comment‘ Technical terms can convey immediate precision that requires far ‘more words in plainer language ACUTE PERSPECTIVE David Oliver Plain English v clinical terminology n 2014 the award winning author John the International Classification of Diseases Lanchester argued in his book How to or medical textbooks. It’s just as hard as Speak Money that the global financial decoding finance speak. crash had occurred partly because The Academy of Medical Royal Colleges is most of us have little understanding encouraging doctors to write to patients in Iof finance, especially of its professional plain English, copying in GPs—rather than terminology and jargon. But he also copying patients in on letters written to GPs. acknowledged that, while jargon can be lazily I certainly support this. What I love about the or deliberately obfuscating and can exclude initiative is that it comes with clear guidance the public, it can also provide precise, on how to structure letters, as well as tips succinct shorthand that’s much harder to explain in to make prose clear, readable, and less likely to cause plain English. upset or anxiety. It also states that precise professional Among his glossary were “derivatives markets,” terminology is still OK in its place within a letter, such as “consumer surplus,” “short selling,” “Laffer curve,” in a clinical problem list. and “VIX index.” Search these online, and they require There’s a growing policy push towards patient held lengthy explanations in plain English, with further or patient accessible records—increasingly, electronic definitions of the terms used to describe them. For ones. This is likely to feature again in NHS England’s instance, a derivative is “a contract that derives its value forthcoming 10 year plan, which has its own plain from the performance of an underlying entity which English consultation guide, as well as its existing can be an asset, index or interest rate.” The Laffer curve guidance such as Offering Patient Access to Detailed “illustrates a theoretical relationship between rates Online Records. I’m just as supportive of this, bearing of taxation and the resulting rates of government in mind that we shouldn’t inadvertently exclude revenue.” Those are just the start of their explanations large numbers of patients who don’t or can’t use the on Wikipedia. internet or some devices. Records are as much the Doctors have a professional terminology of our own, patients’ notes as the practitioners’, and it’s their lives which can seem equally inaccessible to patients and their we are discussing. families. A well written medical court report, newspaper Yet, if doctors have to check and clarify their prose column, or leaflet explaining conditions and treatments to avoid needless jargon, will that take time away to the public, if it is to be useful, requires plain English from direct patient contact or other work? Might it explanations alongside the clinical language. This can mean that we have to spend more time giving long make a court report longer as each technical term is form explanations of precise shorthand terminology, explained in parentheses. abbreviations, and acronyms, mindful that patients Yet such terminology can convey immediate precision may read them? Will it hamper inter-professional to fellow practitioners that would require far more words communication? I have no idea, but I’d love to hear in plainer language, often losing that precision. For from any readers who have done this already and to find instance, try explaining the TNM staging of a tumour or out how it went. the subtype of cardiac arrhythmia, glomerulonephritis, or David Oliver is a consultant in geriatrics and acute general fracture with the precision and brevity of terms designed medicine, Berkshire [email protected] by professionals for professionals—or in accordance with Cite this as: BMJ 2018;363:k4487 the bmj | 3 November 2018 189 PERSONAL VIEW Edward Ridyard Being charged to park a car demoralises hospital staff The NHS is run on goodwill, yet unfair parking fees show a thorough disregard for the workforce

iven that most hospital many healthcare staff are already staff are required to do “struggling to get by on a pay rise shift work, it wouldn’t well below the cost of living, and be unreasonable to these extortionate fees are an extra expect to have easily tax on their wages.” Gaccessible parking. Yet for many, NHS trusts’ typical response—that being able to park near their place they encourage staff to use forms of of work comes at a high cost, with transport other than cars—doesn’t figures released earlier this year take into account the reality of showing that three out of 10 NHS shift patterns. In a system where hospitals charge staff—including night shifts and unusual hours are Night shifts liable to pay a car park management doctors, nurses, and the many other commonplace, trains and buses do and unusual company for fines incurred from workers who come into hospitals not always run, and many health hours are parking in the visitor car park when every day to keep the NHS running— workers live in the surrounding rural commonplace, there was not enough room in for car parking. The hospitals with areas, meaning that this advice is not at times when designated staff spaces. the highest average charge cost £2 always practical or even possible. trains and Cases like this show that there is no per hour, which equates to £80 for a buses do not understanding for, or concessions to, 40 hour working week. No guarantee of spaces those who are using hospital car parks And in news that is sure to make Even once you’ve paid for a permit, always run and why their work commitments these workers feel further aggrieved, this is no guarantee that you’ll have might mean that they have to park it was reported recently that the a parking space when you need it. frequently or for a long time, at English health service made a profit This can mean that workers have to antisocial hours, or with sudden of £69.5m last year from parking arrive way in advance of their shift in urgency. The NHS is run on goodwill, charges levied on its own employees. order to secure a space—potentially yet practices like this show a thorough At a time when staff are facing pay turning a 12 hour shift into a 13 hour disregard for staff and make it easy for freezes and real pay reductions as shift before travel time is even employees to feel that this is becoming a result of inflation, these charges factored in. Nor do permits protect a one way street. are demoralising and excessive. As staff from being fined; a court ruling I understand that car parking the union Unison has pointed out, deemed a group of NHS workers at hospitals is in short supply and

BMJ OPINION Greta McLachlan Put on your own oxygen mask before helping others Alcoholics Anonymous is probably If we don’t sleep, it is “a syndrome of emotional the most well known support group look after exhaustion.” It can present as an around the world. One of its main ourselves erosion of a physician’s compassion, principles is that before you can start then we will professionalism, and sense of calling; to heal, you must first admit you be no good at this translates to worse performance have a problem. Well, healthcare looking after at work and poor patient care. In some professionals, we have a problem. our patients cases it can manifest in excessive This was made painfully clear at drinking, drug taking, or suicide. Wounded Healer, the 10th annual Dike Drummond is an expert on conference of the Practitioner burnout, having treated over 20 000 Health Programme (PHP). Burnout doctors in 63 countries. He describes among doctors has been shown to hearing from doctors who wished to be as high as 50%, and it seems to be hit by a car just so they didn’t have be getting worse. Burnout is not to go to work—a red flag of burnout. simply being tired and needing some Yet, alarmingly, he says that this is a

190 3 November 2018 | the bmj

BMJ OPINION Samir Dawlatly Advancing healthcare: less self improvement, more system development Healthcare systems are notoriously bad at embracing innovation. The reasons for this are many, complex, and ultimately frustrating. This resistance can stifle change that could improve the lives of our patients. One stumbling block is the mantra “First, do no harm,” and the understandable aversion to risk when the health of patients is at stake. No one wants to expose their patients to the next scandal—the next Vioxx, vaginal mesh, or a dodgy implant. But is this just one of the many excuses we use to shun innovation? Another is the assertion that we’re so stretched and overworked that we haven’t got time to think about how we could do things better. Meaningful It’s also argued that healthcare needs to be regulated, but there cycle routes and more regular buses change often doesn’t, really, contribute much should be a more sensible and or trains during off peak hours, which happens in to the health of our patients, and appropriate method of doing this. may encourage those that live closer small steps, one overall health can be up to 90% Add to this the problem of the to opt against driving. For employees foot at a time dependent on social factors. postcode lottery created by hospital who have to commute long distances Instead of investing in health technology, perhaps we trusts having such starkly different or who don’t have the option of should be investing in reducing inequality in the social fees (or not charging at all), and public transport, a park and ride determinants of health. the obstacles parking charges system could also be an option. These are valid points, but should not obviate the can create for patients too, and it Hospitals’ current approach to need or desire to continually improve healthcare. becomes clear that this is a system car parking is undermining the Meaningful change often happens in small steps, one in need of an overhaul. morale and financial security foot at a time. of NHS workers. This practice Instead of blaming systemic factors that delay Third parties should be banished from hospitals healthcare innovation—such as funding, ethical There are some key changes that in place of a fairer and more approval processes, subject recruitment, or the selective could be introduced. For starters, understanding system. reporting of findings—I should ask myself whether I have we should completely do away with Edward Ridyard is specialty trainee year 4, developed a mindset that inhibits meaningful change. having third parties run this service. ophthalmology, North Yorkshire Deanery After all, I am trying my best to make a difference for Next we should look at improving [email protected] the patients I look after, but I don’t always believe I can transport links to hospitals, including Cite this as: BMJ 2018;363:k4529 do that much for them as I can’t always influence the determinants of their health. I try my best, but this may BMJ OPINION Greta McLachlan not mean I’m actually doing my best. I already feel like I’m constantly having to improve (as common thought among those he We seniors must look out for our Put on your own oxygen mask before helping others well as prove) how I work as a doctor, through appraisals has treated. juniors. “I did it in my day” doesn’t and by regularly collecting structured feedback. It So, how can we help? Perhaps make for good training or pastoral strikes me that self improvement doesn’t necessarily we need a sea change in the culture care and we should no longer tolerate lead to significant advances in patient care. Perhaps I of medicine. The idea that it’s okay this line of thinking. If you’re worried should take the focus off myself and ask my patients to put yourself first for five minutes about a colleague there are good what could be done to improve their experience. can be unsettling, but one initiative organisations out there—such as the Using this as a starting point could help identify, albeit that aims to do just this is Schwartz Practitioner Health Programme, the imperfectly, areas of care that can be changed, little by rounds. These are multidisciplinary Sick Doctors Trust, and the Doctors’ little. The focus could then shift from self improvement forums where the emotional strain of Support Network. If we don’t look after to system development. caring for patients can be discussed ourselves then we will be no good at Beginning the process of change with this one confidentially and in safety. Jill Maben, looking after our patients. We must question to patients has the potential to provide a professor of health services, research, remember to put on our own oxygen fulfilment—doctors would feel that they are making a and nursing, reported that Schwartz masks first. difference—and would also improve care. rounds not only improve patient care, Greta McLachlan is a general surgical Samir Dawlatly is a GP partner at Jiggins Lane Medical Centre, but also self reported wellbeing among trainee currently working at The BMJ Birmingham Twitter @SDawlatly those who attend. as editorial registrar

the bmj | 3 November 2018 191 ANALYSIS The unfulfilled potential of primary care The Alma Ata declaration’s compelling vision of health for all will not be realised until we take community level prevention seriously, argue Trish Greenhalgh and colleagues

o mark the 40th Local drivers in the quality and coverage of disease in individuals (and only those anniversary of the of morbidity primary care have delivered with the means and motivation to 17 Alma Ata declaration and mortality important population health gains seek care). Although patients may on primary healthcare around the world.3‑12 But primary care be opportunistically screened for 1 include in October 2018, transport, teams have come under pressure from hypertension or offered support with Tworld leaders gathered in Astana, substantial increases in workload, smoking cessation, there is often no the food Kazakhstan, to renew their including paperwork and the systematic approach to engaging with commitment to health for all. environment, delegation of care from hospitals to the the broader health determinants at Although primary healthcare pollution, community setting.6 13 Task shifting to the community level.18 is about much more than primary poverty, primary care is often appropriate, but care services, getting this element early years reallocation of responsibility is rarely Social determinants right is crucial to supporting the education, followed by adequate reallocation of This is a lost opportunity. In concert overarching principles of equity, housing, road resources.13 with public health teams, primary population level primary prevention, safety, exercise Primary care teams have been on care teams are well positioned to and action on the social determinants spaces, alcohol, the front lines of this century’s major identify the local drivers of morbidity of health. In the context of increasing and tobacco demographic and epidemiological and mortality, including transport, chronic multimorbidity and ageing challenges, including ageing, the food environment, pollution, populations we consider why socioeconomic inequalities, chronic poverty, early years education, European primary care has broadly diseases, rising consultation rates, and housing, road safety, exercise spaces, failed to engage with the prevention multimorbidity.13‑15 and the availability and affordability oriented approach set out 40 years The future sustainability of our of alcohol and tobacco. These non- ago, and what conditions are required health systems depends on primary medical factors are responsible for to realise its potential. care successfully meeting increased up to 90% of health outcomes.19 need with affordable, person centred, Primary care teams see these local Contemporary challenges high quality care. social determinants at work every Primary care has been defined By shifting the emphasis of day20 and have overlapping moral, as “first-contact, continuous, primary care from treatment towards professional, and (where they are comprehensive, and coordinated proactive care, prevention, and health paid by capitation) financial interests care provided to populations promotion at the local population in tackling them. undifferentiated by gender, disease, level, it may be possible to deal with Through collaboration with or organ system.”2 A stronger primary health challenges at an earlier stage. public health, social care, and other care sector is associated with greater Population level interventions16 tackle community organisations, primary equity, better health outcomes, and, environmental risk factors as well as care professionals are uniquely in some settings, lower overall costs.3 4 social and economic determinants of placed to translate their insights Over recent decades, improvements health. Community level interventions into priorities for community level include investment in green spaces, prevention. Primary care teams KEY MESSAGES housing, active transport networks, have detailed patient datasets • The 1978 Alma Ata declaration called for a smoke-free zones, traffic calming and a unique ecobiopsychosocial shift in focus from reactively managing sick measures, and local licensing and perspective, and they often develop individuals to prevention and health promotion zoning regulations. a high stock of community trust and at community level Many practices are taking first a rich ethnographic understanding • Increasing chronic multimorbidity and rising steps towards dealing with social of the local population.21 Although demand make preventive action more pertinent, determinants through social the Alma Ata declaration called yet the Alma Ata vision remains unrealised prescribing. However, this is an for population level prevention • Most primary care systems constrain rather than individual level approach rather than to become the central organising facilitate engagement with local public health seeking to influence structural or activity of primary healthcare, teams teams, communities, and initiatives to tackle system determinants that affect whole that operate this way remain rare. social determinants subpopulations. Early general practitioners such as Primary care financing, training, organisational • In many European countries the William Pickles and Frans Huijgen structures, and incentives can and should be remit of primary care extends only felt responsible for population and better aligned with community level prevention as far as diagnosing and treating individual level practice,22 but the

192 3 November 2018 | the bmj QUOTE TO COME MURDO MACLEOD/GUARDIAN/EYE VINE MACLEOD/GUARDIAN/EYE MURDO role of contemporary primary care Riverside Garden, than it is to change the environment; work. And can we blame them when teams is much narrower in many part of the prevention and health system modern primary care teams are not European countries.11‑25 Riverside Hall reforms require upfront political and trained, paid, held accountable, or community Financing has played a large role. capital investment but the benefits given time for delivering community centre in Govan, 37 Once ubiquitous fee-for-service Glasgow, is part are invariably conferred to political level prevention? systems can lead to the underuse of an initiative to successors; it is hard to take credit of preventive services,29 30 and it is help people with for things that haven’t happened Realising the potential of primary care difficult to make people contribute to addiction issues or (such as deaths averted); and it is European primary care teams are action on the social determinants as with poor mental difficult to obtain robust evidence well positioned to assess and tackle and physical health the benefits are a “public good.” (That for the effectiveness of population structural determinants of health at is, one person benefiting does not level interventions within the current the community level, but what does reduce the benefit for others and no evidence model. this look like in practice? one can be excluded.)31 The degree to which primary The Hedena Health GP practice care teams engage with even basic in Oxford has worked with housing Capital for investment individual preventive activity developers, the city council, public The international move to capitation varies widely across Europe, with health teams, and NHS England to has helped provide capital for variation underpinned by differing develop a health promoting housing investment in primary prevention at financing arrangements.11‑35 development in a deprived area. The the community level, but growing Experience from other continents “healthy new town” gives primacy multimorbidity often seems to absorb shows that state regulators often to cyclists, pedestrians, and public any extra money.13 32 Governments restrict the practice of primary care transport as well as focusing on tend to govern and finance public professionals to individual level social inclusion, safe housing, and health and primary care functions functions and disproportionately the food environment.38 39 separately, and insurance companies direct regulatory measures to In Belgium, the Botermarkt have been reluctant to pay for public sector practices (which Community Health Centre in Ghent community prevention delivered may be more likely to consider has led several preventive initiatives through primary care.33 public health than their private prompted by assessment of the local Policy makers may be reluctant counterparts).8 36 population’s health needs. These to invest in pivoting primary Anecdotally, our primary care have included leading a coalition of care systems towards population colleagues believe that social community stakeholders to redesign prevention for numerous reasons. It determinants simply are not their a dangerous road section and is much easier to blame individuals responsibility, even though they successfully lobbying the council for for making poor lifestyle choices appreciate that these issues affect their a new playground. These activities the bmj | 3 November 2018 193 Enablers of primary care reform have helped to reduce road traffic The “deep complemented by easy access to injuries and childhood obesity.21 40 end” practices public health specialists. Deeper POLICY MAKERS The “deep end” practices serving serving integration can be achieved through Governance: deprived areas in Glasgow and Clyde co-location, regular meetings, and • Health in all policies deprived areas work closely with members of the in Glasgow shared information systems, work • Intersectoral collaboration and local community to assess and reduce plans, and budgets.32 Qualitative and coordination local drivers of disease through and Clyde quantitative primary care data should • Merging of health and social sectors initiatives such as walking groups, work closely be used routinely to develop public • Align professional health financial advice, community gardens, with members health interventions.49 curriculums towards skill gaps 50 51 and supporting the reforestation of the local Scotland and Catalonia have Financing: of disused land. Recognising that community tried to improve the coordination • Earmarked funding for population tackling social problems can reduce of multiple health and social care level prevention activity demand by improving health services around the needs of patients • Strategic purchasing—mixed payment models that include outcomes, Garscadden Burn medical and populations. This integrated population based weighted practice closes one afternoon a working allows primary care teams to 41 42 capitation month to train staff in this area. engage directly with agencies working 52 • Allocate resources for transformation on social determinants of health. in operations System recalibration Finally, a cultural shift is required Monitoring and evaluation: Certain conditions are required within modern medicine, from • Performance management—devising to facilitate this style of working, specialist hospital treatment to financial and non-financial incentives starting with financing. The community led prevention and care. and key performance indicators Botermarkt practice successfully The NHS Five Year Forward View53 aligned with overall health system lobbied for capitated payment, which and Astana declaration54 are good goals it used to employ a community health examples of policy commitment to • Accountability—holding primary care teams accountable for delivering worker to engage with issues such as prevention oriented care. Medical activities housing, playgrounds, street lighting, associations carry enormous weight Enabling environment: healthy food availability, and active and will need to catch the vision of 21 44 • Seeking out and disseminating transport. England and Estonia’s what primary care can accomplish for examples of best practice quality bonus schemes could be patients when their sphere of concern • Lowering barriers to safe innovation modified to encourage action at the enlarges to encompass more than Luke N Allen, GP local population level. consultation rooms. Commissioners through accountability structures academic clinical and payment mechanisms that Moving away from fee-for-service fellow, Nuffield and individual practitioners also prioritise outcomes over processes. and towards mixed payment models Department of need to be convinced that this MANAGERS that include population based Primary Care Health enlarged scope is good for their Sciences, University 55 • Commissioning and managing weighted capitation is important patients. The box (left) outlines a of Oxford local services for sustainability and encouraging few suggested enablers of reform. 21‑46 luke.allen@ population based practice. • Training phc.ox.ac.uk More important is ensuring that the Time for action • Building and maintaining relations Shannon Barkley, with community stakeholders primary care sector is adequately Primary Healthcare Primary care teams provide • Convening stakeholders financed. Even in countries like Services, WHO, invaluable medical care for • Data analysis and performance the UK, where primary care is Geneva individuals, and this will always management well developed and delivers more Jan De Maeseneer, be required. However, they are also • Routine reporting to providers on than 90% of all health system emeritus professor, well positioned to help identify the health status of their population interactions, primary care receives Ghent University, and influence the local social • Improving the financial and human around 10% of government health Belgium determinants that make their resources allocated to health spending.47 Many of our English Chris van Weel, patients ill. Given that primary care promotion and disease prevention emeritus professor primary care colleagues believe workers are not currently trained, of general practice, PRACTITIONERS that this is not enough to provide a the Netherlands paid, or managed to think about Working with public health and bare bones individual level service, Hans Kluge, director, community drivers of disease, it is community members to: let alone expand to include social WHO Europe, not surprising that this approach is • Monitor population health status determinants. Long time horizons Copenhagen rare. Policy makers in Astana talked • Survey risks and threats to are required to realise the gains of Niek de Wit, the talk, recommitting to orienting public health investing in primary prevention. professor, University health systems around prevention. • Identify local social determinants Empanelment is a second Medical Center Introducing empanelment, of health prerequisite as primary care teams Utrecht, population weighted capitation, the Netherlands • Risk stratify the population need to know who they are serving enhanced training, unified Trisha Greenhalgh, • Develop and deliver appropriate and the characteristics of their budgets, and intersectoral working interventions professor, Nuffield patient population.48 Staff also need arrangements would show that they • Monitor and evaluate interventions Department of better training on how to identify are willing to walk the walk. with community involvement Primary Care Health and deal with social determinants, Sciences Cite this as: BMJ 2018;363:k4469

194 3 November 2018 | the bmj LETTERS Selected from rapid responses on bmj.com See www.bmj.com/rapid-responses

SERVICES FOR TRANS HEALTH Benefits and harms should LETTER OF THE WEEK be evaluated from a societal Transgender does not Gender identity perspective, as harms are equate to mental ill health services: we need undervalued and models use The BMJ’s article refers to parameters most favourable to “gender dysphoria” (Specialised good evidence industry. The Treasury is absent Services, 18-25 August), a term from this discourse. used in DSM-5. The critical A recent feature implied that new services are all that’s needed Public Health England’s 2016 element of gender dysphoria to improve transgender healthcare (Specialised Services, evidence review provides many is the presence of clinically 18-25 August). The article did not mention the potential harms evidence based suggestions. significant distress associated of medical overdiagnosis and overtreatment, given the lack of Minimum unit pricing is critical with the condition. comprehensive evidence of better outcomes after major surgery but seems to have been shelved Trans people (and others) and taking lifelong hormones. The proposed terminology misleads: by the government—where is argue that distress is associated biological sex is not “assigned” but determined at conception the advocacy from the NHS? with many factors, including and observed at birth, whereas gender is a fluid, social construct. Making public health a fifth stigma and prejudice, long Subjective gender identity, legal status, and external appearance licensing objective would give waiting lists, and difficulty can be realigned, but biological sex cannot. Diagnosis is depicted as local government licensing in accessing services. But a straightforward application of criteria. committees additional power. before publication of ICD- We disagree with the claim of Action For Trans Health Many councils have strong 11, people who experienced (a campaign group quoted in the piece) that “the continued recovery models, which should gender variance were given a existence of gender identity clinics amounts to wilful abuse.” be encouraged. Finally, we must psychiatric diagnosis to access People who question their identity or self define as trans should focus on fetal alcohol syndrome have access to high quality, joined-up, and person centred treatment. Removing gender as a major preventable cause of healthcare based on good evidence. variance from mental and learning disability. Medical practitioners should follow a framework of evidence, behavioural disorders represents Greg Fell, director of public health; Chris not simply respond to clients’ expectations. Creating that progress, but conflating gender Gibbons, health economist; Helen Philips- evidence to inform quality standards is an ethical imperative. We Jackson, senior commissioner, drugs and with sexual health may introduce need to explore the interplays between gender identity, mental alcohol team, Town Hall, Sheffield further complications. health and neurodevelopmental problems, sexual orientation, Cite this as: BMJ 2018;363:k4516 The result has been a complex autogynephilia, and unpalatable gender roles. The national association between mental reconfiguration is an opportunity to establish research, including Tackling alcohol harm would health, mental health services, trials for key uncertainties such as approaches to assessment make huge savings and identifying as trans. Removing and supportive wait-and-see versus intervention strategies. This How can the government allow the assumption that being trans is a vital opportunity to establish an ongoing cohort for all those continued health harm and such equates to mental ill health may referred, so that outcomes can be monitored. a high expenditure on treating it empower trans individuals to use Richard Byng, professor of primary care research, Plymouth; Susan Bewley, in the NHS when the causes are services to access psychological emeritus professor of obstetrics and women’s health, London; Damian Clifford, largely preventable? help if and when they need it. consultant liaison psychiatrist, Cornwall; Margaret McCartney, GP, Glasgow Cite this as: BMJ 2018;363:k4490 Introduction of the 50p Susan M Benbow, visiting professor; minimum unit pricing policy now Paul Kingston, director, Centre for going ahead in Scotland would Ageing Studies, Chester endocrinology, general surgery, APPROACH TO ALCOHOL HARM give a £2.7bn cumulative saving Cite this as: BMJ 2018;363:k4492 or medicine? What should over 10 years. Restoration of the emergency doctors do in the Alcohol policy needs alcohol duty escalator would Improve hospital referrals middle of the night? societal perspective save £1bn over a five year period, for trans patients The admitting service doctors Thank you for speaking some including £132m of direct costs to We would like to see better may argue that they have no sense on the government’s the NHS. guidance on referrals of trans experience of managing trans incoherent alcohol policy (Acute Not having to spend large sums patients to inpatient services. patients. But we cannot Perspective, 15 September). on the consequences of largely Gender dysphoria clinics are not simply keep patients in the We underinvest in alcohol preventable illness would allow available in every geographical emergency department until treatment relative to need. investment in the social services region and are not open 24/7. the gender dysphoria clinics Local government cuts have for treatment of those most in When trans patients require are open. We need to enrich consequences and will simply set need. That a fifth of people’s life urgent in-hospital consultations, the knowledge and experience up future demand for the NHS. expectancy is spent in ill health for management of the adverse of physicians, regardless of Communicating the evidence is a damning statistic, which effects of hormone therapy or specialties, on management of of the harm of alcohol remains should resonate strongly among postoperative complications, trans patients. confusing. The recent coverage of government and policy makers. where should they be referred Eugene Y H Yeung, physician, the Lancet paper on there being Roger Williams, director, Institute of to? Gynaecology, plastic Lancaster; Roxanna S D Mohammed, “no safe level” of alcohol erodes physician, Ottawa Hepatology, London surgery, urology, psychiatry, Cite this as: BMJ 2018;363:k4493 public trust in the evidence. Cite this as: BMJ 2018;363:k4519 the bmj | 3 November 2018 195

OBITUARY Bongani Mayosi Renowned cardiologist and visionary medical researcher

Bongani Mayosi (b 1967; q University his doctorate at Oxford University. of KwaZulu-Natal, Durban, South Africa, As the first doctoral student of Hugh 1989), died by suicide on 27 July 2018 Watkins, he would end up being an author on more than 300 papers. In More than 2000 people attended the 2006 he was appointed chair of UCT’s funeral service for Bongani Mayosi. Department of Medicine. “He was a brilliant academic,” Mpiko Ntsekhe, who was mentored eulogised South Africa’s minister by Mayosi and is head of cardiology of health, Aaron Motsoaledi, at the at UCT, told The BMJ that three of service in Cape Town on 4 August. Mayosi’s many research contributions “He believed in the potential of black were particularly important. The students, and he mentored them first was his work in “defining the with passion and love.” optimal methods for the diagnosis and Hugh Watkins, an Oxford University treatment of tuberculous pericarditis”: cardiologist who supervised Mayosi’s the Investigation of the Management doctoral degree, spoke at the funeral of Pericarditis (IMPI) trial resulted of his former student who had become in a landmark paper, published in HAMMOND MICHAEL a friend and colleague. Tributes from 2014 in the New England Journal Mayosi few weeks later protests broke out Mayosi’s family—written as letters of Medicine. Watkins also noted its believed in on the UCT campus, led by students addressed to him—were read out importance, adding that Mayosi’s the potential demanding lower university fees. aloud, including letters of farewell superb leadership of the trial “showed of black Mayosi’s office was occupied by from his three daughters. Eight days that it was possible to do definitive, students, and protesting students for two weeks. before the funeral, Mayosi—who practice altering, clinical research Family members said that he had he mentored was dean of the Faculty of Health across the African continent, using spoken to them about feeling isolated Sciences at the University of Cape local infrastructure and resource.” them with and let down by colleagues, the Town (UCT)—took his own life. He His second important contribution passion faculty, and the university. was 51 and had achieved more in was founding “the first global and love Sipho Pityana, chair of the UCT his life than most could manage in study of clinical characteristics and Council, said, “We need to ask several lifetimes. His family issued outcome in rheumatic heart disease ourselves if we have become so a statement after his death, saying (the Global Rheumatic Heart Disease bloody minded and entrenched in that he had battled with depression Registry or REMEDY study),” said defending our own positions, that we in the past two years and “took the Ntsekhe, which “put the concept of have lost an ability to listen, to view desperate decision to end his life.” primary prevention of rheumatic each other as human beings, and to Bongani Mawethu Mayosi was fever as a means to eradicate act with empathy and kindness.” born on 28 January 1967 in Mthatha, rheumatic heart disease on the global Speaking to The BMJ, Watkins and aged 1 he moved with his family agenda of the World Heart Federation said of Mayosi, “Almost every photo to the village of Ngqamakhwe. and the World Health Organization.” of him shows his wonderful smile, Aged just 16, Mayosi started at The third was his establishment of and that’s what we all miss. He the University of KwaZulu-Natal “genetic studies of cardiomyopathy was, truly, a visionary. He was bold in Durban. He qualified with and familial fibrosis, which have scientifically because he knew that distinction in 1989. The following led to the discovery of novel he had to tackle Africa’s major health year he and his wife moved to Port biological mechanisms of heart problems. He believed in excellence Elizabeth, where they did house jobs disease and fibrosis.” and rigour, never cut corners, and at Livingstone Hospital. In 1992 he built things that would last. joined UCT as a senior house officer Faculty dean “Throughout his life he was a in the Department of Medicine; he In November 2015, UCT announced champion of the disadvantaged and would remain affiliated with UCT for Mayosi’s appointment as dean of the indeed had himself overcome the the rest of his life. Faculty of Health Sciences. Before injustice of apartheid. But he always assuming the post, he spent eight saw solutions, not barriers. His Research and evidence months in the US on sabbatical at legacy is huge.” Mayosi became increasingly interested Harvard University. He returned to Ned Stafford, Hamburg in cardiology and in 1998 moved to Cape Town to take up his duties. The [email protected] England on a fellowship to complete timing was unfortunate, as only a Cite this as: BMJ 2018;362:k3672

196 3 November 2018 | the bmj