BMJ - British Medical Journal

Individuals in the UK with health conditions may be entitled to two types of benefits: incapacity benefits (for those whose condition prevents them from working) and disability benefits (to help with living costs arising from the disability). The cost of health related benefits for people of working age is now £48 billion this year.1 This is predicted to increase to £63 billion by 2030.1 If spending on health related benefits continues to grow as forecast, the UK will likely become one of the highest spenders on health related benefits among comparable countries. The latest figures show there are currently 2.83 million people who are “economically inactive,” primarily due to long term sickness. This reached a near-record high in the period of December 2023 to February 2024.2 Given the right incentives and support from GPs, this group could go back to work.Obtaining a fit note is the first step in the...

What you need to knowMost closed, stable hand fractures do not require surgery and heal well with immobilisation or protected early range of motion to prevent stiffening as well as dedicated hand therapyWash out open fractures thoroughly and promptly in the acute care setting and administer antibiotics to prevent infection, according to local guidelinesWith the exception of uncomplicated tuft fractures, refer all fractures to a hand surgeon for evaluation, ideally within a week of injury; bite wounds, open fractures, and irreducible fractures/joints warrant more urgent evaluationHand fractures represent roughly 20% of all fractures, with a global incidence of 179 per 100 000 individuals.12 In adults, the metacarpals are most commonly fractured, especially the neck of the fifth metacarpal—a boxer’s fracture—which is often a consequence of striking an object or person with a closed fist. Fractures of the phalanges, particularly the fifth, fourth, and third, are common and often result from...

More than half of England’s integrated care boards (ICBs) are planning to cut spending on services for young people with eating disorders from April, an analysis by the Royal College of Psychiatrists has found.1The planned spend for young people’s eating disorder services in England for 2024-25 is £101m, a real terms increase of 2.9% (or £2.9m) on the 2023-24 spend (£98.1m). But after analysing the NHS mental health dashboard for the first quarter of 2024-25 the college found that 24 out of 42 ICBs have reported planned spending cuts for the coming year compared with last year of more than £835 000.The college said that the planned cuts come amid 7933 new referrals for children and adolescents with eating disorders in the quarter ending December 2024, an increase of 13% from 7003 in the same quarter in 2023.There are also high thresholds to access services, which results in more young...

Fenton and Prochaska call for more restrictions on gambling advertising.1 GambleAware, the leading charity and commissioner of gambling harms prevention and treatment services in Great Britain, is supportive of the points raised and has been working to highlight the evidence that gambling advertising disproportionately affects children, with those exposed to it being 2.3 times more likely to experience “problem gambling” in their lifetime. Based on evidence, we think that stricter gambling advertising and marketing regulations would substantially help to protect children from gambling harm.To tackle the link between gambling advertising and harm, GambleAware is calling for three new measures. Firstly, we would like to see the introduction of a pre-watershed ban on all broadcast gambling advertising, including sports sponsorships. Countries like Australia, Germany, and Ireland have successfully implemented similar bans, with public surveys showing support.Secondly, all gambling advertising, marketing, and sponsorship activity should contain evidence led health warnings to communicate...

NHS EnglandChief executive Pritchard resignsNHS England’s chief executive, Amanda Pritchard, has announced that she will step down at the end of March after three and a half years in the role. The surprise announcement followed recent strong criticism by two parliamentary committees that questioned NHS leaders’ ability and “dynamism” to implement the government’s desired changes to the health service. Pritchard, who has also been chief operating officer at NHS England since 2019, said that now was the time for her to leave, with the NHS continuing to make progress in its recovery from the covid-19 pandemic. (Full story doi:10.1136/bmj.r399)CancerDeprivation is linked to higher death ratesPeople living in the UK’s most deprived areas are much more likely to die from cancer, with death rates almost 60% higher than in the most affluent areas, an analysis by Cancer Research UK found. Around 28 400 extra deaths from cancer a year were linked...

US president Donald Trump has begun his attack on women’s health. In his first two weeks as president, he began taking action as detailed in Project 2025, the blueprint for his second presidency developed by right wing think tank The Heritage Foundation.1 He signed an executive order to withdraw the US from the World Health Organization; reinstated the global gag rule2; condemned and abolished equality, diversity, and inclusion initiatives; instructed the censorship of scientific publications that include reference to LGBTQ+ or gender “forbidden terms”3; attempted to end the US President’s Emergency Plan for AIDS Relief (PEPFAR); and began his assault on US foreign aid, public health, and disease control abroad and in the US.4 Sexual and reproductive health organisations are predicting and experiencing the harm of these measures. According to Guttmacher, the 90 day freeze in United States Agency for International Development (USAID) funding will lead to 11.7 million women...

Assisted dying for terminally ill people is set to soon become lawful in the Isle of Man.1 It is on the legal horizon in England and Wales too, as the Terminally Ill Adults (End of Life) Bill is currently proceeding through parliament.2 Introducing its second reading in November 2024, the bill’s proposer, Kim Leadbeater, emphasised its unique “layers of safeguarding,” specifically “a thorough and robust process involving two doctors and a High Court judge.”3Having heard evidence at committee stage, Leadbeater now proposes dropping the layer of scrutiny by a High Court judge and having an Assisted Dying Review Panel instead,4 like the model already adopted in Spain.5 The panel would include a senior legal professional, such as a current or former judge, along with a psychiatrist and social worker. It would be overseen by a voluntary assisted dying commissioner, who would be a serving or retired judge. The panel proposal...

Last year a 17 year old, Patient X, was admitted to Kamuzu Central Hospital, a tertiary referral centre in Malawi, with generalised peritonitis. An examination found that a stick had perforated and remained in the patient’s uterus and that the organ was pus filled and necrotic: the result of a botched backstreet abortion. Patient X underwent a total abdominal hysterectomy and in the following weeks developed a fever and fascial dehiscence, a serious complication that occurs when the abdominal wall separates after surgery. Throughout, the patient and her mother denied that she had visited one of Malawi’s thousands of clandestine abortion providers.1The teenager didn’t die, so her fate could have been worse: more than 1000 women a year die as a result of unsafe abortion in Malawi,2 a country that criminalises abortion except when the pregnant individual’s life is in danger. As in aid dependent nations throughout the global south,...

This man in his late 30s, who was otherwise well, presented with a five month history of episodic right facial pain, right nasal discharge, and halitosis. He had undergone an extraction of his upper right maxillary molar six months earlier. He was initially diagnosed with chronic maxillary sinusitis and received multiple courses of antibiotics, with no improvement. Oral examination showed a 2 × 2 mm opening at the extraction site (fig 1). A computed tomography scan confirmed the diagnosis of an oroantral fistula (OAF). bmj;388/mar06_7/e083050/F1F1f1Fig 1 A communication between the oral cavity and the maxillary sinus post-extraction is called oroantral communication; left untreated, it will epithelialise to become an OAF.1 Oral debris and bacteria can enter the maxillary sinus through this opening, resulting in chronic sinusitis.1 Sinusitis can also be associated with chronic dental infections,2 highlighting the importance of ruling out dental causes in patients presenting with unilateral maxillary...

In the farmlands of India—the country with the highest rate of snakebite deaths in the world, at nearly 58 000 a year—a unique initiative once held great promise. Gnaneswar CH, a wildlife conservationist, spearheaded a project in Tamil Nadu’s Tirunelveli district from December 2019 to May 2020 to equip farmers with simple tools designed to reduce the occurrence of snakebites: boots, gloves, flashlights, and mosquito nets. The kits, each costing about 1000 rupees (£10; €11; $12), aimed to protect members of vulnerable communities from deadly encounters with snakes.Months later, however, Gnaneswar was left puzzled. The mosquito nets were being used for fishing and the boots lay untouched, gathering dust. What had gone wrong? The answer, he says, is an essential truth about public health interventions: even the best solutions can falter if they clash with local customs and practices.Culture clashIndia accounts for nearly half the global deaths from snakebite each...

Digoxin in atrial fibrillationFor rate control in older people with established atrial fibrillation, low dose digoxin saves £500 each year compared with beta blockers. It’s not the cost of the drugs—both digoxin and beta blockers are cheap—but the number of adverse events in those taking digoxin is substantially lower, so savings are made because there’s less use of primary and secondary healthcare. Patient reported quality of life is better with digoxin too (Heart doi:10.1136/heartjnl-2024-324761).Cardiovascular disease after twin pregnanciesPregnancy places considerable demands on the maternal cardiovascular system. These demands are higher still in twin pregnancies and pregnancies complicated by pre-eclampsia. A huge database study from the US that investigated hospitalisations for cardiovascular disease in the year after delivery finds that, compared with uncomplicated singleton pregnancies, women with twin pregnancies or who developed hypertension in pregnancy were at higher risk (Eur Heart J doi:10.1093/eurheartj/ehaf003). Nonetheless, the absolute rates were low—even after a...

bmj;388/mar06_1/r451/FAF1faSea sickness is an occupational hazard for anyone working on water, and after serving five years in the Royal Navy John Brand described himself as well qualified to study it, having “suffered severely” at times.As a research fellow at the University of Edinburgh, Brand and his co-investigator, James Reason, came up with what has become the most cited hypothesis for the causes of motion sickness—the conflict theory. Brand and Reason suggested the condition occurs because of a “conflict between the senses and stored patterns of motion.” The research, published in 1975, has been cited more than 2000 times.1Brand also studied the effects of anti-motion sickness drugs. For one experiment he and his co-investigators took 100 Royal Navy volunteers, gave half a placebo and half varying doses of an anti-motion sickness drug, put them on life rafts, turned on a wave machine, and recorded the results.While the experiment took its toll...

From Whitehall and Westminster, the NHS can look like an enormous machine made of units of governance, categories of activity, and financial flows. But from my point of view, having spent most of my career as a psychologist and a leader, it looks more like a culture and a society of hundreds of thousands of human beings, with values, histories, and deep affiliations.It is in this social world that the knottiest problems in our health service lie—and nearly all of the solutions.The way people speak and relate to one another should not be an afterthought. It lurks at the heart of the most troubling and tragic failures in our health service. Overconfidence and a culture of “them and us” can cause a reluctance to involve colleagues or refer patients elsewhere. This was identified in the Ockenden review1 as a driver of the maternity incidents investigated, along with the failure to...