comment‘ Care was arguably more regimented and ‘paternalistic, and patients more deferential ACUTE PERSPECTIVE David Oliver Rose tinted lenses and the NHS he NHS turned 70 this year and On the other hand, back in the day faces numerous challenges. many senior registrars, long qualified to This has prompted many to become consultants, waited endlessly debate current and future for consultant posts to become vacant. Thealthcare services and to look And not for nothing were senior house back at the NHS’s journey since 1948. officers called “the lost tribe,” as so many A fond nostalgia has its place. But doctors were drifting at that grade. Nor one step beyond is “rosy retrospection.” did we have today’s transparency and Excessively positive retrospective scrutiny around preferential selection narratives sometimes come from people based on sex, race, or patronage. who weren’t there but speak confidently about Another example of la vie en rose is those imagined golden eras. I’ve doubtless donned rose yearnings in sections of the media for golden tinted lenses myself but, as I enter my 30th year ages of nursing—where A levels, let alone degrees, as an NHS doctor, I’d prefer to avoid them when weren’t required, and where fearsome matrons discussing present and future healthcare. ruled wards with a rod of iron, insisting on shipshape Before the EU Working Time Directive placed ward cleanliness. Yet patient case mix and healthcare restrictions on junior doctors' working hours brutal were far less acute and complex; pressure and on-call rotas were common, including continuous throughput on beds was lower; and a far more limited 80 hour weekend and 36 hour weekday blocks, with range of interventions was available for nurses no guarantee of sleep. Tired doctors put patients’ to carry out, let alone as independent advanced and their own health at risk. On the other hand, practitioners or prescribers. Care was arguably far the exhaustion came with free (if basic) onsite more regimented, institutional and paternalistic, accommodation, peer support, and the continuity of and patients more deferential. Besides, the research a firm structure, and we quickly gained vast amounts evidence tells us that graduate nurses improve of experience. The loss of those hours is still lamented patient outcomes. in surgical specialties, but—with minimal induction, Nostalgia makes us forget just how far healthcare far less senior supervision, a “see one, do one, teach has come in terms of evidence, interventions, one” approach to many quite risky procedures, and far safety, and outcomes. Clinical staff may formerly less scrutiny on safety and preventable harm—the rosy have had more professional autonomy, a filter effect starts to diminish. greater sense of belonging, less managerial and The historical switch, in Modernising Medical political interference, and a far lower burden of Careers, to run through higher specialty medical documentation and public scrutiny; but some of training from more meandering routes has also that burden came about precisely because, when the attracted adverse comment, as has the botched professionals ran their own show, not everything introduction of the Medical Training Application was rosy. Service or more recent findings that junior doctors David Oliver is a consultant in geriatrics and acute general medicine, often feel rushed or pressurised to decide on a Berkshire [email protected] specialty stem too early in their career. Cite this as: BMJ 2018;362:k3866 the bmj | 22 September 2018 357 PERSONAL VIEW Tom Nolan The heart age test will put yet more pressure on overworked GPs Providing tools that don’t acknowledge uncertainty can only erode the public’s trust in the health service hy are so do—and perhaps this is the point: it’s Lumping GPs are predictably cross about it. many of us good to know your heart age because everyone I’m sure I wasn’t the only one fielding heading it’s good to take more control of your in an area calls from people worried that their for an early health. The problem is that the NHS together and cholesterol might be high. But will grave?” heart age tool isn’t up to scratch. using the there be a spike in cholesterol testing? “Wasked the Guardian earlier this One of its major flaws is its And if so, what will the consequences average for month. The NHS online heart age test obsession with cholesterol. It tells of this be? made headlines when Public Health everyone from the age of 30 to get heart age England revealed that 81% of the 1.9 their cholesterol checked (in large estimates Socioeconomic factors million people who have taken the red capital letters), despite there doesn’t The use of postcodes is also a test had a heart age above their real being no national guidelines to this make sense problem. Socioeconomic factors have age. If only the public would exercise, effect. And it seems that anyone who a far greater effect on our health than eat well, and stop smoking. If more doesn’t know their cholesterol or cholesterol being a bit high. people knew their heart age, perhaps blood pressure gets a high heart age A baby girl born in Richmond they would? calculation. upon Thames is likely to live 17.8 Unfortunately, the evidence to As Ben Goldacre pointed out years more in good health than a support risk calculators being used on Twitter, if everyone in their 30s baby girl born in Manchester. But as standalone tools for behaviour checked their cholesterol, that would that doesn’t mean that a woman change is lacking. In my own be 8.7 million visits to the GP for a living in Richmond will have a qualitative research on this subject blood test. If even a fraction of these younger heart age than one living I was struck by how differently tried to book an appointment in the in Manchester. There can be huge people responded to seeing their wake of this publicity it could cripple differences in wealth, education, heart age on a screen. But even general practice—anyone with actual and opportunity within postcodes: those who didn’t like what they symptoms of a heart problem could lumping everyone in an area saw thought it was a good thing to be waiting months to see their GP. together and using the average for BMJ OPINION Mark Taylor Why doctors’ letters should be addressed to patients “What am I, chopped liver?”—I’ve And yet, over the years, I have been obstetrician from The Meaning of always loved this old Yiddish saying, copied in to a number of letters Life, “we’re not qualified.” chopped liver being just the side between medical professionals But, let’s take a step back. The dish, not the main course. I often where my various chronic Academy of Medical Sciences quote it when I feel I am being conditions have been described recently published a report on the spoken about, but not to. in great, and occasionally challenges healthcare systems Recently the Academy of Medical obscure, detail. face in managing patients with Royal Colleges released guidance From a patient perspective, multimorbidity. We know that the calling for hospital doctors to write The only aside from the structural number of these patients is on the outpatient clinic letters directly to constant and paternalism of treating a patient rise and we know the system is not patients, free of jargon or confusing permanently as a spectator of his or her own designed to treat them. I should language. The push for doctors engaged point treatment, does it matter that know. I am one of those patients. to communicate effectively and letters between consultants and It may be that the GP is meant to is the patient directly with their patients feels GPs are not addressed to us? coordinate my various treatments, like such an obvious point to make. Surely, to paraphrase John Cleese’s my various pathways. Perhaps 358 22 September 2018 | the bmj BMJ OPINION Trish Greenhalgh Cochrane—what crisis? Last week the governing board of Cochrane voted to expel one of its members, Peter Gøtzsche, for activities that allegedly threatened to bring the organisation into disrepute. Four of the 13 members resigned in solidarity with Gøtzsche, and two appointed trustees volunteered to step down. In a single day the organisation lost over half its board. Is there a crisis—and, if so, of what nature? Gøtzsche’s three page statement did not name a heart age estimates doesn’t “a month older than me. Must do specific incident. Rather, it appears that his overall make sense. more exercise!” approach to overseeing and commenting on Cochrane Take the calculator at face value What is the chance that the reviews was deemed (by some but not all board and it’s an incredible thing: answer calculation will be inaccurate? What members) unacceptable. Gøtzsche might be classified 16 questions, and the programme is the 95% confidence interval? as an evidence based medicine purist. But why would will work out your heart age. This I’ve looked at the supporting he be asked to leave Cochrane, whose mission so is presented with great confidence: documents and can’t find any closely reflects his own? “your heart age is 38.” Not “38, based answers. Perhaps they’re there if The philosophical explanation is that facts are not on what you’ve told us,” or “38, plus you dig deep enough—but if I can’t self interpreting: they are value laden. Even when or minus a couple of years because, find the answer after 20 minutes of there are agreed criteria for including or excluding you know, this is just a clever bit of looking, who else is going to bother? a study in a review, multiple subjective judgments programming and we can’t really look The public deserves to know how need to be made.