this week ZOOM BOOM page 87 • CANCER DELAYS page 88 • ASSISTED DYING page 90 MARCO MANTOVANI/GETTYIMAGES MARCO England gets three tier covid alert system

Liverpool and neighbouring authorities will in hospital with covid-19 than when the Figures show there are now be the fi rst in England to have restrictions country went into full lockdown on 23 more patients in hospital imposed under the new three tier risk March, restricting transmission was vital to with covid-19 (3665 as at 12 system designed to stem rising covid-19 saving lives. As at 12 October England had October) than when lockdown was first implemented (3097 infections, the government has announced. 3665 patients in hospital with covid-19, on 23 March) Liverpool had 609 cases per 100 000 compared with 3097 on 23 March. population on 13 October, a 14.3% rise on Initially, only Liverpool City Region will the previous week. Knowsley—subject to be in tier 3, which applies to areas where the measures that apply to Liverpool City transmission rates are rising most rapidly. Region, which also includes Halton, Sefton, On 14 October p ubs, gyms, betting shops, St Helens, and Wirral—had 669.5 cases per and casinos were told to close, and social 100 000. Liverpool has the steepest rise and mixing between households was banned highest number of covid-19 admissions to indoors and in private gardens. Shops, LATEST ONLINE hospital in England, with more than 250 schools, and universities remain open. patients in Liverpool University Hospitals Johnson suggested that areas in the North Johnson & Johnson Trust beds, around 15% of capacity. The West, the North East, and the Yorkshire and coronavirus trust is now scaling back non-urgent Humber regions could move into tier 3 soon. vaccine trial is operations to help cope with the surge. A reas that are already subject to paused because of unexplained illness Boris Johnson, the prime minister, set local measures on top of the national in participant out plans on 12 October for a “simplifi ed” rules, including Greater Manchester, Junior doctor three tier system that will grade every area of Nottinghamshire, parts of Cheshire, and struck off for England as medium, high, or very high alert. Newcastle, moved into the tier 2 “high alert” dishonesty The announcement came after warnings category, which prohibits indoor mixing is restored to that without new measures the NHS faced between households and applies the “rule medical register being overwhelmed. But experts disagree on of six” outdoors. Former US doctor the best way to control the pandemic, with Johnson also announced that all NHS who ran fraudulent government advisers recommending last staff in high risk areas would be regularly clinical trial sites month that a two week national lockdown tested, whether or not they have symptoms. is sentenced to or “circuit breaker” was needed (see p 88). Gareth Iacobucci, The BMJ 28 years in prison Johnson told MPs that, with more people Cite this as: BMJ 2020;371:m3961 the bmj | 17 October 2020 85 SEVEN DAYS IN Withdrawal of lithium product is paused while competition watchdog investigates The manufacturer of Priadel, a brand of lithium widely used to treat bipolar disorder, has halted plans to withdraw the drug aft er the Competition and Markets Authority launched an investigation into whether the company had broken the law. The CMA is investigating whether Essential Pharma has “abused a dominant position” aft er it announced it would withdraw Priadel next April, forcing patients to switch from a drug that costs £4.02 for a pack of 400 mg tablets, to Camcolit, priced at £48.18. The regulator said it had reasonable grounds to suspect an infringement of the Competition Act 1998. The investigation follows a letter from representatives of doctors’ and pharmacists’ bodies and mental health charities that called on England’s health secretary, Matt Hancock, to intervene to ensure Priadel remained available to treat patients in the UK. The Department of Health and Social Care had asked the CMA to impose interim measures to stop the drug’s withdrawal while the investigation is ongoing. However, Essential Pharma said it will continue to supply the drug to facilitate discussions on pricing, removing the immediate threat to patients.

Jacqui Wise, London Cite this as: BMJ 2020;371:m3923

Covid-19 Cautious optimism for would produce a case definition Patient safety Labour analysis: infection neutralising antibodies of long covid by the end of this Trust faces criminal rates rising in hotspots Eli Lilly submitted a request month and publish guidelines on charges over baby’s death Nineteen of 20 areas in England to the US Food and Drug managing patients in November. The Care Quality Commission is that have recently been under Administration for emergency use An online rehabilitation service, prosecuting East Kent Hospitals covid-19 lockdown restrictions authorisation of its neutralising Your Covid Recovery, is also being University Trust in the first for two months have seen an IgG1 monoclonal antibody (mAb) developed and further research criminal case of its kind. The increase in infection rates, a bamlanivimab in higher risk commissioned. scandal hit trust is charged Labour Party analysis showed. patients with mild to moderate with exposing newborn Harry Bolton, which has been under covid-19, after what experts Surgical procedures are Richford and his mother, Sarah restrictions since 30 July, saw said were promising results. On “less risky than thought” Richford (below), to a significant its infection rate rise from 20 to 16 September Lilly announced Researchers in Bristol found that risk of avoidable harm. Harry 255 people per 100 000. Rates the treatment reduced the rate tracheal intubations died a week after his in Bury and Burnley, both under of admission and emergency including face mask emergency delivery restrictions since 31 July, rose department visits in care home ventilation produced by an inexperienced from 20 to 266 and from 21 to residents and staff with mild to 500 times fewer locum doctor at the 434 per 100 000, respectively. moderate covid (5 in 302), when aerosolised particles Queen Elizabeth compared with placebo (9 in 150). than a single cough, the Queen Mother EU signs deal on while extubation Hospital in Margate in remdesivir supply Long covid centres produced 15 times November 2017. An The European Commission are set up in England more aerosolised particles than inquest concluded that he died signed a deal with Gilead for Simon Stevens (below), NHS intubation but still 35 times as a result of neglect after “wholly enough doses of remdesivir England’s chief executive, fewer than a cough. Writing avoidable” errors. to treat 500 000 patients in 36 announced a package of in Anaesthesia , they said that countries, including the UK. A measures to boost support their findings did not support £4000 fine for global shortage has arisen after for patients with long covid, the designation of elective failing A&E patients the US bought up all stocks from including £10m towards tracheal intubation as an aerosol Shrewsbury and Telford Hospitals June to October. In May the UK designated clinics with generating procedure. William NHS Trust was fined £4000 by the government said that selected respiratory consultants, Harrop-Griffiths, the Royal CQC for failing to triage emergency patients with covid-19 would be physiotherapists, and GPs. College of Anaesthetists’ vice department patients within 15 treated with remdesivir because They will help to assess, president, said that current minutes. The trust also failed to of limited stocks, but it did not diagnose, and treat precautions to protect ensure that children who left the specify criteria. In Europe and illness in patients who healthcare workers against emergency department without the UK remdesivir is indicated report symptoms such as infection by aerosol being seen were followed up. for the treatment of covid-19 in breathlessness, chronic transmission took up a lot The fine follows the trust’s failure adult and adolescent patients fatigue, “brain fog,” of time and decreased to adhere to conditions on its with pneumonia requiring anxiety, and stress. throughput of registration imposed in 2019 after supplemental oxygen. Stevens said NICE patients. breaches at two hospitals.

86 17 October 2020 | the bmj SIXTY SECONDS MEDICINE ON . . . Covid vaccine THE ZOOM BOOM US and Russia remain outside vaccine initiative HAS DONALD TRUMP LAUNCHED A China said that it would join NEW SPACE MISSION? Covax, the international vaccine For once this has nothing to do with the US effort led by the World Health president, and the only lift off we’re talking about is around the facial region. Organization, leaving Russia and the US the only major vaccine EYE, EYE making nations on the outside. China joining Covax Indeed. Plastic surgeons are reporting that Covax, which has 170 member leaves only Russia and more people are coming to them seeking countries, aims to distribute fairly the US outside WHO’s otoplasty, blepharoplasty, and Botox at least two billion vaccines to vaccine distribution group because wearing masks and appearing on high risk people in each member virtual calls has placed more emphasis on country. China has four vaccine longer term data on coronary their eyes and ears. candidates in phase III trials and artery bypass grafting (CABG) CANCER WE CAN’T HEAR YOU . . . estimates that it can produce versus percutaneous coronary More than Sorry, I forgot to unmute myself. In a 610 million doses next year. The intervention (PCI). Whether PCI is nutshell, surgeons say requests for Trump administration refused as safe and effective as CABG has 350 000 cosmetic facial procedures have risen since to join Covax last month, saying been questioned since the BBC’s the covid-19 pandemic and the subsequent that it would not be “constrained Newsnight revealed last year that people who would switch to online meetings and conferences. by multilateral organizations unpublished data from the EXCEL normally be WHY ARE PEOPLE SEEKING influenced by the corrupt World trial showed patients given stents urgently referred TREATMENT NOW? Health Organization and China.” to hospital with Ashton Collins, director of Save Face, a suspected cancer register of accredited cosmetic practitioners DNACPR approved by the UK government, says CQC to r eview do not symptoms since the end of March “‘lockdown face’ has become a thing.” resuscitate decisions She said the many hours of staring back The Department of Health and were not at ourselves on video calls is prompting Social Care asked the CQC to [Cancer Research queries about everything from frown lines review how Do Not Attempt UK] and lips that need doing to crooked noses. Cardiopulmonary Resuscitation (below) were at greater risk of (DNACPR) decisions have myocardial infarction. The review SO, ZOOM HAS CAUSED INTEREST TO SKYROCKET? been used during the covid-19 is due to be published next May. You could say that. The British Association pandemic. It is expected to of Aesthetic Plastic Surgeons (BAAPS) has look at people’s experiences BMJ Awards reported that its doctors have seen up in care homes, primary care, NHS chief hails to 70% increases in requests for virtual and hospitals. Earlier this year clinical leaders consultations during lockdown this year. concerns were reported that The NHS was never a “covid only” elderly and vulnerable people service even at the height of WHAT ABOUT FACE MASKS AND PPE? may be being subjected to the coronavirus pandemic, said BAAPS vice president Marc Pacifi co said the DNACPR decisions without being NHS England’s chief executive, association and its members were regularly fully informed. Providers were Simon Stevens, at the virtual BMJ encountering comments from patients concerned that their eyes were more reminded in April that advance Awards ceremony on 7 October. on show now because of wearing facial care plans, with or without He said that 2020 would probably coverings, the reported this week. DNACPR orders, should not be be the “defining year” in the Times applied to groups of people. NHS’s history, given how it had IS “ZOOM BOOM” been tested. But he said that staff JUST A UK THING? Cardiology had responded “impressively, Not at all. Australia, Review of m yocardial with conviction and with agility,” Japan, South Korea, revascularisation guide saving many lives. They were now and the US are among The European Society of gearing up to counter a further the nations to have Cardiology and the European rise in the prevalence of covid-19 reported an increase Association for Cardiothoracic alongside restarting a “wider in bookings for treatments over recent months. Surgery agreed to review their range” of services, he said. For guidance on treating patients award winners see bit.ly/3iJju8C. with left main coronary artery Gareth Iacobucci, The BMJ stenosis in the light of emerging, Cite this as: BMJ 2020;371:m3951 Cite this as: BMJ 2020;371:m3943

the bmj | 17 October 2020 87 COVID-19

should not be applied in too specifi c a Leading doctors and advisers geographical area.” David Nabarro, the World Health argue against local lockdowns Organization’s special envoy for covid-19, has separately appealed to government leaders: “Stop using lockdowns as a primary means of THE SAGE DOCUMENTS he government’s own scientifi c controlling the virus. Develop better systems.” ALSO SUGGESTED advisers and other leading Speaking in an interview with Spectator experts argued against a policy magazine he said, “The only way that Advising people to work of increased restrictions in lockdowns are justifi ed is to buy you time to 1from home if they can T local areas to control the covid- reorganise, regroup, rebalance your resources 19 pandemic, instead calling for a short and protect your healthcare workers.” Banning all contact period of national lockdown or “circuit 2within the home with breaker,” documents show. Circuit breaker members of other households The newly released documents reveal On 11 October Anthony Costello, that the Scientifi c Advisory Group for professor of global health and sustainable Closure of all bars, Emergencies (SAGE) recommended on 21 development at University College London 3restaurants, cafes, September that such an immediate circuit and a member of the Independent SAGE indoor gyms, and personal breaker was the best way to control cases. group, wrote a long thread on Twitter services, such as barbers Rumours about SAGE’s advice had been arguing against local lockdowns and circulating for some weeks, but the minutes calling for a national circuit breaker All university and college were offi cially released only after the prime together with immediate reform of the test 4teaching to be online minister announced a new three tier system and trace system. for England, with Liverpool facing the most “We’re in a mess. Cases, hospitalisations, Of all the measures SAGE stringent restrictions (see p 85). and deaths are rising,” wrote Costello, a proposed, only one—advising people SAGE said, “The more rapidly former WHO director. “It’s too late for test to work from home—was implemented interventions are put in place, and the and trace to stop it. Things will just get by the government at the time more stringent they are, the faster the worse.” reduction in incidence and prevalence, and He wrote that local restrictions (rather the greater the reduction in covid-related than a national lockdown) risked increasing deaths (high confi dence). Both local and numbers of cases and deaths, with possible national measures are needed; measures exponential spread. “It also means we shall Cancer care falls as referrals recover slowly, show figures

The number of patients with September. Around 17 500 two thirds (66%) of the 1000 GPs cancer who started treatment week referrals for suspected surveyed (between 4 and 30 between April and July 2020 in lung cancer were made between September) reported longer the UK was 26% lower (31 000) March and September—the waits for chest radiography than in the same period in expected number was 34 000. since the end of March, while 2019, show fi gures analysed Royal College of Radiologists half (48%) experienced by Cancer Research UK. The president Jeanette Dickson said, increased waiting times for charity said this was due to “My personal practice is lung computed tomography, and

fewer people being referred to cancer. During the pandemic, SPL CUTHBERT / COLIN 78% faced increased delays to or attending secondary care for a month or two I saw no of pre-covid-19 levels at the end non-obstetric ultrasound. and to the pause in screening patients with a curable disease, of September. Between March Cancer Research UK’s chief programmes and some because of late presentations. and September there were executive Michelle Mitchell diagnostic tests because of the That is beginning to recover; we 70 000 referrals, around 46 000 said, “We need a plan and covid-19 pandemic. are beginning to see patients fewer than expected. investment in diagnostics and with potentially curable A GP survey commissioned by workforce, because we were Lung cancer illnesses.” the charity found longer waiting behind before covid-19. We Figures for England show that Suspected urological cancers, times and delays for diagnostic need to retain our ambition, and urgent referrals for suspected including those of the prostate, tests, including blood test the comprehensive spending lung cancer have been the bladder, and kidney, are services (reported by 53% of review is an important time for slowest to recover, at 60% of another area that has seen slow GPs) and upper gastrointestinal the government to indicate that pre-covid levels at the end of recovery, with referrals at 78% and lower gastrointestinal they are not just clapping for the endoscopy (reported by 70% NHS but backing it.” During the pandemic, for a month or two I saw no patients with and 62%, respectively). Elisabeth Mahase, The BMJ a curable disease, because of late presentations Jeanette Dickson The survey reported that two Cite this as: BMJ 2020;371:m3958

88 17 October 2020 | the bmj Government told to release 2016 pandemic report

The Information Commissioner’s Offi ce has ordered the government to release an Drinkers in a Liverpool bar watch Boris Johnson unpublished report on Exercise Cygnus, a announce the city’s lockdown 2016 exercise to test the UK’s preparedness CHRISTOPHER FURLONG/GETTYIMAGES CHRISTOPHER for a fl u pandemic. reach a new state of ‘endemicity’ with centralised, privatised, and ineff ective Six months ago the NHS doctor Moosa repeated surges and falls until such times companies,” had “failed miserably.” He Qureshi (below) submitted a request under as the virus has eaten its way through all called for Dido Harding, the head of NHS freedom of information legislation to the exposed and vulnerable people.” Test and Trace, and England’s health Department of Health and Social Care for He said a circuit breaker should stop secretary, Matt Hancock, to be removed and England requesting the release of a report transmission within and between areas and an experienced minister such as Greg Clark into Exercise Cygnus and threatening legal might also break the oscillation of surges or Jeremy Hunt and a strong public health action if the health and social care secretary, and falls in infections. However, delaying a leader and independent public health team Matt Hancock, failed to release the report. circuit breaker risked an exponential rise in put in place to lead a test and trace scheme. The Information Commissioner’s cases, as in March. “Without major reform He called on the government to fund Offi ce has now intervened, ordering the of Find, Test, Trace, Isolate, Support (FTTIS) local test and trace systems, to be run department to either release the information the UK will be back in trouble in two to through district outbreak management or explain its decision for withholding it three months,” he warned. teams that included public health, virology, within 20 days. Costello said that the current test and primary care, and council leaders, backed In mid-September Qureshi’s lawyers, Leigh trace system programme, “based on by volunteers. The government must cover Day Solicitors, wrote to the commissioner full salaries of people asked to isolate, he to complain about the latest delay in We’re in a said, and compliance with isolation should responding to Qureshi’s request. mess. Cases, be monitored through calls, home visits, or The lawyers’ letter said, “Perhaps hospitalisations, an app, as in South Korea. conscious of the political ramifi cations that and deaths are rising Jacqui Wise, London disclosure of the Cygnus Report might have Anthony Costello Cite this as: BMJ 2020;371:m3959 whilst the pandemic rages on, the DHSC is clearly playing for time. As a result, it is preventing Dr Qureshi either receiving Research will assess pandemic’s copies of the Cygnus Report or exercising his legal rights to challenge any refusal to effects on wellbeing of NHS staff disclose the same. Its actions are a clear and obvious breach of the statutory requirement A study of the effects psychological medicine at have reported negative under s.10 FOIA [section 10 of the Freedom of the pandemic on the King’s College London. He effects of the pandemic of Information Act] to respond within a psychological health told The BMJ that the study on the mental health of reasonable period of time.” of England’s NHS staff began in April in King’s health workers, “most were This prompted the Information has received £530 000 College Hospital Trust “on a rubbish with poor response Commissioner’s Offi ce to write to Hancock, government funding. shoestring” but that the new rates.” He told The BMJ, saying, “Public authorities should aim The NHS Check study is funding meant it could be “Overall mental health has to respond fully to all requests within 20 one of six research projects expanded to 18 other trusts. deteriorated during the working days. In cases where the public to share £2m from UK Everyone on the trusts’ pandemic, and healthcare interest considerations are exceptionally Research and Innovation payrolls will be contacted. workers are not immune to complex it may be reasonable to take and the National Institute The study will use a that. But we don’t know if it longer but, in the commissioner’s view, for Health Research. Three combination of online is as bad as some studies in no case should the total time exceed 40 will look at the effects of the questionnaires carried out seem to be saying.” working days.” pandemic on children and at regular intervals and He added that health The department said it was younger adults, and two will more detailed interviews workers had reported considering the commissioner’s focus on people with serious with a smaller group of positive aspects of working decision and would respond in due mental health problems. participants. It also hopes to in the pandemic, including course. Another will focus on NHS assess the myriad support increased leadership, Gareth workers from ethnic minority systems that are in place in teaching, and supervision. Iacobucci, backgrounds. different trusts. Jacqui Wise , London The BMJ NHS Check is led by Wessely said that, Cite this as: BMJ Cite this as: BMJ Simon Wessely, professor of although several surveys 2020;371:m3942 2020;371:m3953 the bmj | 17 October 2020 89 BMA’s opposition to assisted dying should end, says members’ poll

he BMA should drop its “Vote shows Commenting on the fi ndings, She said, “We look forward to the stance against changing BMA’s opposition Jacky Davis, chair of Healthcare BMA reviewing its position so it can the law on assisted dying, was completely Professionals for Assisted Dying, said, truly claim to represent the range of say a majority of members unrepresentative “We now know what we’ve suspected opinions of its members.” T voting in an historic poll. of its members” for many years: there is a wide range of Within the past two years the Royal The poll, the fi rst by the BMA on views among doctors, and support for College of General Practitioners and Sarah Wootton, the issue, found that a third (33%) law change is growing. For too long the Royal College of Physicians have both of those responding supported its Dignity in Dying medical establishment has opposed surveyed members on assisted dying, position of opposing a change in the assisted dying without listening to the and the results showed that 51% law (see table). Forty per cent said the opinions of the profession as a whole.” and 57%, respectively, wanted their BMA should support a law change But she added, “The BMA should colleges to stop opposing a change in that would permit doctors to prescribe be commended for conducting a very the law on assisted death. The RCGP drugs to eligible patients for self- thorough and fair survey.” decided that the result did not support administration to bring on death, 21% Sarah Wootton, chief executive of a change in its view, but the RCP said it should take a neutral stance, Dignity in Dying, agreed, describing changed its position and now adopts a and 6% were undecided. the poll as an “historic vote” that neutral stance. John Chisholm, chair of the showed the BMA’s offi cial opposition Gordon Macdonald, chief executive BMA’s medical ethics committee, to assisted dying was “completely of Care Not Killing, said that in all of emphasised that the results would not unrepresentative of its members.” these surveys the strongest opposition automatically change policy to oppose assisted dying in all its forms. “That SHOULD THE BMA SUPPORT A CHANGE IN LAW TO PERMIT DOCTORS TO PRESCRIBE will only change should members DRUGS FOR ELIGIBLE PATIENTS TO SELF-ADMINISTER TO END THEIR OWN LIFE? at the BMA’s annual representative Support Continue to Take neutral Undecided meeting (ARM) vote to do so,” he oppose stance said in a blog. “The next meeting is All doctors 40% 33% 21% 6% scheduled to take place in June 2021; By specialty the results will play an important role Anaesthetics 51% 22% 22% 5% in informing that discussion.” Clinical oncology 29% 44% 22% 4% The anonymous poll, conducted Clinical radiology 52% 24% 18% 5% in February by Kantar, is one of the Emergency medicine 50% 22% 22% 6% largest ever surveys of doctors’ views General practice 34% 39% 21% 6% on assisted dying. Sent to 152 004 Geriatric medicine 27% 44% 24% 5% BMA members, it generated 28 986 Intensive care medicine 48% 24% 24% 4% responses (a 19.4% response rate). Palliative medicine 7% 70% 29% 4% Half of the respondents (50%) said Renal medicine 21% 42% 33% 4% they were in favour of a law change, Respiratory medicine 30% 39% 25% 5% although many considered it better Trauma and orthopaedic surgery 52% 23% 19% 5% for the BMA to take a neutral position. By country Those opposed to a change in the law England 41% 32% 22% 6% accounted for 39% of respondents, Scotland 40% 33% 21% 6% and 11% were undecided. And when Wales 39% 33% 22% 6% it came to their willingness to prescribe Northern Ireland 31% 46% 18% 4% life ending drugs themselves, 36% By practice were prepared to do so, 45% were not, Medical student 53% 20% 19% 8% and 19% were undecided. Retired 44% 27% 24% 5% Junior doctor 43% 28% 23% 6% Consultant 40% 35% 21% 5% These results will play Staff and associate specialist 35% 35% 22% 8% an important role in General practice 34% 40% 20% 6% informing the discussion Registration status (with licence to practise in UK) at our meeting in June Registered 38% 35% 21% 6% BMA’s John Chisholm Not registered 47% 25% 22% 6%

90 17 October 2020 | the bmj Those personally opposed to a change in the law accounted for 39% of respondents, and 11% were undecided. And when it came to their Judges to assess whether children willingness to prescribe life ending drugs themselves, should receive hormone blockers 36% were prepared to do so, 45% were not, and 19% were undecided The High Court in London is to rule “retransitioning” back to her original on whether children with gender identity but had been left with “no dysphoria can continue to be given breasts, a deep voice, body hair, a to changing the law came from hormone blockers to delay puberty beard, affected sexual function, and doctors who worked most closely with without a judge’s declaration that the who knows what else that has not terminally ill, elderly, and disabled treatment is in their best interests. been discovered.” patients in palliative care, geriatric Three senior judges are expected medicine, and general practice. to give judgment on the issue within “Little is known” weeks, after a two day court hearing. The NHS website says there is “Discriminatory message” Keira Bell (below), 23, who was “some uncertainty” about the long He said, “These doctors are concerned For too long treated as a teenager, and “Mrs A,” term risks of cross-sex hormone about the discriminatory message that the medical the mother of a 16 year old girl with treatment but that it can cause singling out terminally ill and disabled autism who is on the waiting list some irreversible changes, such as establishment people would send. for treatment, are challenging NHS deepening of the voice, and may “Many active medics have has opposed guidelines on hormone blocker use. cause temporary or even permanent repeatedly rejected the mendacious assisted dying They argue that the guidelines are infertility. On the long term side claims made by those pushing for without listening unlawful because children are unable effects of puberty blockers, it says this change, namely that legalising to the opinions of to give informed consent. “little is known.” assisted suicide and euthanasia can the profession The challenge has been brought Jeremy Hyam QC, for Bell and be done with safeguards and would Jacky Davis against the Tavistock and Mrs A, told the court in not put pressure, real or perceived, on Portman NHS Foundation written submissions, “That vulnerable people to end their lives Trust’s gender identity children are not capable of prematurely.” development service giving informed consent to The results of the BMA poll also (GIDS), the UK’s only undergo a type of medical show that non-practising doctors, specialist service for young intervention about which such as students, the retired, and those people seeking gender the evidence base is poor, who do not hold a licence to practise, reassignment. The service has clinics the risks and potential side effects are more supportive of change than in London and Leeds. are still largely unknown, and which practising doctors and that doctors in In 2014, as part of a study, NHS is likely to set them on a path towards Northern Ireland are less supportive England approved changes to permanent and life altering physical, than those in other UK nations. permit puberty blockers, previously psychological, emotional, and While there was overwhelming available from age 16, to be offered developmental consequences . . . support for a change in the BMA’s to children aged 12 and above. is the commonsense and obvious stance on assisted dying, far fewer Lawyers for Bell and Mrs A argue position.” He said referrals to GIDS doctors were supportive of a change there is a very high likelihood that had increased 20-fold, from 97 in in the BMA’s position on voluntary children who start taking hormone 2009 to 2590 in 2018. euthanasia. Only 30% of respondents blockers will later begin taking cross- Fenella Morris QC, for the Tavistock believed the BMA should support a sex hormones, which can cause and Portman trust, said few children change in the law to permit doctors irreversible changes. were referred to GIDS under the age of to administer drugs to end a patient’s In a witness statement Bell said 13. In a written submission she said life, while 40% said it should continue she had been treated with hormone that the use of puberty blockers “has to oppose voluntary euthanasia, 23% blockers and later male hormones been widely researched and debated said it should take a neutral stance, as a result of a “brash decision for three decades,” and added, “It is and 7% were undecided. as a teenager.” She was now a safe and reversible treatment with a Almost half of the respondents well established history.” (46%) were opposed to a change in She said GIDS referred children the law on voluntary euthanasia, 37% and teenagers with gender dysphoria supported a change, and 17% were to University College London undecided. More than half of doctors Hospitals NHS Foundation Trust or responding (54%) would not want to Leeds Teaching Hospital NHS Trust. administer life ending drugs, only 26% Those trusts, not the Tavistock said they would be willing to do so, and Portman, were responsible for and 20% were undecided. prescribing the hormone blockers. Ingrid Torjesen, London Protesters from Our Duty parents’ group Clare Dyer , The BMJ Cite this as: BMJ 2020;371:m3936 outside the High Court on 7 October Cite this as: BMJ 2020;371:m3940 the bmj | 17 October 2020 91 THE BIG PICTURE Empty chairs mark US deaths

Twenty thousand empty chairs, each representing 10 of the 200 000 Americans who have died from the coronavirus, are laid out at the National Covid-19 Remembrance on the Ellipse, behind the White House. The memorial formed part of the national day of remembrance on 4 October. It was organised by Covid Survivors for Change, a network formed to provide support for survivors and the bereaved during the pandemic. Alison Shepherd, The BMJ Cite this as: BMJ 2020;371:m3949

92 17 October 2020 | the bmj the bmj

| 17 October 2020 93

TASOS KATOPODIS/GETTYIMAGES EDITORIAL Towards a carbon neutral NHS New report commits to net zero carbon emissions by 2040

istory will supplement to the report.6 A 2040 commitment minorities make up 20% of remember 2020 It off ers more detail on sends a strong signal the NHS workforce, and many as the year when how recommendations to health services come from low and middle the covid-19 might be implemented and around the world income countries. Despite pandemic highlights studies showing the their experience of delivering H 5 plunged the world into turmoil, substantial variation in carbon increase demand for energy, healthcare in resource poor leaving climate change footprints across the health to provide cooling in hotter settings, these professionals consigned to the backroom of industry, specialties, and summer months or for fl ood are largely excluded from global news. Yet, the climate healthcare interventions. rescue operations.9 The report’s planning and service emergency1 2 is by far the call for climate adaptation improvement discussions.12 biggest public health threat Bold plan and mitigation measures to be Ethnic minority communities we face,3 and since the start of The bold NHS plan involves every closely aligned with the net zero whose everyday lives are defi ned the pandemic we have already relevant sector from estates and agenda is therefore welcome. The by socioeconomic inequalities moved a year closer to the facilities to travel, transport, inclusion of patient and visitor and racism must be at the table. 2030 deadline to halve global and medicines. It seeks to distil travel in emissions calculations Their insights will ensure that, emissions of carbon dioxide, key learning from the rapid is encouraging, but aviation for example, digitised health and the 2050 deadline to reach changes in service delivery such emissions of internationally delivery does not reduce access net zero emissions.4 as digitised care, which covid-19 recruited staff should also to care and widen existing health The recent publication of compelled the NHS to introduce, be added, especially when inequalities. The NHS should the UK report Delivering a “Net and to retain best practice. increased overseas recruitment is draw on deliberative democratic Zero” National Health Service is Equally creditable is the aim planned.10 processes such as those used in therefore welcome.5 It sets out to achieve net zero emissions After reducing emissions as the recent UK climate assembly the NHS’s ambition to become for the NHS supply chain by far as possible, off setting may to help defi ne priorities, ensure the world’s fi rst carbon neutral 2045.5 The objective is to make need to be considered to deal that all voices are heard, and national health system by more effi cient use of supplies, with residual emissions. The secure a just transition to a zero 2040. The report describes the seek low carbon options and NHS should consider adopting carbon health service. urgent need for such a strategy; innovations, and encourage a framework such as the The leadership shown in how the carbon footprint, decarbonising behaviours Oxford off setting principles11 setting a 2040 commitment targets, and trajectories among its 80 000 suppliers. to provide a clear approach is admirable and important, have been estimated; the Challenges remain, however. for managing residual not just in reducing emissions interventions planned and Firstly, large gaps in data and emissions and participating but in sending a strong signal the emissions reduction they knowledge need to be fi lled 6 to in off setting projects. to health services around the are likely to achieve; how the ensure the accuracy of the carbon world in the lead up to the recommendations fi t within the estimates and achievement of Everyone included United Nations Framework framework of the NHS long term milestones. The carbon footprints The report rightly recognises Convention on Climate Change plan; and next steps. of many medical specialties and the importance of staff and summit in November 2021. Salas and colleagues’ treatments are still unquantifi ed, public ownership of the plans.5 The summit, hosted by the article (opposite) is a timely for example. But it is silent on the need to UK, should be a catalyst for Neil Jennings, partnership Carbon reduction plans democratise the engagement collaboration on healthcare development manager will be implemented as global by off ering everyone, especially decarbonisation globally. [email protected] temperatures rise and trigger those from ethnic minority Cite this as: BMJ 2020;371:m3884 more frequent extreme weather backgrounds, the opportunity Mala Rao, professor , Imperial Find the full version with references at College London events. These changes may to contribute. Staff from ethnic http://dx.doi.org/10.1136/bmj.m3884

94 17 October 2020 | the bmj ANALYSIS KEY MESSAGES • Greenhouse gas emissions from healthcare are substantial, and the A pathway to net health sector has generally lagged most other industries in reducing zero emissions its carbon footprint • Healthcare leaders and organisations have both a responsibility and an opportunity to chart a path to net for healthcare zero emissions • Doing so can improve health, protect healthcare delivery The sector has a profound responsibility and by minimising disruptions, yield economic benefi ts, and opportunity to reduce its greenhouse gas establish the healthcare sector as a leader in climate action production to limit the widespread health harms • Broad transformative steps are required, such as reducing demand through preventive care, using only clean energy, of climate change. Renee N Salas and colleagues choosing medical supplies with lower carbon footprints, set out a map to achieve the ambitious aim and reducing travel through telemedicine

he Intergovernmental Panel on Climate Change has although some sectors, such as steel and cement manufacturing made clear that limiting global heating to 1.5°C above and long distance air travel, will prove more diffi cult. Nations, pre-industrial levels will greatly reduce the probability cities, investors, and businesses are increasingly committing to net of sustained public health catastrophes. To achieve this, zero targets. To date, one national healthcare system—the NHS in human caused carbon dioxide (CO ) emissions must England—has committed to delivering a net zero health service across T 2 fall to roughly half of 2010 levels by 2030 and to net zero by 2050. its full scope. Emissions of other greenhouse gases (GHGs) must reach net zero soon Healthcare delivery is substantially more energy intensive than thereafter (by 2063-68).1 most other commercial and service activities, 2 and the health To achieve net zero GHGs, emissions from all sources—electricity sector has lagged in eff orts to reduce emissions. By striving for net generation, industry, transportation, buildings, and so on—must be zero, the healthcare industry can help limit climate change and its reduced to as close to zero as possible, and any remaining emissions downstream consequences, promote public health through reduced must be balanced by removing CO2 from the atmosphere, through air and water pollution, create cost savings by eliminating waste and such means as reforestation and direct physical-chemical removal. ineffi ciency, and become leaders in the global eff ort to limit global Net zero is technically feasible across much of the world’s economy, heating to 1.5° C .

Waste 12% treatment Transport & Scope 2 Electricity 3% distribution 12% 28% Processing of Chemical/ sold products Computers/ pharmaceutical electronics/ products End-of-life optical equipment 5% treatment of 0.2% sold products Other Leased Agriculture sectors/services 9% 8% assets Scope 3 Other manufacturing Investments 71% 11% Rubber/ plastic products Other Franchises 1.3% primary industries Employee commuting 4% Purchased 3% Other Transport goods and Capital 3% services fuel/energy goods Operational activities emissions Business 13% Waste travel Scope 1 generated in operations 17%

Many components of scope 3 are “unmeasured” and are not fully captured in the 71% of total emissions. These are depicted in blue. Measured and unmeasured healthcare sector activities that contribute to greenhouse gas emissions by scope.3 These scopes are defined in Box 1 (p 96) the bmj | 17 October 2020 95 contribute to reducing the many adverse health eff ects of the climate Box 1 | Key concepts and definitions crisis.25 More immediate benefi ts 26 include the increased physical Two core concepts for greenhouse gas emission quantification activity, improved air quality, reduced noise, and avoided car crashes Life cycle analysis —“cradle to grave” assessment that captures all associated with shifting from automobile travel to walking, cycling, emissions associated with a product or activity, from manufacturing to 27 use and disposal. and transit ; the improved air quality associated with a shift from 28 29 Multi-region input-output modelling —an analytical approach that tracks fossil fuel combustion to renewable power sources ; the reduced flows of goods and services from different sectors of the economy into risk of cardiovascular disease and some cancers associated with a shift 30 the health sector, monetises these flows, links monetary accounts from meat heavy to plant forward diets ; and the improved health, to GHG emissions in each sector, and allocates “embedded” carbon wellbeing, and productivity associated with green, energy effi cient emissions to the health sector3 - 7 hospitals and clinics.31 Three emission scopes Global assessment of healthcare environmental footprints shows ∙ Scope 1 emissions fall under the direct control of the healthcare that they are wide ranging, often avoidable, and predominantly facility (eg, on-site fuel combustion, fleet vehicles, anaesthetic gas leaks) indirect (scope 3, see box 1). 5 Healthcare systems need to use ∙ Scope 2 emissions derive from electricity purchased by the facility their considerable infl uence to decarbonise not just their internal ∙ Scope 3 comprises all other indirect emissions (eg, embedded operations, but their total supply chains and models of care and carbon in purchased supplies and equipment, employee commuting, prevention. Getting to net zero will enable healthcare providers to waste disposal).8 deliver high quality care today and in the future. Quality of care and Over 70% of healthcare emissions arise from the diverse categories in environmental performance should be increasingly connected given 3 scope 3, which very few health systems calculate or report. The NHS is a their interdependence.5 notable exception. Health institutions can realise substantial fi nancial benefi ts through Healthcare’s carbon emissions spending less on energy, maintenance, supplies, and other factors and through reducing waste, even when up-front investments are taken Decarbonising healthcare begins with identifying and quantifying into account.32 - 34 The shift to carbon neutral energy use, together with the sources of CO 2 emissions, known as the “carbon footprint,” reduced energy use through conservation, for example, is projected and of other GHG emissions. This is complex. It requires defi ning to save Boston Medical Center $153m (£120m; €130m) between system boundaries, which encompass the production and transport 2010 and 2030.35 Getting to net zero also off ers health institutions of medical supplies, patient and staff transportation, energy an opportunity for broader community leadership. 36 Lastly, use in medical facilities, the investment portfolios of health care environmental initiatives can motivate the healthcare workforce and organisations, and more (fi gure). Complete accounting requires build employee morale.37 consideration of the entire life cycle of healthcare products and processes and allocating all associated carbon footprint contributions Solutions within and outside of healthcare systems (box 1). If a blanket, defi brillator, or medication used in a hospital is manufactured at a distant factory in a process that emits large Recovery from the covid-19 pandemic and its associated economic amounts of CO2 , then that item is said to carry “embedded carbon,” downturn provides the opportunity to reimagine and transform which is attributed to the hospital, not the manufacturer. healthcare systems so they are resilient to future social, economic, Globally, the carbon footprint of healthcare in 2016 represented and environmental challenges, particularly towards net zero an estimated 4-6% of all emissions.4 The United States has the second performance. A range of transformative solutions must be considered highest per capita emissions, with healthcare estimated to contribute both within and outside of healthcare (table 3, see bmj.com). Some upwards of 10% of carbon emissions,9 second only to Iceland, where solutions are system-wide, such as creating a culture of sustainability import emissions are substantial. 10 Emissions rose in many countries and implementing consistent and valid carbon metrics, an explicit between 2007 and 2016, including China (180%), South Korea reduction trajectory, and associated accountability processes. (75%), Japan (37%), and the US (19%).4 The dramatic rise in China Estimated carbon footprint across procedures and treatments came during a decade of major poverty reduction and investment in Procedure or healthcare services. treatment Carbon footprint Carbon footprints vary across medical specialties and treatments 18 Cataract 0.182 tonnes CO2 e/cataract surgery (University Hospital Wales, Cardiff, U.K.) 19 (table). The carbon footprint of renal dialysis, for example, varies surgery 0.006 tonnes CO2 e/cataract surgery (Aravind Eye Hospital, Pondicherry, India) fourfold depending on technique,24 and that of pharmaceutical The Welsh analysis included patient and staff travel, paper and ink, and food, whereas the Indian analysis did not. Aligning the two results for comparison manufacturing varies fi vefold across companies,16 indicating yields 0.130 tonnes CO 2 e/procedure in Wales and 0.0006 tonnes/procedure in considerable room for improvement among high emitters. India, approximately a 20-fold difference 20 Comparison is stymied by heterogeneity in assessment methods. The Asthma 0.6-28 kg CO2 e/device inhalers 0.017 metric tonnes CO e/patient/year for Relvar-Ellipta/Ventolin-Accuhaler carbon footprints of entire specialties and treatments have not yet 2 0.439 metric tonnes CO2 e/patient/year for Seretide-Evohaler/Ventolin-Evohaler been quantifi ed. 21 Anesthetics Global heating potential relative to CO2 : Sevoflurane: 210 Benefits of reducing emissions Isoflurane: 510 Desflurane: 1620 22 Laparoscopic 355 924 metric tonnes CO2 /year for all US laparoscopic procedures Approaching and achieving net zero off ers a wide range of benefi ts for surgery including scope 2 and scope 3 emissions 23 healthcare. Perhaps most importantly, it advances the core mission Hysterectomy 212 000 metric tonnes CO2 e/year for 500 000 hysterectomies in the US of health institutions—improving health—because measures that Renal dialysis 3.8 tonnes CO2 e/patient/year in centre; 1.8-7.2 metric tonnes CO2 e/patient/ 24 mitigate the climate crisis yield numerous health benefi ts (often called year at home, depending on technique

“co-benefi ts”). In the long term, healthcare emissions reductions will CO 2e = carbon dioxide equivalent

96 17 October 2020 | the bmj Box 2 | Case study examples of efforts to reduce emissions A national health system getting to net zero has also made other major changes to transition Food The NHS has now set out clear targets and a to clean energy, including installation of 4 star Every day, the Melbourne Health Production process to reach net zero for the emissions it electrical appliances, swapping conventional Kitchen prepares nearly 3000 meals for patients controls directly (its carbon footprint) by 2040, light bulbs for LEDs, and installation of auto lock at the Melbourne Hospital City Campus. and the entirety of its emissions by 2045. 57 58 This on doors to maintain temperature and minimise Previously, all surplus food was sent to landfills. plan is now the most ambitious decarbonisation unnecessary energy use.63 Beginning in February 2018, the extra food was effort under way in the world, but the NHS has diverted to the community, preventing 25 kg of already shown its capability to reduce emissions, food from waste, providing 4200 meals a month, decreasing total GHG by 26% from 1990 to 2020. and reducing emissions due to food waste by 68 This work and future targets have been informed 17 tonnes of CO2 equivalent (CO2 e) per year. by a Net Zero Expert Panel,59 a nationwide call The Buddhist Tzu-Chi Dialysis Centre in for evidence, 60 and national and international Malaysia has reduced its carbon footprint by technical expertise. The full suite of interventions promoting vegetarianism and using reusable food needed to reach net zero covers a broad containers. Implementing an “only vegetarian” range, from technical and engineering based policy since the centre opened in 1997, the centre

interventions to improving buildings and transport saves 4.9 kg of CO2 systems and rethinking new models of care emissions for every that will enable a more sustainable, less carbon Buildings kg of tofu served in intensive approach to health and care. Butaro District Hospital, a 150 bed facility place of chicken. located in the Northern Province of Rwanda, They have also Individual health systems was constructed as a low carbon building in seen major falls in Gundersen Health System, an integrated collaboration with Partners in Health, the Rwandan carbon footprint by organisation serving communities in Wisconsin, Ministry of Health, and MASS Design. The hospital reducing the use of Minnesota, and Iowa, represents one of the minimises energy consumption through the use plastic bags.69 biggest US efforts to achieve net zero for its of non-permeable continuous flooring, natural portfolio of buildings. It relies heavily on wind daylight, natural ventilation, and optimised Travel energy; wind farms in Lewiston, Minnesota, fans and UV lights to ventilate while minimising Taiwan’s Taichung Tzu Chi Hospital has and Cashton, Wisconsin, each generate about transmission of airborne infections. Many of the reduced its carbon emissions through the 5 megawatts of energy, enough to collectively construction materials were sourced locally, and implementation of a hospital carpooling system power 2600 homes each year. Together with other targeted labour practices were implemented so that carried 277 534 passengers between 2010 efforts, such as waste reduction, it calculates that 4000 jobs were created for local residents and 2016 and saved 3112 tonnes of CO2e from annual operational savings of $3.7m.61 62 and 85% of the costs of building construction 2011 to 2015.70 were channelled into the local economy, resulting Landspitali , the National University Hospital in substantial economic savings compared with of Iceland, has substantially reduced its carbon other Rwandan hospitals.64 - 66 footprint by increasing eco-friendly travel to and from work from 21% to 40% of employees.71 Specialty specific interventions In 2012 Albert Einstein Hospital, located in Sao Supply chain and purchasing interventions

Paulo, Brazil, found that nitrous oxide (N2 O) made The Philippine Heart Centre has adopted a Bhagat Chandra Hospital, a multispecialty, 85 up over half of its hospital emissions. It convened a green procurement strategy and incorporates

bed facility in Dwarka, New Delhi, has achieved team focused on limiting reliance on N2 O and was environmental considerations into purchase considerable financial and environmental benefits able to reduce its use for anaesthetic procedures decisions. It plans to utilise carbon emission by transitioning to solar energy, conserving by 23%. It need only be used when it lowers the accounting to more accurately estimate the effects 72 approximately 93 000 kg CO2 emissions since morbidity and mortality compared with other of green procurement on carbon output. 2016. Through a hospital-wide initiative, Bhagat anaesthetic drugs. The hospital was recently By purchasing environmentally responsible Chandra has installed 50 kW solar panels that presented with the 2020 Challenge Climate computers Kaiser Permanente, an integrated connect to the electrical system and reduce Champions award for its 7% reduction in total GHG managed care consortium in Oakland, California, 66 67 73 20-30% of its energy consumption. The hospital emissions solely through reduced N2 O. has made energy cost savings of $4m a year.

Other solutions pertain to specifi c operational aspects of healthcare levels. The creation of a chief sustainability offi cer position could delivery, from clean, renewable energy to transportation, from food help ensure that sustainability is prioritised across institutional services to supply chain management, and still others relate to decision making, 51 but senior leaders need to support and hold to individual specialties or treatments. Innovative care models might account a pan-organisational approach to avoid isolating the actions be more acceptable in the wake of covid-19. Many of the adaptive to one department. practices that were implemented at scale and pace during the Accurate carbon footprints for healthcare are essential for decision pandemic—more telehealth consultations, more care closer to home, making and evaluating cost eff ectiveness. 52 Assessments that extend more empowered self-care, less travel—could benefi t patient, purse, beyond carbon emissions can look at other environmental impacts populations, and planet. that harm health, such as air pollutants and water depletion.5 But Creating a culture of sustainability in healthcare can draw from current measurement practices need to be better standardised, and models in other industries and from successful healthcare quality because a large portion of healthcare emissions relate to the supply improvement and change management eff orts, such as in patient chain, scope 3 emissions need to be routinely included. New metrics safety. 47 - 49 An inclusive culture can be created by connecting the could be developed to refl ect the carbon intensity of care per unit climate crisis to clinical practice and the institutional mission, 50 as of health improvement delivered, applying the methods of value well as to fundamental healthcare values such as “do no harm,” based healthcare to environmental performance.53 54 Transparent and by defi ning institutional success according to the triple bottom reporting should extend to healthcare supply companies and lead to line (social and health improvements, economic performance, and open commercial advantage, assisting in selection by hospitals and environmental impact).5 This can engage people at all institutional incentivising low carbon production. the bmj | 17 October 2020 97 Achieving net zero requires eff orts that extend beyond conventional innovations to be tested to establish safety and effi cacy. Fourth, we clinical care. Primordial and primary prevention—including poverty need economic analyses of low carbon innovations to establish their and inequality reduction, strong social networks, tobacco and costs and benefi ts. Fifth, we need sustained collaborations between substance abuse control, healthy diets, and physical activity—are healthcare providers and senior management, technical experts in intrinsic to this transformation because they reduce the need for sustainability, and behavioural scientists to develop and test methods healthcare and therefore for energy and resource intensive treatments. of accelerating progress towards net zero and to move the fi eld towards Investment policy is also a part of this transformation. Healthcare evidence based change management procedures. The research needed institutions, by divesting their fi nancial holdings in fossil fuels, can to achieve these broad knowledge goals requires multidisciplinary both advance their mission and help normalise the withdrawal of collaborations, including engineers, process analysts, and clinicians. social license from this industry.55 Specifi c initiatives within healthcare systems around the globe are Unique considerations in low and middle income shown in box 2. countries

Overcoming barriers to transformation Healthcare settings in low and middle income countries generally have small per capita carbon footprints and expenditures, but the System change at scale is challenging. Complex systems have overall environmental intensity can be quite large.5 But many of these considerable inertia, vested interests have outsize infl uence, and healthcare systems might not be in a position to reduce energy use, even well intentioned people are often too busy to engage in the alter procurement practices, or make other disruptive changes. With process of change. 59% of healthcare facilities in low and middle income countries Leadership commitment is critical. Industries and companies reportedly lacking reliable electric power,87 the scarcity of energy and whose leaders champion sustainability goals are the most successful materials in many facilities is the pressing challenge.88 89 91 in meeting those goals. Boards of healthcare institutions should For healthcare facilities in such circumstances, the path to net zero require this commitment in the leaders they select, and professional must include provision of reliable electricity. This requires leapfrog associations should promote environmental sustainability as a core technologies (bypassing fossil fuels and conventional electrical grids value among their members and use sustainability or environmental in favour of solar and wind generation and on-site battery storage) performance as one of their measures of quality.74 At the same and local innovation. 93 Fortunately, this approach is aff ordable and time, commitment among healthcare personnel is critical.75 76 practical and is increasingly being implemented. Between 2008 Environmental performance should be integrated into position and 2015 the Indian state of Maharashtra, for example, installed descriptions, on-the-job training, performance evaluations, and 407 hybrid solar photovoltaic systems, mostly in remote health promotional activities in the workplace. facilities, to promote reproductive and child health.94 Such strategies Evidence based principles of individual and organisational are championed by the non-governmental organisation Sustainable behaviour change can be systematically applied to accentuate and Energy for All, 95 which the United Nations launched in 2011.96 accelerate the process of culture change,49 - 79 although policy changes Many of the supply chains to healthcare institutions in low and are the most powerful way to aff ect behaviour and culture change. 80 81 middle income countries are global. As manufacturers and suppliers Incentives for change are also critical. In addition to healthcare improve the effi ciency and reduce the carbon footprints of their reimbursement schemes, other fi nancial incentives include products, they should ensure that those benefi ts reach healthcare discounting the purchase of renewable energy and tax incentives systems in low resource settings.97 for reduced carbon emissions. Standards and regulations also have Experience in low resource settings can off er invaluable guidance a place. These might apply to medical equipment and supplies, to for wealthy countries. The carbon footprint of phacoemulsifi cation medical procedures, and even to entire clinics and hospitals. cataract removal, for example, is reported to be 20 times lower in India Transparency is eff ective in motivating change. We need validated, than in the UK, with similar clinical outcomes.19 standardised, and widely accepted indicators of GHG emissions across the health sector. Institutions should use these indicators to track Conclusion their emissions and disclose their results regularly. “Eco-labelling” of products and supplies with their carbon footprints might also be Without decisive and urgent action, the climate crisis will increasingly useful, both in infl uencing consumer choices and in driving industry undermine human health and disrupt healthcare delivery. There are practices, although further research is needed on its eff ectiveness. 84 85 both moral and practical reasons for health professionals to be at the Finally, gaps in knowledge are frequently a barrier to change that forefront of climate action98 99—to embrace the drive to decarbonise the must be fi lled. economy and to reach net zero emissions. Healthcare must lead from the front. Critical knowledge gaps Renee N Salas, affiliated faculty, Harvard Global Health Institute, Cambridge, Massachussets [email protected] Knowledge gaps fall into several categories. First, we need a detailed Edward Maibach, distinguished university professor, George Mason University, understanding of the sources of emissions across the healthcare Fairfax, Virginia delivery life cycle. Of particular importance are major elements of the David Pencheon, associate and honorary professor, University of Exeter supply chain such as pharmaceuticals and medical equipment. This Nick Watts, executive director , Lancet Countdown: Tracking Progress on Health and requires sophisticated but user friendly methods of quantifying carbon Climate Change, London footprints, which require further development.86 Second, research and Howard Frumkin, professor emeritus, University of Washington School of Public development eff orts need to deliver innovative equipment, supplies, Health, Seattle, Washington and practices that reduce the carbon footprint. Third, we need these Cite this as: BMJ 2020;371:m3785

98 17 October 2020 | the bmj EDITORIAL Covid-19: primary care for long term conditions Change is required to prevent avoidable excess deaths

uring the height of the primary care to reduce unnecessary covid-19 pandemic, bureaucracy, retaining only essential attention was diverted tasks that are fully justifi ed. For D away from primary example, the onerous expectation care’s key roles in early of coroners’ offi ces that general detection of disease and management practitioners must have seen a of long term conditions. patient within two weeks before Comparing April to August 2020 death could be modifi ed to accept with the same period in 2019, the video reviews within an extended total number of general practice time frame . appointments in England fell by Evidence suggests that use of 20.8%, from 120.66 million to 95.52 point-of-care testing to monitor million.4 Although these statistics intermediate markers of chronic should be treated cautiously, they disease, such as lipid profi les, suggest that substantially fewer glycated haemoglobin, and albumin- planned care appointments took creatinine ratios improves practice place in 2020. The resulting backlog, workfl ow and increases satisfaction combined with the prioritisation of of clinicians, other primary care covid-19 in secondary care, has led to Suboptimal to enhance the human connections staff , and patients. 10 11 Point-of-care further shortfalls in the care of non- management between patients and clinicians. testing might also reduce costs, save covid illness. of people with Unanticipated fi ndings occasionally time, and minimise non-attendance, Between 27 March and 5 June save lives.7 and research should now be done on long term 2020, most excess mortality was Digital exclusion of those most in these important outcomes. associated with covid-19.5 However, conditions will need of healthcare could compound delays in diagnosis and suboptimal cause rises the inverse care law, 8 since many Recruitment and retention management of people with long in non-covid long term conditions are strongly Finally, recruitment and retention term conditions will cause rises in mortality associated with social determinants of primary care clinicians must non-covid mortality, particularly of health.9 Research should be done improve. Concerns about workload from cancer and cardiac disease.6 If to identify solutions for patients who and remuneration need to be lower consulting rates persist and the are unable or unwilling to connect addressed. Optimising the role of backlog of planned care is not cleared, with health services remotely. nurse practitioners, pharmacists, people with long term conditions are Patients and clinicians also need paramedics, and physician more likely to experience adverse educating on the eff ective use of assistants can help in areas such as outcomes, including death. telehealth and remote consultations. monitoring chronic disease, care Next, further underfunded shifting planning, medication reviews and Delivering change of patients’ care from secondary care reconciliations, and even home Patients, healthcare staff , and Louis S Levene, to the community must be avoided, visiting for minor illnesses in patients policy makers are now recognising honorary lecturer allowing overburdened primary unable to leave their home. that the fl uctuating health needs of Samuel Seidu, care teams to prioritise a worsening It is too early to predict what the populations will require changes in primary care backlog of deferred care. In addition, “new normal” will look like. But we how primary healthcare is delivered research fellow in there should be better coordinated must avoid suboptimal management beyond the covid-19 pandemic. Any diabetes, University and more proactive engagement with of long term conditions contributing changes should aim to maximise the of Leicester staff and carers of patients in care to avoidable excess mortality in the capacity and eff ectiveness of primary Trish Greenhalgh, homes or receiving care at home. medium term. Primary care must be care but must also ensure that health professor of primary Use of detailed advanced care plans sustainable, with a workload that care health sciences, inequalities are narrowed. and agreed pathways for seeking is manageable, safe, and equitable. University of Oxford Firstly, appointments systems may and providing professional help can Clear, realistic, and fully resourced Kamlesh Khunti, need reviewing. Although telehealth ensure that patients remain safe, priorities must now be agreed through professor of primary reduces patients’ direct exposure to care diabetes and carers feel supported, and demands collaboration between the public, infection, it cannot entirely replace vascular medicine, on practices are balanced. providers, and commissioners. face-to-face contacts. Physical University of Policy makers and commissioning Cite this as: BMJ 2020;371:m3793 examinations are still needed to make Leicester and regulatory entities should Find the full version with references at certain diagnoses and, more generally, [email protected] also review their demands on http://dx.doi.org/10.1136/bmj.m3793 the bmj | 17 October 2020 99 PRIMARY CARE Why telemedicine is here to stay Virtual consultations and triaging have reached a tipping point, pushed on by the covid-19 pandemic. Chris Stokel-Walker reports on what a market worth at least $250bn means for doctors

t’s arrived with a told The BMJ in April. “What we bang,” says Sam have now is a new normal. Going Wessely, a London GP. back to how we used to consult “When covid-19 hit, would be a big change, and we’re “I we were instructed to going to see many practices around discourage patients from entering the country employing this remote the practice to keep them and the triage fi rst approach.” staff safe.” But how were they to support patients remotely? A tale of two practices The obvious answer was Wessely’s practice was better telemedicine. Telephone prepared than most. The surgery consultations have been in use had been moving towards adopting for over a century and video calls an app developed by eConsult were fi rst trialled by doctors in that helps triage patients. The Nebraska in 1964 (using television system asks patients to answer text signals instead of the internet). questions about their illness so a But, while not unfamiliar, neither doctor can assess their needs. It the next phase of dealing with were in popular use with doctors or was to roll out six weeks before the coronavirus—delivering care patients, and the experience of the coronavirus hit, so the practice was to our patients while avoiding technology had been mixed. able to bring forward the timescale. community transmission—we don’t Yet the signs are that we have The rollout was not without its see eConsult as a replacement for now reached a tipping point, problems. “Within two days of face-to-face appointments,” says pushed by the pandemic. Across using it we discovered a fl aw in Wessely. “It’s an adjunct to it.” the US alone, nearly half of its pathways, and another four In the US, Devin Mann, an healthcare consumers are now weeks later,” says Wessely. In one internal medicine specialist at using telehealth, according to instance, the system didn’t pick New York’s NYU Langone Health consultancy fi rm McKinsey—up up a patient expressing suicidal We’re going practice, says they “had about from one in 10 last year. thoughts through a pathway to see many fi ve years of plans accelerate in a That’s to be expected when designed to process sick notes practices around matter of fi ve days.” Like Wessely, physical visits to hospitals and (the patient was contacted quickly the country long term plans to integrate GP surgeries have been limited. and was fi ne). Another time, employing this telemedicine into Mann’s practice Doctors who have long held out it didn’t highlight the nuance were quickly implemented. From against the idea of telemedicine between a child presenting remote triage an average of 25 to 50 telehealth have now seen how it can work symptoms of potential meningitis first approach “visits” per day, NYU Langone and like it. Some of the burden and coronavirus in a test of the Sam Wessely quickly expanded to 8000. has been shouldered by telephone technology. The system told “Insurers and regulators allowed calls, particularly for patients patients to call 111 and under us to use the tools we’ve had for whom Skype or Facetime is a no circumstances to present to a ready to care for the patients at step too far. A survey by the Royal GP. Wessely says both problems a distance. The patients remain College of GPs found that six in were fl agged up to eConsult and incredibly satisfi ed,” he says. 10 appointments in mid-July were quickly remedied. Virtual urgent care—defi ned as conducted by telephone. But others Four months after the UK’s “for patients who have minor are embracing video chats. lockdown was fi rst declared, medical conditions, and not for “GPs are a pretty conservative eConsult seemed to be largely emergencies”—increased by nearly profession, and we do tend to working for them. “As we come 700%, while non-urgent virtual revert to what we know,” Wessely out of the fi rst phase and go into visits to family doctors increased

100 17 October 2020 | the bmj necessarily appropriate.” Patient “The genie isn’t going back in advocacy groups are also worried the bottle,” says Paul Testa from about security: health records, New York’s NYU Langone Health particularly when combined with practice. What will happen is a video calls, could become a data more nuanced conversation about management headache. where telemedicine can work to Jessie Cunnett, head of health streamline the process, and where and social care at Traverse, an it can’t. organisation that helps improve Mann highlights continuity of health and social care services care for long term patients, such in the UK, is carrying out similar as monitoring blood pressure I’ve used the surveys. “Patients see it as or regular check-ups, as areas phrase 10 years of convenient,” she says. “They don’t that could continue digitally. change in 10 weeks have to travel or park, and it takes McKinsey’s report predicted Juliet Bauer less time out of their day.” that one in four people visiting But there is an underlying worry outpatient clinics could instead be about long term shifts in healthcare. seen online, with a third of home “People were initially willing to do visits carried out digitally. digital appointments because of the And with such a rapid pandemic, but how long will that expansion, there’s also the willingness continue?” Cunnett question of regulation and asks. “Some are expressing anxiety standardisation to ensure that face-to-face appointments will consistency and quality of the never come back.” experience, as well as privacy and There is another risk too. A US security. In the UK, the BMA has study showed that patients who named four video consultation Some patients could aff ord in-person appointments systems (Accurx, EMIS, TPP, Vision) fear face-to-face were continuing to do so, while that the NHS recently made free appointments will poorer patients were pushed to to access, but NHSX advises that never come back digital. Whether this is a detriment to Skype, FaceTime, and WhatsApp Jessie Cunnett more than 4300% between health outcomes remains to be seen, are acceptable. “The consent of the 2 March and 14 April. but equivalent healthcare it is not. patient or service user is implied by them accepting the invite Patient buy-in Here to stay and entering the consultation,” Pre-pandemic, Healthwatch “We are in extraordinary times. reads their advice, “But you England, a patient lobby group, I sometimes use the phrase 10 should safeguard personal or surveyed patients about what they years of change in 10 weeks,” confi dential patient information in wanted from the NHS. “People says Juliet Bauer, former chief the same way you would with any were more bothered about how digital offi cer for the NHS and other consultation.” quickly they got to see medical now managing director of LIVI, an At a time when medical staff professionals than the method by online GP provider with a platform are more overworked and under which they got to see them,” says that works similar to Skype and pressure than ever, there is another The patients Jacob Lant, Healthwatch’s head of Facetime, but also off ers a paid-for benefi t. “Clinician wellbeing has remain incredibly policy and public aff airs. service to see a private doctor been enhanced by employing this satisfied That said, it would be natural more quickly. mode of practice,” says Wessely, Devin Mann for patients to worry that LIVI’s app has seen signifi cant escaping what he calls “the telemedicine was simply an take up from doctors and patients tyranny of the waiting room.” excuse for inferior healthcare. alike: the number of patients Running 10 minutes late has a Early studies, conducted during accessing it increased fi ve times knock-on eff ect. “Your behaviour the pandemic by the lobby group, above normal levels in the early is driven by who’s waiting, and the revealed mixed patient feedback. stages of the pandemic—at one guilt when you run over is a source “For some, it’s revolutionised point 500 doctors a week were of a huge amount of stress in our their experience—particularly for applying to work with the app. profession.” Being able to triage those who have regular catch-ups McKinsey estimates that in the US patients online and see many with their GP or consultants for alone, the telemedicine industry through carefully timed video calls, routine matters,” says Lant. “We’ve is now worth $250bn with health unlocks some of that anxiety. also heard negative experiences insurers in Germany and the US Chris Stokel-Walker , freelance journalist , The genie isn’t from some groups, including seemingly backing the move to Newcastle upon Tyne going back in those with learning disabilities or allow virtual consultations to [email protected] the bottle autism, for whom the format isn’t count for claims. Cite this as: BMJ 2020;371:m3603 Paul Testa the bmj | 17 October 2020 101 THE BMJ INTERVIEW Tim Spector: How data can arm us against covid-19—and help save lives and money T he epidemiologist and popular science author, whose symptom tracker app has revealed some vital information about covid-19, tells Rebecca Coombes about opportunities to use data better—and how he thinks the UK’s leadership has failed in the pandemic

t’s the sleeper hit of the doctors,” he says. “As with nutrition, PHE behaved indicate the patients most likely to pandemic in the UK, even though they have behaved with covid—like like a secret develop what’s become known as its creator thought that it might a secret society that makes decisions society “long covid,” where symptoms such be shut down after a week. More behind closed doors.” that makes as fatigue and breathlessness last for than four million people use the many weeks, or even months, after I decisions Covid Symptom Study app, a symptom Test triage tool and long covid predictor even a mild infection. reporter designed by doctors and When the study was launched at the behind He says, “We are still identifying scientists at King’s College, London, end of March, after a sleepless week of closed doors data, but there is a slight excess of and the health science company Zoe. engineering during the height of the females, a slight excess in people Data generated over nearly eight pandemic, Spector feared that it would who are overweight, and some months, from users regularly logging have to be handed over to the NHS symptom clusters that seem to their health and reporting their within a week. It wasn’t—and today indicate long covid more than others. symptoms, have created the closest he’s lobbying for its data to inform an These are all things you would put thing to a national covid-19 registry. algorithm to help triage the patients into an algorithm rather than expect The smartphone app has made most in need of a test. a GP to know that they will go on and a household name of its genial and “We do have quite a large testing have long covid. wiry leader, Tim Spector, professor capacity in this country but no “This lends itself to AI/‘big data’— of genetic epidemiology at King’s. clear system about who is being you input the patient details, and Previously better known for his tested,” he tells The BMJ . “The if they still have a certain cluster of nutrition research and popular system is never going to keep fully symptoms on day 7 you might put science books, Spector is eager to share up with demand: the government them into a steroid treatment trial, emerging fi ndings from the study, really ought to be thinking of ways for example. But we need a clear plan which was the fi rst to identify loss of of selecting people rather than the to try and stop this immune process smell as a leading symptom of covid; worried well. early on—before a month—then you to spot that children with covid often “That’s why I think some triage will save the country a huge amount present diff erently from adults; and system allowing GPs to be more of money and suff ering.” to show that delirium is a key sign in involved would clearly improve it. For He believes that long covid patients older, frail people. example, if you have anosmia and fever are being overlooked. “As far as I can Although the app is now partly there is no point having a test, as it is so see, no one has taken responsibility funded by government, Spector is likely to be positive.” With children, he for them,” he says. “I would be happy clearly frustrated by the speed at which adds, “runny nose, swollen glands, and if my old specialty, rheumatology, government guidelines have refl ected sneezing are all negatively associated started some clinics and got some the research fi ndings generated by its with a positive test.” expertise, but no one has done that. data. It took Public Health England Data harvested by the app have Everyone is waiting for someone else (PHE) until May to add anosmia as a identifi ed symptom clusters that to take the lead. symptom despite the app gathering “GPs don’t have enough cases to good data early in the pandemic that COVID SYMPTOM STUDY’S SUCCESSES really be good at this, and it is still loss of smell was “probably 90%” Key facts about covid-19 to come out of the symptom fairly rare: we estimate 20 000- predictive of a positive covid test. tracker app so far: 60 000 people with more than three “Most other countries had acted by • Anosmia is one of the most predictive symptoms for a months’ illness. That’s double the May,” he says. “I had dealt with six positive test; size of lupus patients but still small diff erent government bodies; nobody • Children may show different covid-19 symptoms than when compared with most chronic knew who was in charge.” He adds adults; diseases.” that it was impossible to speak directly • Delirium is a key sign of covid-19 in frail older people; and with anyone at PHE. “I was sceptical Causes for optimism • For hotspot identification, the study built a data model that they had public health interests There are some cautiously optimistic that can identify hotspots quickly: it identified Leicester at heart: they didn’t seem to want to signs from the study that this winter ahead of the government placing it back into lockdown. engage with the public, to speak with may not see a return to the mayhem

102 17 October 2020 | the bmj We aren’t seeing of this spring, including a conviction many who have been that immunity in the wider population reinfected—which has been underestimated. hopefully means “More people have been infected than we think,” says Spector. immunity for the “Studies from my colleagues at majority of people King’s have shown that only half who’ve had covid of people with ‘barn door’ covid in hospital had antibodies a month later, so there is this whole issue of the other T cell immunity being there. It looks like both groups must be immune, because half of those people without antibodies would be reinfected.” Yet data from the app have shown that reinfection is rare. He says, “The good news is that, even with several million people, we aren’t seeing any more than a couple who have been reinfected—which hopefully means immunity for the majority of people who’ve had covid .” He sees this picture being played out in his home city of London, one of the cities hit fi rst and hardest in the pandemic. “In London, it was only in mid-September that cases started to pick up again,” he says. “I think many of the people out on the streets must be immune by now. That’s why all the outbreaks are in the north. You go to Soho, it’s all pedestrianised streets, crowded restaurants, a mass of people every night.” Almost three decades ago, Spector set up the UK Twins Registry. Its cohort of 15 000 identical and non- identical twins are now also engaged in covid-19 studies. He says, “We have done studies with our twins and sent antibody tests to them, which suggest that a quarter have been exposed to the virus. It would be double that in health workers.”

TIM SPECTOR’S CV • Masters in epidemiology at the London School of Hygiene and Tropical Medicine • Founder (1992) and director of the UK Twins Registry, set up to unravel the contribution of genes to human characteristics. It now comprises 15 000 identical and non-identical twins around the UK. A recent focus has been the gut and how the microbiome affects health. Today the cohort is also taking part in covid-19 research • Professor of genetic epidemiology and head of department, Department of Twin Research and Genetic Epidemiology at King’s College, London • Director, European Twin Registry Consortium (Discotwin) • Senior investigator, National Institute for Health Research • Fellowship of the Academy of Medical Sciences • Former president, International Society for Twin Studies the bmj | 17 October 2020 103 “Nutrition should be the number one medical specialty” Tim Spector’s latest book, Spoon-Fed , specialty—it should be the number one laments the lack of evidence behind many specialty, and all the best doctors should government nutrition guidelines and the go there. There are virtually no medically way they perpetuate food myths. trained nutrition experts out there. That obesity raises your risk of severe “All the nutrition departments are illness from covid-19 brings new urgency massively underfunded and depend to tackling the problem in the UK, says on food companies to keep going. It is Spector. “We need to do three things: outrageous, really, when you consider increase the sugar levy, which food that obesity is the number one problem companies have successfully lobbied facing this country. We have the most junk against; improve nutritional support for food in the whole of Europe, we are the patients; and treat obesity as a disease,” most obese, and we are the most poorly he explains. educated about nutrition and obesity. That But it will require a major shift in medical needs to change.” training, workforce, and research. “The Spoon-Fed: Why Almost Everything whole emphasis needs to change,” he We’ve Been Told about Food is Wrong is says. “It shouldn’t be this underfunded published by Jonathan Cape

However, the app’s survey of 1000 most prevalent and dangerous myth I worry that to turn to—is it the chief medical offi cer, daily swab tests since May shows about food,” he explains. “Normal this country NHS England, NHSX, the Department that the recent increases in cases is people can vary 10-fold in their blood is focused on of Health? We need one group, whose real and not just due to increased sugar responses to identical foods. a centralised, leader is the one who goes on TV. It testing, as some believe. “We are We all respond diff erently to the same ‘keep it was far from clear, when you saw the defi nitely seeing an increase in foods, and the idea that we can all chief medical or chief scientifi c offi cer, simple’ cases,” Spector confi rms. “I suspect follow the same advice and calorie whether they were in charge. it won’t be as bad as it was in the limits no longer makes sense. message, “Most countries have their own spring and that there will be a slower “In the same way we couldn’t be which treats equivalent of the US Centers for Disease lag hitting hospitals. And deaths will comfortable with the same car seat the north west Control: the German one seems to have be lower because we should be much without adjusting it, just because it and south worked very well. And they should better at dealing with covid, and a lot was made for the average person.” west in the be in charge—we shouldn’t need fi ve of susceptible people have died. But Spector is struck by the parallels same way diff erent groups answering to diff erent it is defi nitely going to get worse, and with covid-19. “The weirdest thing ministers. It’s become so bureaucratic.” this is not an artefact of testing. about this virus is that everyone The data gathered by the app have “But it could be milder overall, reacts totally diff erently to it,” he identifi ed hotspots around the UK, because we could be spreading less says. “There are hardly any examples showing 10 times more daily cases virus by socially distancing ourselves in medicine like this. This is true not now in the north west and Yorkshire and wearing masks, so this dose only in terms of the 20 to 30-odd than in the south west and south east— eff ect could be important. It will be symptoms caused by covid but also and explaining why Spector strongly interesting to see.” the timescale, the severity, and this supports diff erent rules for diff erent To this end, the app has introduced variation in immune response. areas and giving power to local leaders. a feature looking at risk taking “We saw this in our twins research “I worry that this country is focused on behaviours to see whether people who and in people with identical doses of a centralised, ‘keep it simple’ message, do get covid after taking precautions the virus. The immune system and gut which treats the north west and south get a milder form of the disease than microbes are unique to all of us. This west in the same way,” he says. those who have been less cautious. uniqueness has been ignored for a The success of the Covid Symptom long time in medicine because it is so Study app may have surprised him, but Personalisation parallels diffi cult to deal with personalisation.” he now believes that it could give us Before the pandemic Tim Spector an insight into the future of medicine. was better known as an epidemiologist Muddled leadership concerns He says, “If this can succeed with focused on the gut, which was the Spector watches his words but very little preparation and millions subject of The Diet Myth, his popular cannot hold back over some of the of people engage with the health app 2015 book. In Spoon-Fed , his new basic mistakes he believes the UK every day, allowing us to get algorithms book published in August (box, above), government has made, chiefl y in its out and personalise it, just think what he shows how our reaction to food muddled leadership of the pandemic you could do with that in all domains. is highly personalised—and that response. “This could be one of the few good nutrition advice should also be. “I worry that there are too many things that come out of covid.” “The assumption that we are all government groups involved and that Rebecca Coombes, head of news and views, identical machines and that we all no one is charge ,” he says. “If there is The BMJ [email protected] respond to foods in the same way is the another pandemic, nobody knows who Cite this as: BMJ 2020;371:m3921

104 17 October 2020 | the bmj