elective activity but includes underestimated over time. For the NHS • £1 in every £8 of local commissioners’ outpatient attendances and emergency as a whole, Office for National Statistics budgets is now spent on care provided work. Although consultants will also spend adjustments for quality (improved waiting by non-NHS providers their time in meetings, management, and times, reductions in mortality, etc) have • Capacity constraints mean that NHS other administrative duties, these are accounted for around 40% of the increase hospitals are increasingly limiting assumed to be intermediate activities that in the productivity of the NHS since 2000 elective care to manage pressure in contribute to their final output. But what and about 17% between 2009 and 2014 emergency care and that a growing about teaching and research? What to (fig 3).4 share of preplanned care is being outsourced to private sector providers include in the overall output measure is not If such an addition, assuming the quality always clear. And though there are ways to increase in 2015 was the same as in 2014, • The NHS should re-examine the aggregate the apples and pears of different was applied to the elective outputs of marginal rate payment tariff for emergency care, which halves types of activity into one overall measure of consultants, it would have been enough to payments for emergency admissions output (weighting them by the proportion have just about compensated for the 3% fall above the 2008-09 levels of their total spend for example), this in unadjusted productivity between 2009 Source: Health Foundation presumes their importance or value is and 2015 (fig 2). related to their cost. Cite this as: BMJ 2017;356:j1520

6 1 April 2017 | the bmj 125 BMJ OPINION Anita Charlesworth Increase in productivity National policy creates barriers 120 that undermine productivity 2015 New Health Foundation research shows that between 115 2009-10 and 2015-16 consultant productivity in 150 acute hospitals fell by an average of 2.3% per year. This decline isn’t because consultants aren’t working hard enough, 110 but because of systemic issues with the way the NHS is organised. Our research analysed some of these factors, al and acute admissions (index 2009=100) which are all too familiar. Most important is workforce planning. Our research finds 105

tive gener hospitals with a higher proportion of nurses have higher

Elec Reduction in productivity consultant productivity. Increasing the proportion of nurses 2009 by 4% in a hospital can increase activity per consultant by 100 around 1%. A more balanced rise in numbers among different 100 105 110 115 120 125 staff groups may ensure that the NHS uses consultants’ skills Fig 1 | More consultants and more work since 2009 but less productivity?2 3 well, but recent years have seen disjointed workforce planning at best. The decision to cut nurse training places in the early 125 part of this decade may have saved some short term costs but looks to have undermined the drive to improve productivity. Consultants 120 It’s not hard to imagine that working in modern, fit for purpose facilities 115 with the right IT and equipment allows Elective general and consultants to work more productively acute admissions 110 Another challenge is capacity: consultant productivity is

Index 2009=100 lower in hospitals with higher rates of delayed transfer of 105 care. Increased pressures on the social care system have exacerbated this issue. The extra £2bn for social care over Quality adjusted productivity the next three years announced in the budget is unlikely to 100 be sufficient as pressures on the social care system are rising Unadjusted productivity even faster than the NHS. We also found that consultants who work in hospitals that 95 2009 2010 2011 2012 2013 2014 2015 invested more in infrastructure and building through private finance initiatives (PFIs) are more productive. The research did not seek to assess the value for money of PFI as a system of Fig 2 | Numbers of consultants and elective procedures relative to 2009 and effect of financing hospitals, but used PFI spending as a proxy measure adjustment for quality on productivity2‑4 for more modern facilities and equipment. It’s not hard to 120 imagine how working in modern, fit for purpose facilities with the right IT and equipment allows consultants to work more productively. So it’s worrying that NHS investment funding 115 is instead being used to bail out hospital deficits. In each of the past three years the Department of Health has raided the Quality adjusted productivity capital budget to prop up running 110 costs, and further transfers are reportedly planned for the next three. The research suggests that national 105 policy can create substantial barriers tivity (Index 2000=100) that undermine consultant productivity.

Produc Three in particular must be addressed: 100 workforce planning, social and Unadjusted productivity community care capacity, and capital. 95 1 3 Anita Charlesworth is director of research 2011 2012 2014 2013 200 2010 2007 2005 2002 2004 200 2006 2009 2008 2000 and economics at the Health Foundation Fig 3 | Improved quality adds substantially to overall English NHS productivity4 the bmj | 1 April 2017 7 Leading anaesthetist praises NHS response to Westminster attacks Clinical‌ director at Imperial says training “kicked in” when incident was declared. Anne Gulland reports

consultant Four people died and 40 were The response “We kept most of the workforce anaesthetist at injured, some critically, when a man to the in theatres, and we called down for one of the trauma ploughed his car into pedestrians Westminster people as we needed them,” said centres that received on Westminster Bridge at 14.40 on attacks Johannsson. “We used every single casualties after last 22 March. The responses to major was more bay in resus. When a patient in a Aweek’s attacks in Westminster has incidents such as this are planned bay went elsewhere we filled that coordinated praised his colleagues for their for under guidance in the NHS’s bay with another team. We always “fantastic response.” Emergency Preparedness, Resilience than the had one in the queue and one Helgi Johannsson, clinical and Response plans. response to team of people waiting to go in. We director of anaesthesia at Imperial Johannsson said that, once a major the attacks in could have coped with a lot more College Healthcare NHS Trust, incident is declared, an automated July 2005 casualties than we did.” which received eight casualties, switchboard calls all relevant Johannsson was not working said that the trust had taken part in individuals. He said that there was at Imperial during London’s last a pan-London simulation exercise a “fantastic response . . . We had major incident in July 2005, but in the past year, which simulated a people not only offering to come in colleagues who were there at the major train accident. He said that there and then but also coming in time said that the response to the training kicked in once the for the night shift. Two of our senior the Westminster attacks was far Westminster incident was declared trainees formed an augmented night more coordinated. He added that at 15.55 on 22 March. shift.” He added that one emergency several debriefs took place after “I couldn’t fault our teams, they did coordinator had worked downstairs Wednesday’s incident. an absolutely fantastic job. The whole in the emergency department and “There’s always something to process worked very well,” he said. one upstairs in theatres. learn. This time it was mainly about

GOOD SAMARITAN ACTS Sally Old and Ethical International Protected Produce clinical Oliver Lord, 1 obligation 2 expectations 3 by law 4 records medicolegal There is no legal obligation In some countries, however, The risk of doctors being If doctors do find themselves advisers at in the UK for a doctor to there is a legal obligation sued after they have helped in a situation where a good MDU, explain volunteer as a “good to provide assistance, and in an emergency is very low Samaritan is needed, they what doctors Samaritan” during an if a doctor fails to help then with only a handful of cases should make a clinical record need to emergency, but they do have they could be prosecuted. ever having been attempted. of any help given, including know about an ethical obligation France, for example, has a Likewise, the Social Action, the patient’s name, if known, being a good to provide assistance, dedicated good Samaritan Responsibility, and Heroism the treatment provided, Samaritan even if they are off law which compels Act 2015 is intended to and the doctor’s contact duty and wherever doctors to protect those acting in an details. Hand over relevant they are in assist in an emergency in England and information to those who will the world. emergency. Wales from legal action. provide ongoing patient care.

8 1 April 2017 | the bmj BMJ OPINION Oliver Loi-Koe, Anya Göpfert HEE report sets out plan to improve junior doctors’ morale

Low morale, extortionate exam fees, and commutes. HEE has promised to analyse the a poor work-life balance are inherent to effects of rotations across large geographical being a junior doctor in the NHS. Junior areas. This should provide evidence on doctors would say these issues have been which to base changes to the current unfair ignored. A new report from Health Education and rigid system. With postgraduate training England details plans to tackle the crisis, costing on average around £17 000 and including cutting the costs of exam fees and anaesthetics training reaching £25 000, making training more flexible (http://bit. juniors have long called for financial support ly/2o907dQ). from their respective royal colleges. Vague Training less than full time (LTFT) is a promises of “best practice principles” are all tempting offer of greater flexibility and that is currently offered by HEE, so proposals improved work-life balance. Until now it was for reducing costs will be welcomed. open only to doctors with a “well founded But ideas on paper and their real how we empty the hospital. Like individual reason.” life implementation are worlds apart. most NHS hospitals we’re full, so it’s The HEE report proposes that everyone The current state of the medical vital we’re able to create space,” he should be eligible. This could encourage workforce demands rapid and effective said. “The theatres have to continue junior doctors to stick with specialties such improvements. Solutions such as running, so in order to do that we had as emergency medicine, where up to 50% the LTFT pilot schemes show that HEE to empty five intensive care beds to leave before completing training. However, will be pragmatic in moving forward. sister hospitals. Charing Cross had this may not help reduce gaps in the rota. Prioritising progress in reducing the cost empty beds, so they were able to take More doctors working part time will mean and disruption of training is, however, some of our patients. fewer on the scheduled rota—how will this essential. As NHS junior doctors we “The Charing Cross teams came work in an NHS already struggling to provide are concerned that promises will not over to St Mary’s and picked up a service? materialise given the constraints of staffing the patients. This meant that our HEE is introducing an LTFT pilot scheme rotas. These proposals may be seen by workforce weren’t affected by having from spring 2017 for all higher trainees some as unnecessary extras. to take a team out of St Mary’s. Their in emergency medicine across England. Yet the crisis in morale in the workforce role was absolutely vital.” If successful, other specialties struggling will only worsen if things don’t change. We He added, “We deal with trauma with recruitment could adopt a similar desperately hope that HEE will ensure that day in, day out. The chief surgeon and programme. This is the first indication of a the NHS understands that this report is I were talking about it. We said it was system willing to be flexible to suit the needs long overdue and that its implementation is like a slightly augmented normal day of junior doctors. urgently needed. at St Mary’s.” HEE is also to be applauded for finally Oliver Loi-Koe is an FY2 trainee at Kent and Anne Gulland, London tackling a huge source of frustration to junior Canterbury Hospital and Anya Göpfert is an FY2 Cite this as: BMJ 2017;356:j1515 doctors. Currently, training is expensive and trainee at Bristol Royal Infirmary disruptive, with repeated moves and long ЖЖCAREERS, pp 37-8 GOOD SAMARITAN ACTS Recognise your 5 limitations Doctors may be asked to act as a good Samaritan at a time when they are unwell or tired. In this instance, it is important to assess whether they are competent to help. If another doctor or healthcare professional is at the scene it may be more appropriate for that person to help instead.

the bmj | 1 April 2017 9 KUNAL PATIL/HINDUSTANI TIMES/GETTY IMAGES 10

1 April 2017 | the bmj THE BIG PICTURE Indian doctors take to streets over poor security

Nearly 40 000 doctors in Delhi and Mumbai have gone on strike to demand better security in government hospitals, after a spate of attacks on medical professionals. Pictured are staff from Sion Hospital, in Mumbai. If the government continues to ignore their safety concerns, doctors have threatened to call a nationwide strike. Last week a 35 year old junior doctor, Rohan Mhamunkar, was brutally assaulted by relatives of a patient in the emergency department of a hospital in Dhule, a city 300 km from Mumbai in the state of Maharashtra. Within days four more doctors in the state were attacked in separate incidents. “The young doctor has lost his eyesight in one eye. In the face of such violence, all we want is more secure working conditions for us from the government,” said Doctor Ashokan of the Indian Medical Association. To demonstrate their feelings about violence against the medical profession, doctors at the All Institute of Medical Sciences in New Delhi wore helmets last week while they tended to their patients. In India’s understaffed, under-resourced healthcare system, violent incidents against doctors are common. A survey conducted by the Indian Medical Association in 2015 found that 75% of Indian doctors had faced some form of violence in their workplace. Data from the past five years of the survey showed that patients’ relatives and attendants committed 68% of the violence. As well as demanding more guards at hospitals, doctors want the government to impose a limit on the number of relatives allowed to visit patients on wards. Writing for BMJ Opinion this week (blogs.bmj.com/bmj), Avinash Supe, professor of surgical gastroenterology at KEM Hospital in Mumbai, pointed to other triggers. “There is a growing misunderstanding that doctors are unnecessarily admitting and treating patients for economic reasons, creating a divide of mistrust. Mounting health bills for services, along with misperceptions like these, become triggers for violence against doctors.” Prashun Mazumdar, New Delhi Cite this as: BMJ 2017;356:j1571 the bmj | 1 April 2017 11 EDITORIAL Pollution of health news Time to drain the swamp

S President Donald The sources and device manufacturers, and We have no evidence that the authors Trump placed the of the industry funded advocacy groups. set out to deceive deliberately, but term fake news in the pollution are When researchers, their journal their preliminary, un-peer reviewed, global lexicon with often public manuscripts, news releases, and and unpublished data were seriously his repeated criticism relations journalists spin findings to emphasise conflicted and had the potential to Uof journalism that doesn’t suit him. the beneficial effect of an intervention,9 mislead. The report called for sweeping news releases But with the viral spread of that term, is that fake news? The definition seems changes in university policy. many now apply it to what is actually emanating to matter less than the imperative to One aspect of this episode deserves sloppy journalism. Fake denotes from these find a solution. more attention, since it has potential deliberate deceit. Sloppy refers to vested The media watchdog ethical ramifications for universities a much broader range of hurried, interests HealthNewsReview.org has everywhere. This excerpt of the incomplete, poorly researched news, systematically reviewed more than 330 Maryland report captures the issue: not necessarily with deceitful intent. healthcare news releases in the past The PI [principal investigator], as well as They are different problems with two years. Our aim is not only to check several others, expressed less concern for, different sources and require different facts but to help citizens learn how to and were perhaps less attentive to, the potential of a research conflict of interest solutions. improve their critical thinking. If we in part because they felt that this project Journalists and had not begun looking, the following was in support of small business which is officials have shown that Trump has troublesome episode would probably highly encouraged by the state and actively promoted fake news about health have evaded scrutiny. promoted by the university. and health policy with, for example, Last year, a University of Maryland The research was funded through his statements about vaccines news release claimed, “Concussion- the Maryland Industrial Partnerships and autism.1 His recent State of related measures improved in high programme, which “promotes the the Union address included false school football players who drank development and commercialization assertions about the Affordable Care new chocolate milk.”10 We raised so of products and processes through Act2 3 and the US Food and Drug many questions that the university industry/university research Administration.4 5 announced an internal investigation. partnerships.” Most universities The democratisation of the internet Its final report uncovered a debacle, now have such technology transfer delivers the unfortunate side effect describing a study with “too many programmes. How much more news of allowing fake health news to be uncontrolled variables to produce that is conflicted or worse will we find spread by websites that deliberately meaningful scientific results, emanating from such efforts, especially publish hoaxes, propaganda, and particularly troubling because students if researchers perceive that this is what disinformation as real news—often were used as subjects.”11 The report they are being encouraged to promote? using social media to drive web traffic stated that the lead researcher did not There is a saying: “Journalism is and amplify their effect.6 Google and declare $200 000 received from the printing what someone else does not Gary Schwitzer, Facebook have taken steps to try to publisher of Allied Milk Foundation as a conflict want printed; everything else is public stop fake health news messengers, at HealthNewsReview.org, of interest, and this was part of “a relations.” Media watchdogs often find least temporarily.8 University of Minnesota concerning lack of understanding substantially more of the latter than the School of Public Health, Minneapolis, MN, USA of the basic principles of conflict of former. Polluted stream [email protected] interest in research at all levels.” Many news organisations have Social media sites are often mere increased their fact checking of conduits for news coming from further political news in recent months. We upstream, including vested interests wish we had seen a commensurate that stand to gain by promoting their boost in checking of news about public ideas in the most positive light. The health, healthcare, and biomedical sources of the pollution are often public research. relations news releases emanating from Journalism has the ability to expose these vested interests, most notoriously and dismantle news that is fake and from questionable commercial interests to refute unsubstantiated criticism of such as companies selling herbal cures news that is not fake. for cancer, but also from mainstream It is time to drain the swamp created government health agencies, by the polluted stream. researchers, universities, clinicians, Cite this as: BMJ 2017;356:j1262 Find the full version with references at hospitals and medical centres, drug http://dx.doi.org/10.1136/bmj.j1262

12 1 April 2017 | the bmj EDITORIAL Whatever happened to the polypill? The idea is slowly but surely gaining ground

t has been nearly 15 years The polypill concept is grounded since Wald and Law proposed in several important epidemiological that a polypill could reduce principles. Key among them is that cardiovascular events if taken a large proportion of cardiovascular by everyone from the age events occur in people with Iof 55 years (one form of primary “normal” blood pressure and I N M TFOR prevention) and all people with cholesterol levels. This prevention ME aspirin tin r pre-existing cardiovascular disease paradox occurs because most people sta t o hibi (secondary prevention).1 Initial are in the middle of the distribution ace-in responses to the idea were mixed, of these risk factors and because with most who voiced opinions there is a consistent proportional The ideal receptor blocker instead of an expressing opposition.2 Others relation between these risk factor formulation for angiotensin converting enzyme were enthusiastic about the idea’s levels and cardiovascular events.9‑11 a polypill has inhibitor would probably be better potential, and since the 2003 Using “diagnosis” of hypertension been a matter tolerated on a population level. The publication several polypill trials or hyperlipidaemia as the basis for of debate statin used should have minimal have shown tolerability and benefit offering risk reducing therapies potential to interact with other on intermediate and some clinical ignores these principles. It also does drugs that might potentiate the outcomes.3‑6 not consider the combined effect risk of myopathy. Of the current In a recent HOPE-3 trial 6 7 a of risk factors or the fact that the proposed components, aspirin is polypill reduced cardiovascular strongest risk factor is age. the most potentially toxic, and the events by 29% over about 5.6 Fortunately, the clinical approach decision to include it needs to be years, relative to placebo, in a to primary prevention has evolved. carefully weighed against the risk of sample of over 12 000 adults all In contrast to the diagnostic gastrointestinal bleeding, which also at moderate risk of cardiovascular approach, calculation of overall increases with age. disease (3.6% v 5.0%; P=0.005). cardiovascular risk allows the How can the polypill idea move No participants had a history of clinician and patient to consider the forward? Only high income countries cardiovascular disease, making this combined contributions of all risk are likely to have the resources and a trial of primary prevention. Rates factors, regardless of their levels.12 infrastructure required to dispense of discontinuation (26.3% v 28.8%) This approach allows clinicians for and monitor large numbers of and serious side effects did not differ to shift focus from assessing and adults taking polypills, even if this is between the groups. treating risk factors to assessing risk done through community pharmacies The use of a polypill for secondary and offering interventions (statins rather than clinicians’ offices. In prevention, typically as a substitute and aspirin) to reduce risk.12 The low and middle income countries, for individual drugs, has become polypill approach builds on this where access to clinical services is more acceptable, especially if it idea, adding drugs to lower blood limited, an over-the-counter or public improves adherence and reduces pressure and taking us a few steps health dispensing approach could be costs.6 In one survey of US closer to a population strategy. evaluated for effectiveness and safety. physicians published in 2011, about We should continue to develop two thirds reported they would Questionable safety more and better evidence in different prescribe a polypill for patients with One of the remaining concerns that populations to firmly establish long established cardiovascular disease.8 makes a population level approach term safety and effectiveness. If it is Even though more than half unacceptable to many clinicians, shown to cause minimal harm and indicated they would prescribe a patients, and the public is the reduce the risk of cardiovascular polypill to moderate risk patients for questionable safety of large numbers events, we may reach a time when primary prevention (people without of people taking such drugs without everyone can choose to take a known cardiovascular disease), supervision and monitoring.6 8 The polypill when they reach a certain its use for primary prevention is ideal formulation for a polypill has age or risk level. It certainly doesn’t still controversial. Data on hard been a matter of debate, but most Anthony J Viera, reduce the need to encourage and professor, Department clinical outcomes are sparse and proposed formulations contain a of Family Medicine, facilitate a healthy diet and taking many clinicians, patients, and the statin, blood pressure lowering University of North more exercise. public remain concerned about drug(s), and possibly aspirin. For Carolina, Chapel Hill, NC, USA Cite this as: BMJ 2017;356:j1474 “medicalising” an essentially primary prevention, a pill without anthony_viera@ 6 Find the full version with references at healthy population. a β blocker and with an angiotensin med.unc.edu http://dx.doi.org/10.1136/bmj.j1474 the bmj | 1 April 2017 13 EDITORIAL The changing role of the CMO for England Chief medical officers today must undertake a careful balancing act

very six months the chief by the World Health Organization’s The expectation Donaldson. In 2007 Donaldson led the medical officers (CMO) Framework Convention on Tobacco now is that development of the government’s first from each EU member Control, concerted international action advice is strategy,7 contributing state meet to discuss is essential. Another is the threat posed grounded in substantially to the then emerging emerging public health by infectious disease and, especially, findings from international global health agenda. Eissues. For more than 40 years, the antimicrobial resistance. This too can Davies has continued this process, research occupant of the British seat, the be tackled only by a coordinated global focusing on the global threat from CMO for England, has been a valued response. antimicrobial resistance.8 She is contributor. If Theresa May has her A second development has been the widely credited with having led the way, and the UK actually manages to weakening of the British civil service, process that culminated in the 2016 leave the EU by 2019 that seat will which has been subjected to relentless UN Declaration on Antimicrobial be vacated. This will be a great loss cuts for many years. The Institute Resistance.9 This process showed to Europe, given the expertise that for Government has warned that it the importance of being able to successive CMOs have brought, but simply may not have the capacity to assemble a solid body of research even more so for the UK, which will be implement the enormous changes and working across many sectors. excluded from important discussions that will result from Brexit.6 These cuts This was exemplified in the report on policies that will, despite Brexit, have had a disproportionate impact she persuaded David Cameron to inevitably have consequences for this on professional advice to ministers. commission from former Goldman country. Yet, this is only the latest Earlier CMOs led teams of highly Sachs chair Jim O’Neill, which change in a role that has continually qualified doctors, each able to offer predicted 10 million deaths per year been evolving since it was created specialist expertise in different areas. by 2050 and a cost of $100trn (£80trn, in 1855.1 The world has changed That has now gone and, when the €92trn) if nothing was done.10 enormously. Has the role of CMO present English CMO assumed office, managed to keep pace? she had no professional staff and only Choose your battles The role of a CMO in the UK, as minimal administrative support. Yet while Davies is widely admired the senior medical adviser to the A third, and related, development internationally, criticisms have government as a whole—not just to a has been the fragmentation of sometimes been voiced domestically. health ministry—is unusual. CMOs in the health landscape in England, Some of the more vocal public health the UK also have more independence, especially after the 2012 Health and advocates had hoped that she would at least formally, than in many other Social Care Act. This created two have been more vocal in opposing countries. Second, although the new organisations—NHS England certain policies of the current English CMO represents the entire and Public Health England—that at government. Notwithstanding their UK, and the dependent territories, least on paper operate at arm’s statutory independence, CMOs must in the international arena, there are length from government and, undertake a careful balancing act, also CMOs in Scotland, Wales, and by extension, from the CMO. choosing very carefully which battles Northern Ireland, with responsibilities The fourth is the growing they will fight in public. As successful divided in keeping with the UK’s importance of evidence, at generals have realised, it is best to constitutional complexity.3 least in advice to ministers choose battles you will win, which even if not always in the is not easy when powerful vested New developments resulting policies. While interests are supported by much Four developments in particular earlier CMOs would often of the British media, shout “nanny have influenced the changing role give advice based on their state” at every opportunity,11 and of the English CMO. The first is the professional judgment, when ministers declare that we have increasingly global nature of health the expectation now is had enough of experts. Despite these threats and the corresponding need for that advice is grounded in difficult circumstances, recent CMOs an international response. The health findings from research, and have had some striking successes. consequences of globalisation are as importantly, is seen to Where they have failed, it is difficult to now well established. One is the role be so. see how others could have done better. of international trade as a determinant These developments Martin McKee, professor of European Public of health4 and, with it, the power have had the greatest Health, LSHTM, London WC1H 9SH, UK of international corporations, such impact on the current [email protected] as the manufacturers of junk food, CMO, Sally Davies, and Cite this as: BMJ 2017;356:j1545 5 Find the full version with references at alcohol, and tobacco. As exemplified her predecessor, Liam http://dx.doi.org/10.1136/bmj.j1545

14 1 April 2017 | the bmj n the year that sees the 50th BRIEFING Health (Access to Terminations) anniversary of the Abortion Bill, was introduced in the House of Act 1967, which created a Commons by the Labour MP Diana framework for legal termination, Abortion Johnson on 13 March. The second campaigners argue that reading will be on 12 May, after MPs Iabortion should be decriminalised voted in favour by 172 votes to 142. It in England and Wales. A coalition of decriminalisation is unlikely to become law. 20 organisations, We Trust Women, says that women who choose abortion Campaigners want repeal of law, writes Have other countries decriminalised? should no longer risk life imprisonment Clare Dyer In 1988 the Supreme Court of under a law dating back to the Canada struck down the criminal Victorian era, when only men could code governing abortion as vote. The organisations include the unconstitutional, so abortion is no Royal College of Midwives and Doctors longer a crime there. The abortion rate for a Woman’s Choice on Abortion. The has remained fairly low and there are BMA has no policy on the matter but few late abortions. Statistics for 2014 has issued a discussion paper. show an abortion rate of 14.7 per 1000, which compares with 15.9 per What is the law in England and Wales? 1000 in England and Wales. In Canada Abortion is a crime under the 1861 0.86% of abortions were performed Offences Against the Person Act. The after 21 weeks. England and Wales Abortion Act creates an exception, have no directly comparable statistic making abortion on licensed but less than 0.1% of abortions premises lawful under specific were done after 24 weeks. In some conditions. Abortions under any parts of Australia abortion has been other circumstances are unlawful. If decriminalised as part of overall a woman obtains abortifacient drugs reform of abortion law. online and uses them at home to terminate a pregnancy, even before bodies. Many countries in Europe The 1861 act is What do opponents say? 12 weeks’ gestation, she commits recognise that a woman has a right punishable by Much of the opposition comes from an offence under the 1861 act that is to end a pregnancy before the fetus is a maximum Christian and antiabortion groups. punishable by a maximum sentence of viable. Campaigners want legislation sentence of life Some midwives opposed to their royal life imprisonment, the harshest penalty repealing sections 58 and 59 of the imprisonment, college’s stance have labelled the imposed by any European country. 1861 act. Decriminalisation would not the harshest measure “extreme.” Maria Caulfield, Two recent prosecutions in mean deregulation: abortion would the Conservative MP who opposed the England involved vulnerable women still be regulated, says Sally Sheldon, penalty bill, said, “It would remove some of who obtained pills to carry out late professor of law at Kent University, imposed by the few protections and regulations in term abortions. who coordinated a letter to the any European abortion law, fuelling unethical and Guardian newspaper signed by more country unsafe practices in many UK abortion What do campaigners want? than 200 legal experts in support of clinics and leaving women less safe Campaigners say that abortion is decriminalisation. and less informed.” the only medical procedure that Clare Dyer, legal correspondent, The BMJ is regulated by the criminal law, How far has the campaign got? [email protected] denying women control of their A 10 minute rule bill, the Reproductive Cite this as: BMJ 2017;356:j1485

COMMENTARY Regulating abortion as heathcare Consider the Canadian experience of Decisions are provide more abortions than hospitals. week earlier they can be performed. nearly 30 years without a criminal law to made in the Overall abortion rates have been in Furthermore, criminal law barriers to police abortion. same way as decline since the mid-1990s despite access are associated with the unsafe Abortion decisions are made in the those about relative stability in birth rate. This is practice of illegal abortions, and can same way as those about vasectomy not surprising. Although globally we prompt women to access abortion or treating a ruptured appendix. They treating a see a direct correspondence between methods without supervision and advice happen in the context of the doctor- ruptured more legal restrictions on abortion from regulated healthcare professionals. patient relationship. Abortion is seen, appendix and increased maternal mortality and W V Norman, associate professor, funded, and regulated as a health service. morbidity, criminalisation of abortion is Department of Family Practice, University Since our criminal law was struck not associated with fewer abortions. of British Columbia, Canada down, Canadian women have had Abortion in Canada has also become [email protected] improved access to abortion in safer. Ensuring access with the fewest J Downie, professor, Faculties of Law and hospitals and through the emergence restrictions or delays is important Medicine, Dalhousie University, Canada of freestanding clinics, which now because abortions are safer with each Cite this as: BMJ 2017;356:j1506 the bmj | 1 April 2017 15 ILLUSTRATION: DUNCAN SMITH

BMJ CONFIDENTIAL Devi Sridhar Governing global health

What was your earliest ambition? To be a professional tennis player and win the Open. Who has been your biggest inspiration? My grandmother. In her 60s she finished a PhD, wrote several books, and even joined me for part of my fieldwork in the slums of New Delhi. What was the worst mistake in your career? Early in my career I used to say yes too often and found it hard to say no. The best advice I got then was that it’s better to be respected than liked. What was your best career move? Turning down a funded place at Harvard Law to do my PhD in Oxford. To whom would you most like to apologise? My dad, for not becoming a real doctor. At least I ended up in a medical school. Devi Sridhar, 32, jokes that she won a Rhodes scholarship to Oxford by going to If you were given £1m what would you spend it on? a Barnes & Noble bookshop and reading Building a massive centre to look at the political economy of global health: yes, the Idiot’s Guides to world conflicts and we need investment in vaccines and drugs and new technologies, but we also philosophy—“a great basic education.” need robust academic analysis of what needs to change to improve human health. Now professor and chair in global public We’re starting to build this through the Global Health Governance Programme. health at Edinburgh University, she had in fact graduated from university What single unheralded change has made the most difference in your field in Miami at 18 (having been born and in your lifetime? brought up there), so it’s unlikely that Millions of children’s lives have been saved because of big partnerships in global the Idiot’s Guides were needed. At Oxford health, such as the GAVI Alliance for vaccines and the Global Fund for HIV/AIDS, she was first a research at All Souls College then associate professor from tuberculosis, and malaria. 2007 to 2012, and her research has What book should every doctor read? focused on the governance and financing Paul Farmer’s Pathologies of Power. He writes beautifully and conveys a powerful of global health. Her latest book, Governing Global Health, was co-written narrative about medicine’s close links to anthropology and politics. with and is published this What, if anything, are you doing to reduce your carbon footprint? week by Oxford University Press. If I can video-Skype into a meeting I do that instead of travelling there. What personal ambition do you still have? To complete a triathlon. Summarise your personality in three words Curious, energetic, and loyal. I’m also usually sleep deprived. Where does alcohol fit into your life? Nowhere—I’m a non-drinker. What is your pet hate? Negativity and jealousy. What would be on the menu for your last supper? Papayas, mangoes, watermelon, dragon fruit, lychees, jackfruit, and starfruit. Do you have any regrets about becoming an academic? None at all. I get to teach enthusiastic and bright students, do interesting research that takes me all over the world, work closely with a focused team, and engage with government and UN officials and the media. If you weren’t in your present position what would you be doing instead? I’d be in the US, finding ways to be politically active. Cite this as: BMJ 2017;356:j1490

16 1 April 2017 | the bmj