this week SHARED APPOINTMENTS page 87 • FOLIC ACID page 88 • CORONERS’ REPORTS page 89

Whistleblower trainee drops claim

A junior doctor who claimed that he was The statement agreed that Day had Chris Day, who worked at unfairly dismissed by an NHS trust for blown the whistle by raising patient safety Queen Elizabeth Hospital in whistleblowing about unsafe staffing concerns in good faith and had “performed Woolwich, fought his claim for unfair dismissal for four years levels and that his career was subsequently a public service in establishing additional destroyed by Health Education England has whistleblowing protection for junior withdrawn his claims part way through an doctors.” But, it added, “The tribunal employment tribunal hearing. is likely to find that both the trust and Chris Day, 33, fought a four year legal HEE acted in good faith towards Dr Day battle to have his claims heard after raising following the whistleblowing and that Dr concerns in 2014 about understaffing Day has not been treated detrimentally on and safety at the intensive care unit of the the grounds of whistleblowing.” The claims Queen Elizabeth Hospital in Woolwich, were “dismissed upon withdrawal.” London, where he was a specialist registrar HEE said in a statement, “We have always in emergency medicine. He claimed that been clear we did not act against Dr Day after he repeated the concerns to HEE it because of his protected disclosures or deleted his training number, making it cause him any detriment. HEE has always LATEST ONLINE impossible for him to continue training. supported healthcare staff blowing the HEE claimed that it was not legally his whistle. It is part of the education and • Physician associates employer, so no case could be brought training we oversee for new clinicians.” will be regulated along same lines as against it under employment law. But in A BMA spokesperson said that it had doctors and nurses 2017 the Court of Appeal ruled that HEE secured legally binding protections, in does employ junior doctors, along with force since August 2016, that “ensure that • Drug companies are incentivised not the trust at which they are placed, opening doctors, whether they are BMA members to improve health the way for junior doctors to bring claims or not, can raise relevant issues in the against HEE at an employment tribunal. workplace, knowing that there is a robust • Number of US children who The tribunal opened this month and was legal apparatus in place to safeguard them are completely expected to last 21 days. Day gave evidence from any detriment that they may suffer unvaccinated has and was cross examined, but after six days from HEE as a consequence.” quadrupled since a statement withdrawing his claims, agreed Clare Dyer, The BMJ 2001 by all three parties, was read out. Cite this as: BMJ 2018;363:k4356 the bmj | 20 October 2018 85 GMC investigators to get training in Flour expected to be fortified system issues with folic acid within weeks

GMC staff and clinical experts who ealth experts have welcomed 14 October, though the Department of Health investigate doctors’ fitness to practise reports that the UK is poised for England wouldn’t confirm the move. will be trained in “human factors” so to start fortifying flour with The incidence of neural tube defects in that the context in which doctors have folic acid to help prevent birth the UK is among the highest in Europe, to work is taken into account when the defects such as spina bifida and affecting around 1000 pregnancies a year. regulator takes decisions. Hanencephaly. Experts say that there is clear evidence that The move follows the case of the Nicholas Wald, of the Wolfson Institute fortifying flour with folic acid would lead to a trainee paediatrician Hadiza Bawa- of Preventive Medicine at Queen Mary significant reduction in neural tube defects, Garba, which sparked a widespread University of London, said, “If this is officially such as anencephaly and spina bifida. loss of confidence in the GMC. confirmed, the UK is taking an important step They say such a measure would reach The regulator has teamed up with in preventive medicine and helping to avoid women who are most at risk, including those Oxford University’s Patient Safety disability or termination of pregnancy.” with poor diet and from low socioeconomic Academy to provide the training, and it groups, as well as women who may not have plans to introduce the same approach In line with other countries planned their pregnancy. in local investigations of doctors’ The Royal College of Obstetricians and Official guidance is that women take 400 μg conduct and performance before they Gynaecologists said that such a move would of folic acid daily while trying to conceive, reach the GMC. see a “significant reduction in the incidence until the 12th week of pregnancy. But Peter McCulloch, co-director of the of neural tube defects, for the benefit of many women do not take the supplements, academy, said, “Our aim in this work women and their babies and families.” especially if a pregnancy is unplanned. is to ensure that context and systems Leading medical organisations and issues are always fully taken into charities have long been calling for account when evaluating a doctor’s mandatory folic fortification, which would OFFICIAL health performance, allowing doctors to have bring the UK in line with other countries, guidance is that all women take confidence in the fairness of the GMC’s including the US and Canada. procedures.” Ministers have now been persuaded of the 400 μg of folic acid daily while Clare Dyer, The BMJ scientific case and will introduce the policy, trying to conceive, until the 12th Cite this as: BMJ 2018;363:k4295 possibly within weeks, said the Guardian on week of pregnancy.

Doctors’ conversations with dying patients need to improve

perceived as a failure and that modern prioritised time for conversations, and medicine was expected to cure all the need to be sensitive to different ailments. However, evidence from cultural and religious beliefs. patients and carers indicated that many One key issue identified by the report people wanted to talk about death and was that healthcare professionals that planning helped them feel more needed to begin conversations about empowered about their care. planning for care at the end of life care nearer to when patients were given a Lack of privacy terminal diagnosis, to give patients a A range of clinicians interviewed for the better experience. report said that they were uncomfortable RCP president Andrew Goddard said, with initiating conversations about “This report is a big step forward in Training did Doctors need to speak to patients the future with patients. Students and helping patients, relatives, and doctors not prioritise with terminal illnesses in a timelier junior doctors had little practice with to talk honestly about death and dying. the “soft” way and handle conversations with real patients and said that their training “We must minimise the barriers in skills needed greater compassion and confidence, did not prioritise the “soft” skills they our systems and culture that prevent says a report from the Royal College of needed. this happening. This is not just about Physicians. Other barriers to talking about death palliative care in the final days but about The report, which examined why included confusion over whether having a series of conversations much clinicians find it difficult to talk to hospital doctors or GPs should be earlier after a terminal diagnosis.” patients about dying, found that some having the conversation, workforce Adrian O’Dowd, London doctors thought that death could be pressures, lack of privacy, lack of Cite this as: BMJ 2018;363:k4330

88 20 October 2018 | the bmj FIVE MINUTES WITH . . . Nicola McKinley The surgical trainee discusses why she is conducting a nationwide survey of doctors’ resilience

urrently, the only study on how resilient NHS doctors are is our pilot study. Our team at Queen’s University Belfast ran a survey Experts say that folic acid fortification will help prevent birth defects such as spina bifida in a single NHS trust in Northern Ireland“ in CAugust 2016. Overall, 283 doctors Wald led research that found that affairs for the British Pregnancy were surveyed, and we found that, despite being there was no need for an upper limit Advice Service, said that fortification resilient, 37% of them were still really burnt out of folate intake and was seen as “will spare hundreds of women the and 72% had high traumatic stress from their job. removing any final barriers to folic heartbreak of receiving the news that “These findings gave us limited information, acid fortification of foods such as flour. their baby has a serious condition.” which is the reason for the nationwide survey. He said that if the government She said that the measure should be “There is no universal definition of resilience, but action was confirmed, “there will brought forward “as soon as possible.” I think it would be generally accepted that it’s the undoubtedly now be discussion The Labour MP Owen Smith, ability to recover from stress or bounce back from an over the level of fortification, which who has campaigned on folic acid adverse incident. should be high enough to prevent an fortification, said, “I have today “We are using three questionnaires that have estimated half of cases of spina bifida written to the health minister seeking a good evidence base. The Connor-Davidson and anencephaly. “Fortification of confirmation that this measure will Resilience Scale asks clinicians flour with folic acid provides a safety go ahead and called on him to make to think about the past 30 days net; it does not mean that women a statement in parliament ahead of and rate themselves on a scale. no longer need to take a folic acid a debate we have secured for spina We also use the professional supplement, and this should be 5 mg a bifida awareness week next week.” quality of life scale, ProQOL day, to obtain the full protection.” Matthew Limb, London 5, which measures burnout, Clare Murphy, director of external Cite this as: BMJ 2018;363:k4348 secondary traumatic stress, and compassion satisfaction—which is the pleasure you derive from Deaths from medicines: lessons doing your job well. The final test GETTING we use is the Brief COPE coping A GOOD from coroners’ reports are missed scale, which asks people to think RESPONSE about how they managed difficult RATE COULD Coroners’ reports often do could be used to prevent to them. So, it is difficult events in the past 30 days. REALLY MAKE A DIFFERENCE not fulfil their statutory future deaths. The report to know whether—with “We hope that our survey will aim to prevent future outlines the coroner’s regards to medicines—the help to target interventions at people who have less deaths in the case of recommendations for coronial system prevents resilience. Or, if we find that people are identifying fatalities related to drugs, action and requires a future deaths. Only a reduced resilience at certain points in their career, a report concludes. response within 56 days, minority of the responses then interventions could be put in place at different The researchers, led outlining action. that we analysed appear career stages to tackle that. If we find that doctors by Robin Ferner of the to provide robust and are using dysfunctional coping strategies, then West Midlands Centre for Responses not published generally applicable ways we could focus on how we can improve those Adverse Drug Reactions, The researchers found to prevent future deaths.” strategies; for example, it could help deaneries to said that alerting that reports of national If coroners’ reports know how best to help their trainees. national rather than importance were usually were routinely sent “I want to encourage doctors to fill the survey in. local organisations to the sent only to local bodies. to bodies such as Getting a good response rate could really change reports would ensure that Despite calls for more NHS Improvement, things. If we can target interventions at specific important lessons about openness to help boost the researchers said, career stages or at specific groups of doctors, then patient safety were learnt. patient safety, many “important information we could really make a difference.” The law in England and organisations did not to prevent future deaths The survey is at www.surveymonkey.com/r/GVWC9GT. Wales requires coroners publish their responses. would be available to the Nicola McKinley is a core surgical trainee and a member of the to write “regulation 28” In addition, said the whole NHS and lessons Quality of Life, Coping, and Resilience (QOLCARE) study group at the centre for public health, Queen’s University Belfast. reports to the appropriate authors, “there appears to less easily forgotten.” bodies if an inquest be no system for auditing Clare Dyer, The BMJ Abi Rimmer, The BMJ reveals information that concerns and responses Cite this as: BMJ 2018;363:k4322 Cite this as: BMJ 2018;363:k4332 the bmj | 20 October 2018 89 A retired GP is standing trial accused of at the practice, “may have felt himself to be molesting dozens of female patients over untouchable and unchallengeable at the time more than two decades for his own sexual because of his position both in the practice grati cation. and in society.” Alan Tutin, now aged , carried out the Tutin faces  charges of indecent assault assaults between  and , when and one of assault by penetration. Among his he retired from Merrow Park Surgery in accusers are a community midwife and a GP Guildford, Surrey, prosecuting counsel Sally trainee linked to the practice. O’Neill told the jury at the Central Criminal The court heard that there were allegations Court in London. of sexual assault in  resulting in two The patients he is accused of assaulting trials, neither of which ended with any included a girl of , who was given a vaginal “adverse ndings” against Tutin. He was also and rectal examination in  that made arrested in , but no prosecution followed her cry out in pain. She asked her mother, then. The criminal GP is accused “Why did the doctor hurt me?” O’Neill said. “The assaults inquiry was reopened “The assaults were typically committed were carried in , and under the guise of breast or vaginal out for sexual letters were sent to of molesting examinations, some of which were entirely gratification” thousands of former unnecessary and were carried out for his patients. dozens of sexual grati cation and some of which may Louise Sweet, defending, said that Tutin have been justi ed, but which were carried was a dedicated doctor who was valued out in a totally inappropriate way, again for in the community. But “all that was to patients over his sexual grati cation,” O’Neill told the jury. change dramatically in  when sexual “Complainant a er complainant say that allegations, for which he has been wholly two decades Tutin behaved towards them in a way which exonerated, were levied at his door. They led they knew at the time wasn’t right, but mostly to the rst explosion of adverse press and, we didn’t have the courage to say anything say, poison, from which he has never been about it. These invasive examinations, o en able to recover.” unnecessary, were carried out for his sexual Tutin denies all the charges and maintains grati cation and his attempts to explain that any examinations he carried out were away what they are saying are an attempt to clinically indicated. The trial continues. blind you with science.” Clare Dyer, The BMJ O’Neill said that Tutin, a senior partner Cite this as: BMJ ;:k Professor sanctioned for pursuing relationship with patient

A professor of clinical compliment that you attract He admitted grati cation from this,” “confused” and “muddled.” nephrology at King’s doctors.” to being he said. “I didn’t want a Melissa Coutino, chairing College Hospital in London The  year old woman “foolish and sexual relationship. I was the tribunal, said it had who told a patient that recorded some of the calls unprofessional” concerned about her. These accepted his explanation he was “a bit infatuated” and reported Macdougall to are  attering comments that “he was pursuing with her must work under the hospital. The tribunal I made to her. As she was emotional support supervised conditions for in Manchester heard the vulnerable I thought I could and escapism from his three years a er a medical recordings but not the help her. circumstances at that time.” practitioners’ tribunal testimony of the woman, “I didn’t think at the time She said the tone and accepted his claim that referred to as Patient A. She it could harm her or harm content of the recordings he did not want a sexual died later in , although me. I stupidly thought did not adequately support relationship but found that the tribunal emphasised bantering with her would a General Medical Council he had improperly pursued that her death was not help her. I should have put charge of sexually motivated an emotional one. related to Macdougall’s the patient rst. I’m very misconduct. But she said Iain Macdougall, , actions. sorry.” He conceded that he that Macdougall had been telephoned ve times and Macdougall admitted enjoyed the conversation late in realising that Patient le a voicemail over a being “foolish and and had a bene t from it. A was vulnerable when it few days in , telling unprofessional” but A con dential session should have been obvious, a patient who struggled told the tribunal that of the hearing heard particularly as she appeared with alcoholism that “you he had been trying to from Macdougall about to be intoxicated during the kind of, slightly, got under boost the woman’s “devastating personal conversations. my skin” and that “you mood and self esteem. circumstances” that had Clare Dyer, The BMJ should take it as a massive “I had no sexual le him temporarily Cite this as: BMJ ;:k

90 20 October 2018 | the bmj NEWS ANALYSIS Cannabis based drugs GPs will have to manage patients’ expectations and increased demand says expert

Ps could be inundated doctors. “Where do GPs and even the said she was interested in seeing the with requests for specialists look for evidence around interim guidance due to be published cannabis derived how to make a clinical decision?” on November. medicines next month he asked. “It just isn’t there at the “Right now, it’s not clear who exactly without the resources moment. The chances are the patients will be able to access cannabis for to G properly advise patients, an are more likely to be better informed medicinal use and how the system will expert has warned. about this than the practitioners.” work,” she told The BMJ. Ian Hamilton, a lecturer in addiction “More than   people live with at the University of York, has welcomed Interim guidance MS in the UK, and we know cannabis the announcement by the UK home To bridge the information gap NHS could help roughly one in  of them secretary, Sajid Javid, that specialist England will later this month publish get relief from pain and muscle doctors in England, Wales, and interim clinical guidance for specialist spasms. We’d encourage people Scotland will be able to prescribe clinicians on prescribing medicines with MS seeking to access cannabis cannabis based products for medicinal derived from cannabis. This will be for medicinal use to speak with their Alfie Dingley (top) use from November. But he warned supplemented by specific guidance for neurologist, or their GP who could refer and Billy Caldwell that patients could face lengthy prescribing for children with epilepsy had problems them to an MS specialist.” waits for treatment because of the from the British Paediatric Neurology getting cannabis Some GPs will have specialist “considerable” demand that the move Association and guidance covering for their epilespy knowledge of cannabis based could create. chemotherapy induced nausea and products and of their benefits in “It potentially gives a lot of patients vomiting and chronic pain from the managing different conditions and will false hope that this is going to be a Royal College of Physicians. relatively smooth and easy process. The Home Office said that the It’s going to be quite protracted: you’ve new law would not limit the types of got to see your GP, and they have to conditions that can be considered. make a referral to a specialist. Whether Finbar O’Callaghan, president you’re in primary or secondary care, of the British Paediatric Neurology the last thing you want is additional Association, told The BMJ that the demand, but that is what it’s going to association’s guidance would create,” Hamilton told The BMJ. mainly be targeted at the  to  paediatric neurologists in the UK NICE guidance due in 2019 who will be treating children with Javid said in July that legislation would intractable epilepsy. be altered to allow medicines derived He said, “The government from cannabis to be prescribed on the legislation is going to say that anyone NHS for patients with an exceptional on the specialist register is going to clinical need. be able to prescribe, but our guidance The move came after advice from would be that for children with England’s chief medical officer, Sally complex intractable epilepsy—which be confident in prescribing, Hamilton Davies, and the Advisory Council on all these children will be—it should be said. To GPs with less experience he the Misuse of Drugs to put cannabis done by a paediatric neurologist who recommends discussing the issue with derived medicinal products in has expertise in the relevant specialty. other members of the practice team schedule  of the  Misuse of “In terms of paediatric epilepsy, our and consulting Google Scholar. Drugs Regulations, after several guidance is to fill that interim period “I think there will be considerable recent cases of children in the UK [before NICE publishes guidance]. demand for information from patients, being unable to access cannabis oil to There are obviously multiple different It’s not clear and GPs are the gateway for these control epileptic seizures. cannabis derived medicinal products, who will be products,” he said. Hamilton said that guidance from but the only robust evidence in able to access “There is currently a lack of summary the National Institute for Health and childhood epilepsy is in the use of a information. But I would start by cannabis for Clinical Excellence on the use of purified cannabidiol product, so our finding out what the patient knows cannabis based products for medicinal feeling is that that’s the product that medicinal use already, staying open minded, and use was not due until October   we feel most confident about using.” —Genevieve asking colleagues if unsure.” and that the absence of an evidence Genevieve Edwards, director of Edwards, Gareth Iacobucci , The BMJ base could place extra pressure on external affairs at the MS Society, MS Society Cite this as: BMJ ;:k the bmj | 20 October 2018 91 92 20 October 2018 | the bmj THE BIG PICTURE Outrunning child obesity trends

London mayor Sadiq Khan and Olympic champion Mo Farah take to the track with schoolchildren in east London this week to promote an anti- obesity programme that is gaining in popularity across Europe. Children from Cubitt Town Junior School are pictured taking part in the Daily Mile, a 15 minute session to get pupils walking or running a mile. The brainchild of a head teacher in Scotland, the idea has spread to more than 3460 schools in the UK and a further 1350 schools in Europe since 2012. There is some evidence behind the scheme. Earlier this year a team from Edinburgh and Stirling universities published a study that found positive changes in fitness, body composition, and activity in children who did the daily mile when compared with those who didn’t. A cluster randomised study of 40 schools in Birmingham completed earlier this year looked at body mass index a year after the Daily Mile was introduced. The study, which has yet to report, is also investigating cost effectiveness. The push to get more London schools to adapt the daily activity came as doctors warned that, given current trends, around 23% of 11 year old boys in England are projected to be obese in 2030, the number having increased by 13% since 2016. Nearly a third of the most deprived boys would be obese in 10 years’ time, the analysis from the Royal College of Paediatrics and Child Health found. International comparison indicates that the UK currently has a higher prevalence of obesity than other northwestern European countries, though the trend seems to be flattening and the UK may see smaller increases than these countries over the next decade. Rebecca Coombes, The BMJ Cite this as: BMJ 2018;363:k4362 NEIL HALL/EPA-EFE/SHUTTERSTOCK NEIL the bmj | 20 October 2018 93 EDITORIAL Alcohol must be recognised as a drug To strengthen policy responses to harms caused by addiction industries

lcohol, actually that are illegal are clearly different.

ethanol (C2H5OH), But there are commonalities is a psychoactive among what have been described molecule ingested as addiction industries—those by 2.4 billion people involved in promoting products and Aglobally.1 A central nervous system activities known to cause addiction depressant, it exists naturally and associated problems10 such as and can be produced in people’s tobacco, alcohol, and gambling. homes. Any alcohol consumption Profiting from addiction is a defining confers health risks, including for a feature of these industries, along range of cancers,2 and any possible with obstructing the implementation cardiovascular benefits are smaller of effective countermeasures.10 than was previously understood.3 The merger of the world’s two Alcohol harms users through biggest brewers, the third largest intoxication, organ toxicity, and merger in any industrial sector, addiction, which cause an estimated means a single company now 2.8 million deaths every year.1 In produces one third of all beer a recent systematic review and sold globally.11 Its second largest meta-analysis the Global Burden shareholder, Altria, owns Philip of Disease Alcohol Collaborators FURLONG/GETTYIMAGES CHRISTOPHER Morris, a tobacco company.12 The concluded that “the level of alcohol The merger policy,7 and the clear identification rationale for this merger was to consumption that minimised harm of the world’s of alcohol as a drug matters a develop alcohol markets in Africa— 1 across health outcomes was zero.” two biggest great deal to the alcohol industry, the smaller of the two companies has Greater access to alcohol increases and to society, because the policy helped to draft the alcohol policies of brewers 13 consumption and a wide range means a single implications are so important. four sub-Saharan countries. of health and social problems in According to expert opinion, company now a dose-response manner, and the alcohol is the drug that causes Coordinated approach most effective policies are those produces one most harm in the UK—more than Contemporary addiction policy that increase the price and reduce third of all beer heroin, crack, or tobacco.8 Like science finds that dichotomies based the availability of alcohol.4 Because sold globally tobacco, alcohol kills some users on the legal status of drugs obstruct such measures threaten commercial slowly through the diseases it learning about management of interests they are challenging causes. Unlike tobacco, alcohol also drug use in populations.14 Bringing to adopt, and ineffectual policy kills quickly, through injury and alcohol, tobacco, and other drugs responses often prevail.5 Broadening poisoning. Consequently, deaths together in unified policies may how we think about alcohol occur at younger ages on average support policy coherence, stimulate policies based on clear recognition than those caused by tobacco. As creative thinking about new that alcohol is a drug could have is the case for many illegal drugs, countermeasures, and improve important benefits for public health. alcohol intoxication also causes societal outcomes. harm to others, including injury and Another feature of the addiction Treating alcohol as a drug sexually transmitted infection. industries is that they provide Tobacco companies for decades Accordingly, although there is psychosocial benefits to their deflected attention from the fact a large difference in the overall users. A more holistic approach that their products were addictive number of deaths from alcohol and must take this into account and drugs. When forced to recognise that tobacco, the difference in overall could be helped by new forms alcohol is a drug, industry actors years of life lost is much smaller. In of public involvement in policy ask, “Why does it matter?”6 Words England these were estimated to be development.16 Clearer recognition do matter in the shaping of public 301 000 years for alcohol compared of alcohol as a drug will help inform Kypros Kypri, professor, School of Medicine with 360 000 for tobacco in 2015. global public health and wider and Public Health, University of Newcastle, That year, alcohol alone accounted society’s management of this costly Australia for 16% of all working years lost in and growing problem. 9 [email protected] England. Cite this as: BMJ 2018;362:k3944 Jim McCambridge, professor, Department of Drug production and distribution Find the full version with references at Health Sciences, University of York, UK industries that are legal and those http://dx.doi.org/10.1136/bmj.k3944

94 20 October 2018 | the bmj EDITORIAL Measles: neither gone nor forgotten Antivaccine sentiment isn’t the only problem

t is 50 years since measles Countering misinformation vaccine was introduced in MMR uptake dropped sharply in the the UK and 20 years since it early 2000s after publication of the was replaced with the highly now discredited 1998 Lancet paper effective measles, mumps, and widely interpreted as suggesting a link Irubella (MMR) vaccine. In 2017, the between MMR vaccine and autism World Health Organization declared and bowel disease.13 Although uptake that measles had been eliminated has now recovered, many older from the UK; this means that measles children and young adults remain is no longer endemic, not that it has unprotected, and this partly explains disappeared.1 the age distribution of current Another 42 of the 53 member measles cases, with a large proportion states in the WHO European region in people older than 15 years.4 have been reported as having Unfortunately, vaccines have interrupted the endemic spread of become even more of a political measles, yet epidemics of measles are issue recently and are now on occurring across Europe.2 The region the agenda of right wing populist saw more cases of measles (over groups in Europe—for example, the 41 000, including at least 37 deaths) National Rally party in France and in the first six months of 2018 than CAMINADA/SHUTTERSTOCK ALEXANDER the Five Star party in Italy. Before he in any other complete year of the Poor uptake should not always be assumed to be was elected US president in 2016, decade.3 In England, three times as because of parental doubts about vaccines Donald Trump tweeted on numerous many cases of laboratory confirmed occasions that MMR vaccine causes measles have been recorded up to 10 for this small decline are not clear. autism. Antivaccine sentiment on September 2018 than in the whole of Uptake of MMR shows regional social media undoubtedly plays a 2017 (876 v 267).4 variation, some of which is likely to part in some distrust of vaccines, but Why is this happening? Detailed be due to inaccurate data collection, how much it contributes is unknown. examination of the cases occurring in but the different reasons for non- In August 2018, it transpired that the European Economic Area (EEA) immunisation will require tailored Russian backed bots and trolls have in the 12 months from July 2017 to actions to improve uptake.8 9 been spreading misinformation June 2018 showed that in the 90% about vaccines.15 Countering of cases where immunisation status Access problems such activities effectively presents was known, 82% had received no In the UK, when children are not challenges. Government information measles-containing vaccine and only fully immunised this is usually is a useful adjunct but cannot replace 2% had received at least two doses.5 because accessing services is difficult discussion with knowledgeable, In 2017, only four EEA countries rather than because their parents trusted healthcare professionals who recorded an uptake of 95% or more have actively declined the vaccine. are equipped to respond to parents’ for two doses of a measles-containing A study of an orthodox Jewish specific questions and concerns. vaccine, and even countries with community in north London showed Timely high uptake of vaccines is a current high uptake overall may that, contrary to preconceptions, the important, not only for individuals have gaps in immunity because of relatively poor uptake of vaccination but to create herd immunity to variation within the country or earlier in the community was not due to protect vulnerable people who lower uptake.6 antivaccination sentiments but to cannot be immunised. In the UK, the uptake of one dose access problems.11 Until these have Whenever a healthcare at 2 years of age has steadily fallen been tackled, poor uptake should not professional has contact with a from a high of 92.7% in 2013-14 always be assumed to be because of patient, child, or adult, in whatever to 91.2% in 2017-187; the reasons parental doubts about vaccines. setting, the opportunity should be Helen Bedford, professor of In many countries, funding for taken to check their immunisation children’s health preventive measures has fallen. status and offer any missing David Elliman, consultant community In Italy, researchers found that for immunisations.. paediatrician, Great Ormond Street Hospital each 1% reduction in public health Cite this as: BMJ 2018;362:k3976 NHS Foundation Trust, London, UK expenditure there was a 0.5% fall in 12 Find the full version with references at [email protected] MMR uptake. http://dx.doi.org/10.1136/bmj.k3976 the bmj | 20 October 2018 95 CONSULTATION SKILLS Should doctors share their personal experiences of healthcare with patients?

It’s a divisive topic, findsFran Robinson: hen the upper Interpreting risk some doctors insist it can help when done gastrointestinal Underwood also uses his experience surgeon Tim of consenting to a cardiac ablation carefully, but others struggle with its potential Underwood to explain to patients the risks of to detract from the patient wants to help his an oesophageal cancer operation. Wcancer patients deal with feelings “I say to them, I have sat where you of loss he sometimes tells them how are, and, although I could have died GMC and medicolegal advice he coped with losing a child at 24 or been catastrophically injured weeks’ gestation. The same night if the operation had gone wrong, The General Medical Council’s guidance on personal beliefs he had to consent to his wife having I still signed the form because I says: “During a consultation, you should keep the discussion relevant to the patient’s care and treatment. If you disclose any an emergency hysterectomy after a understood the risks and because personal information to a patient, including talking to a patient massive bleed. I am human I assumed it wouldn’t about personal beliefs, you must be very careful not to breach Some doctors might raise their be me. I tell the story because I the professional boundary that exists between you. These eyebrows at the thought of sharing want them to understand how I boundaries are essential to maintaining a relationship of trust personal experiences like this interpreted the complexity of between a doctor and a patient.” with their patients. But the limited that risk and that these problems A GMC spokesman says: “Personal information could include research shows that self disclosure, happen to somebody; it could details of the doctor’s medical treatment. Doctors need to use when doctors reveal something be them.” their judgment depending on the specific circumstances but in general they should be cautious about sharing information personal, is common in medical He says he shares his experiences about their own treatment because there is a risk patients practice. to show patients that although it might give it more weight than would be justified in their own Underwood, professor of says professor on the door of his specific circumstances.” gastrointestinal surgery at the office, he is also a husband, a father, Ellie Mein, a medicolegal adviser at the Medical Defence University of Southampton, tells this and a son who has feelings and has Union (MDU), warns of three potential pitfalls: story to patients very infrequently, some understanding of what his • It could take the focus off the patient, leaving them feeling that and only if he feels it is appropriate. patients are going through. their consultation has been hijacked He uses it to articulate not only that “My nature is to be direct, open, • The doctor’s story could influence the patient so that they do not he understands what loss is about and honest with everyone. But I tend make an objective decision about their treatment but that something positive can to share personal experiences with • A doctor’s experience that had a positive outcome could make the come out of a distressing time: only a select few patients when I feel patient feel awkward for worrying about their condition. four years later he and his wife the timing is right. If I use a personal She says: “It is understandable that doctors will share personal experiences because they want to relate to their adopted a little boy. story it’s to help patients understand patients and they are human. There will be times when He sometimes uses the story to that the decisions they have to make patients will find it helpful. help patients facing a recurrence of are complicated. We all make them “We would never say don’t share an experience. If you do, their cancer. Patients with young differently, but it can be done.” make sure you keep the discussion relevant to the patient’s children may be concerned about Underwood says his perception care, be guided by your knowledge of the patient, be mindful telling them about their illness is that doctors are generally wary of the ways it could go wrong, and be careful not to breach because they don’t want them to about sharing personal stories. any professional boundaries. For each patient and doctor that worry that they will die. “We had a “It’s a personal thing, and each boundary is probably going to be a grey area.” daughter and were completely honest individual is different. I am probably Be guided by your knowledge of the patient, with her about everything, so I use at one end of the spectrum. I don’t and be mindful of the ways it could go wrong my experience as an example of how know whether it is right or wrong, Ellie Mein, MDU I reacted to the situation and how to but none of my patients has ever be open with children,” he says. complained.”

96 20 October 2018 | the bmj Providing a role model her patients without talking about her GPs’ experience of self disclosure in primary care Thomas Jones, a general practitioner own experience. She is conscious that at Lockside Medical Centre, she should not influence her patients’ A study comprising interviews Stalybridge, shares with patients his decision making because they might with 16 GPs in New Zealand experience of coping with anxiety, compare themselves with her about found that self disclosure was common and was seen as a which he learnt to control in his the choices she has made and the way positive activity that had the mid-20s through cognitive she has handled her illness. capacity to improve the doctor- behavioural therapy. “I can’t be a patient advocate while patient relationship. “I hope that by admitting to I’m trying to be a doctor again,” she • Family and physical topics were having had these issues and by says. “It would be a mistake to try to most commonly discussed, but demonstrating that they can be be the patient’s friend and tell them psychological and relationship overcome and consigned to the past, you coped, especially when they are None of my problems were also shared I’m providing a positive role model dealing with cancer. They might not patients • Physical health problems for patients. I don’t dive in with be in the right place to hear it from has ever disclosed by GPs included my experiences, and only tend to you. The consultation must always be musculoskeletal and skin complained problems, diabetes, and weight mention them in a second or third all about that person in the room. The Tim Underwood, management consultation. minute I say, ‘I’ve had it, I know what upper gastro- • Only two GPs said they would “I do it only if I sense that the it’s like,’ I’m detracting from them.” intestinal surgeon disclose mental health or patient feels really alone with their O’Riordan admits that she can psychological problems, and anxiety, and I try to say it in a ‘this can feel vulnerable when she is in the then only to guide patients happen to anybody’ way.” consulting room doing follow-ups down a particular therapeutic Normally private about his personal with a patient. “When it’s just the path by offering real life life when talking to patients, Jones two of you, it is easy to say things examples of success says he doesn’t talk through specifics, you later think you shouldn’t have • Knowing the patient made self disclosure more likely, but a GP’s he just explains enough to help said. There are times when it may decision to disclose was mainly the patient realise that he has been feel right to let them in and say, based on intuition through something similar. He finds it ‘Actually I found this really hard, • The doctors thought that helps patients to feel that it isn’t a sign try this.’ I worry about the ethics sharing personal experiences of weakness to disclose something of there being two patients in the made them seem more human personal. “It helps them to hear the consultation. Often it’s just me and approachable; helped to message, ‘we can get through this—I and the patient and there is no one I do it only if I support the patient; created a want to see you overcome it.’ else listening in to tell me if I have sense of closeness and trust; “It’s an incredibly personal overstepped the boundary. sense that the made the patient more receptive patient feels to advice and more motivated to judgment on behalf of the doctor as to “I’m learning from my mistakes adhere to treatment; helped the how much gets shared, to whom, on and am very much aware that I need really alone patient to be more forthcoming any particular day.” to have checks in place to remember I Thomas Jones, with information; and helped He believes that patients usually am a doctor.” GP reduce any power imbalance in want doctors to be objective during Few studies have investigated the relationship the consultation. “In other words, we the effect on patients of doctors • Potential disadvantages of self need to preserve boundaries in order disclosing personal experiences disclosure were considered to to provide that objectivity. However, (box, left). But Richard Baines, a be that it could skew the doctor- on occasion, it feels the right thing to patient from Winchester, says that patient relationship; burden the patient; take the focus away do to break down those boundaries after he had a stroke he felt that his from the patient’s needs; risk just enough to help the patient over a GP was reaching out to him as a expanding the professional hurdle. If we can bring some personal fellow human when he told him how relationship into a more experience to achieve that, then that his family had been affected by his personal or intimate one; invoke can go a very long way.” father’s stroke. curiosity and dependency in the “He was giving me a message patient; and reduce the doctor’s Patient advocate versus doctor about the importance of staying credibility Liz O’Riordan, a consultant breast active and was expressing that he • GPs’ perceptions of their disclosures were very positive, surgeon at Ipswich Hospital who has understood the daily difficulties and I worry about and none had experienced an recurrent breast cancer, says she finds humiliations that people who survive the ethics of adverse response it difficult to be a patient in her own stroke have to cope with. there being specialty while returning to work and “He was offering me psychological • The study concluded that two patients training would be helpful to being a doctor again. support and empathy, and he left me prevent future mistakes and to A natural communicator, she has feeling that he would remember me in the protect the doctor and patient already shared her experience of after I had gone out of the door.” consultation from unintended harm, such cancer in a blog, on social media, and Fran Robinson, freelance journalist, London Liz O’Riordan, as developing a dependent in a recent book on breast cancer. But consultant breast relationship. [email protected] she struggles to work out how to help Cite this as: BMJ 2018;363:k4312 surgeon the bmj | 20 October 2018 97 NHS Back at NHS at to the YEARS future aspects of the NHS that should never

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Social solidarity Many the sense of justice and inclusion have further undermined the ability changes to expressed by the existence of the NHS of clinicians to prioritise on the The NHS was founded on the and a clear majority are willing to pay basis of need. The eff ect has been to principle that comprehensive the NHS in its more tax to fund it. privilege the most demanding and healthcare should be freely available rst 70 years Anyone who has worked in to penalise those who are in greater to all, prioritised on the basis of have been for the NHS for some years will have clinical need. To me, and perhaps to need rather than the ability to pay, noticed that sequential “reforming” others, the NHS now feels harder to and funded through taxation. In the the better. reorganisations proceed in circles. understand and less fair. immediate post-war context of severe But not all These manifest the dangerous fi nancial constraint and ruined towns change is tendency to see change as progress, Available to all and cities, the NHS represented a good, writes but all change involves loss and each remarkable commitment to William cycle of reform seems to shave off The original intention of the NHS was Beveridge’s insistence that “the Iona Heath, a little more of the essential core of that everybody should be eligible for purpose of victory is to live into a pointing out the service that is expressed in the care, including temporary residents better world than the old one.” the aspects founding principles. or visitors to the country. The These founding commitments politically motivated exaggeration of established one of the few social of the health Prioritisation on the the costs of “health tourism” and the institutions in the UK which gives service that basis of need creation of a “hostile environment” its citizens a sense of a moral should be for immigrants deemed to be here foundation to our society that they The pre-eminence of need is illegally has undermined this recognise, take pride in, and wish preserved essentially an expression of social founding principle. It has also led to protect. WH Auden wrote that the solidarity and justice, and yet both to the denial of care to members of role of art was to teach people to have been severely undermined and the ageing Windrush generation, love not to hate. For the people ought to be reasserted in healthcare Caribbean immigrants from the of the UK, the NHS has seemed to policy. The problems began when second half of the 20th century, fulfi l a similar role. Margaret Thatcher sought to recast so many of whom made major It is not surprising that these NHS patients as consumers and contributions to the functioning foundations are being shaken by the legitimated demand alongside need. of the NHS, oft en in the vital but predations of late capitalism, with Successive time targets for waiting less remunerated roles of catering, its insistence on the pre-eminence lists for elective treatment and for cleaning, and portering. The of the market as the driving force of waits in emergency departments reinstatement of the principle of every aspect of society. Yet, despite universality would rid the NHS of the NHS’s recent travails and the The current wave of racism a burdensome bureaucracy and ideologically driven withdrawal and xenophobia disfiguring minimise the possibility of similar of adequate resources, a large our society undermines scandals in the future. The cap majority of patients, citizens, and social solidarity and the NHS, on visa applications for skilled professionals remain committed to damaging us all workers has exacerbated the severe

98 20 October 2018 | the bmj shortages of clinical staff within Since 1948 the particularly for the most sick, The devaluing of continuity of the NHS and has underlined the NHS’s founding needy, and vulnerable patients. care makes it more difficult to principles, extent to which it has depended on Yet healthcare must, by its including engender trust and easier to immigration. Doctors have recently universality and very nature, be delivered within disseminate fear been removed from the cap but it will continuity of care, relationships and so it follows that take considerable time to make up have built a social the NHS can only fulfil its function if to the numbers of patients seen the shortages. The current wave of institution that it is committed to sustaining human every day, has remained largely racism and xenophobia disfiguring gives UK citizens relationships between professionals unchanged. our society undermines social “a sense of a moral and patients, and between differently O’Neill saw clearly the future foundation to our solidarity and the NHS, damaging society” skilled professionals. Joy, kindness, trajectory of regulation in general, us all. courage, thoughtfulness, and which has been reflected over trust matter at every level of the recent months in that of the General Relationship-based care organisation and within every Medical Council in particular: interaction. “Underlying the ostensible aim of Since its inception, the NHS has accountability to the public, the real operated a list system for general Trust v regulation requirements are for accountability practice and has insisted on general to regulators, to departments of practitioner referral to secondary At the start of the NHS, Aneurin government, to funders, to legal care except in emergencies. From Bevan told the medical profession: standards.” 1948 to 2004, every patient was “My job is to give you all the And she might well have added, registered with a GP, whose name resources and help I can, and then “to a sensationalist media,” whose appeared on their medical card. leave you alone as professional men reporting makes both patients and In 2004, as the drive towards and women to use your skill and professionals evermore fearful. Trust competitive privatisation of the BIOGRAPHY judgment without hindrance.” must be earned within an ongoing provision of service accelerated, Iona Heath There could be no more telling relationship and the devaluing of this was replaced by the name of the was a GP for 35 contrast to the situation that has continuity of care makes it more years in an inner practice. Predictably, this led to an developed over recent years. Despite difficult to engender trust and easier London practice unhelpful and unpopular dilution the warnings delivered by the to disseminate fear. in Kentish Town of individual responsibility, and and president of philosopher Onora O’Neill in her The NHS was founded in part to the named GP was reinstated in the Royal College 2002 Reith Lecture, the NHS has reduce fear and surely this should 2016, so restoring a potent driver of General been subjected to an increasingly remain an aspiration. We need to of relationship-based care which Practitioners burdensome and expensive explore much more carefully how had been highly valued by doctors from 2009 to superstructure of regulation. This this can be achieved. As the US and patients alike. Sadly, successive 2012. She wrote seems to have demoralised and patient safety expert Don Berwick governments have prioritised a regular column disempowered professionals while and colleagues have argued, access to any doctor over the for The BMJ the incidence of service failures and “Fear is toxic to both safety and importance of continuity of care, until 2013. scandals, always low in relation improvement.” the bmj | 20 October 2018 99 Education and support Care and kindness in face of junior colleagues of more technology

The NHS has been providing the At the start of the NHS, doctors had setting for the education of healthcare a limited range of investigations and professionals since its inception. treatments available and had to rely Most medical students have their first much more on their clinical skills conversations with patients in an NHS of history taking and examination. general practice or hospital, and junior Over the succeeding 70 years the use doctors complete their clinical training of technologies, both investigative while being supported by more senior and pharmaceutical, has increased colleagues in NHS settings. This used exponentially as the medical-industrial to occur within a small consultant-led complex has flourished and generated team. enormous profits, which in turn have Somehow, as we have lost sight of stimulated greed and corruption. the importance of continuity of care Clinicians, patients, and the public are for patients, we have also allowed the the market to provide better outcomes A human touch faced with an avalanche of “evidence,” continuity of care of junior colleagues at lower cost has led to the provision alongside new much of which may be misleading, to wither away in many clinical of services being outsourced to the equipment: and we need perhaps to rediscover the a premature baby settings and perhaps particularly in private sector at an increasing rate culture of frugality which informed cared for overstretched and under-resourced over the past three decades. This at Burtonwood the early years of the NHS. This acute hospitals. The failure of a small began with the outsourcing of non- in 1956 matter becomes more pressing as minority of senior colleagues to take medical support services including thresholds for diagnosis are lowered responsibility for juniors when things cleaning, finance, IT, contracting, and the harms of overdiagnosis and go wrong seems to have become more and planning but has now spread to overtreatment are documented. frequent and appears symptomatic include whole hospitals, GP practices, Machines have displaced listening and of this particular breakdown of and out-of-hours services. The obvious touch, numbers have displaced words, continuity of care. When I was a doctor problem is that the NHS has always and care and kindness are slowly in training, the NHS was less than half operated on a tight budget and private leaching out of the system. as old as it is now and, at that time, providers need to provide a profit for All this, to a greater or lesser extent, although I worked very long hours, I the owners or shareholders of the seems to be a global phenomenon, never felt unsupported, unprotected, companies involved. This imperative but within the NHS, particularly in or afraid. Regrettably, this is not the means that private providers try to England, these tendencies have been experience of too many junior doctors save money by reducing staff and exacerbated by the imposition of today, as the shocking treatment of resources and problems of quality and rules in the form of targets for clinical Hadiza Bawa-Garba exemplifies. reliability have become increasingly care that are blind to the context and obvious, most notably in the case of aspirations of each patient and which Public provision Hinchingbrooke Hospital which had have operated more in the interests of been privatised in its entirety and its company profits than those of the sick No British politician, however care found “inadequate” by the CQC. and vulnerable. committed to the virtues of market The NHS began with the It is entirely possible for the NHS economics, has yet had the courage nationalisation of the pre-existing to fund the care provided by a service to attack the founding principle of network of teaching, charitable, and that actively seeks to minimise waste, care being free at the point of use, municipal hospitals and there is stark harm, and futility; prioritises on the although there has been considerable contrast with the recent financing of basis of clinical need; and engenders erosion of the scope of this provision new hospital building through the trust by providing care and kindness. with exclusions that include dental notorious private finance initiative, However, it will be impossible to and optometry services. A system of which has leached huge amounts meet levels of demand that are being charging for prescriptions, introduced of taxpayers’ money into the private artificially manufactured in the within a year of the start of the NHS, purse. interests of the pharmaceutical and remains unfair to those of working age Most citizens intend that the tax health technology companies. We who have a chronic condition that is they pay should be spent for the need to provide health protection at not exempted from such charges. A public good and resent the creaming the level of society rather than pursue system which capped the annual cost off of part of the budget for private the destructive seduction of prevention of prescriptions to any one person profit. Successive governments have at the level of the individual and the would be much more equitable. argued that it does not matter who absurd ambition of minimising every Iona Heath , London Despite all this, the idea that the provides the services as long as they perceived statistical risk: an ambition iona.heath22@ NHS is free at the point of use has remain free at the point of use. The that serves only to frighten the well, yahoo.co.uk remained largely untouched. However, failures of a succession of big private divert attention from the sick, and Cite this as: the neoliberal faith in the power of companies suggest otherwise. BMJ 2018;362:k3187 torture the frail and dying.

100 20 October 2018 | the bmj