BMJ - British Medical Journal

bmj;388/mar21_10/r565/FAF1faAt the height of the Troubles in the early 1980s Ian Bownes, a young trainee psychiatrist in Northern Ireland, was sent into the notorious H blocks in Belfast’s Maze prison to assess if its paramilitary inmates were mentally fit to go on hunger strikes.It would have been an unsettling experience for anyone to go inside the Maze, which mainly housed republican prisoners. For a young Protestant like Bownes, however, it must have been even tougher. That Bownes did so for many years spoke to his “quiet heroism,” how much his professional opinion was valued, and how fully he was trusted to uphold the confidentiality on which his access depended, says friend and former colleague Harry Kennedy, a professor of forensic psychiatry at the University of Dublin.When Bownes first went into the Maze, republican prisoners were escalating a campaign of protest against the British government. This included demands to reinstate special...

Great British Energy, a new, publicly owned company created by the government, is to invest £200m to fit solar panels to the roofs of 200 NHS hospitals and 200 schools in England. The aim is to cut costs and carbon and make key areas of the public sector less dependent on the uncertain energy market. The programme is expected to save £400m over the lifetime of the panels (30 years), with savings reinvested in the NHS and education. The NHS spends an estimated £1.4bn a year on energy, a figure that has more than doubled since 2019.The programme is expected to last two years, and the first panels should be on NHS sites and schools by the end of summer 2025. The educational component of the programme will focus on schools in deprived areas, particularly in the north east, north west, and west Midlands.Mark Harber, special adviser on healthcare sustainability...

Weight management programmes for obese or overweight children may be effective, but their impact has been hampered by low uptake and completion rates, an evaluation of eight pilot projects across England has suggested.1A report from the Office for Health Improvement and Disparities evaluated eight projects funded through a £4.2m government grant in July 2021, which piloted extended brief interventions (EBIs) and expansion of behavioural weight management services for children aged 2 to 19 and their families.EBIs involve a practitioner discussing a child’s weight and growth with their parent or carer, and can include the use of behaviour change techniques, tailored support, and onward referral to services. Weight management services usually involve 12 week programmes and include diet and physical activity guidance. Their primary aim is weight maintenance and growing into a healthier weight, rather than weight loss.The pilots were funded for a year and took place across several areas in...

The World Health Organization (WHO) has called for an urgent international public health response as tuberculosis (TB) funding cuts threaten to reverse two decades of progress in containing the world’s deadliest infectious disease.The UN health agency said that it was particularly concerned about services in the world’s worst affected nations collapsing, allowing the respiratory disease to spread almost unabated.More than a million people died from TB last year, but that number is expected to rise sharply as public health systems, particularly in Africa, are no longer able to diagnose, treat, and monitor the disease. WHO warned that the situation could quickly deteriorate, as 27 countries faced “crippling breakdowns” in their TB response as funding cuts hit every stage of detection, treatment, and prevention.“The huge gains the world has made against TB over the past 20 years are now at risk as cuts to funding start to disrupt access to services...

A US judge has blocked drastic job cuts to the US Agency for International Development (USAID).On 18 March Judge Theodore Chuang of the US District Court for Maryland ruled that the moves—which effectively shut the agency—had probably violated the US constitution. The case was brought by more than 20 current and former USAID employees and contractors.The fired employees are not back at work but have been placed on paid administrative leave. The judge said the fast shutdown of the agency “deprived the public’s elected representatives in Congress of their constitutional authority to decide whether, when, and how to close down an agency” authorised by Congress.1The cuts were initiated by the Department of Government Efficiency (DOGE) which is headed by billionaire Elon Musk, adviser to President Donald Trump. Around 1600 of USAID’s US employees were fired and most of the rest were placed on administrative leave. USAID had about 13 000...

Liz Calhoun was halfway through her three year emergency physician training when she learnt from a text message that her hospital was closing in three months. She and the other 571 resident physicians at Hahnemann University Hospital in Philadelphia did not know how or where they would finish their training. In the end they didn’t have three months to figure it out: the training programme closed 30 days later.Hahnemann, located in the heart of the city, was a “safety net” hospital, meaning that its staff provided care to patients regardless of their insurance status or ability to pay. At the time of its closure in 2019, Hahnemann made headlines as the model for what can go wrong when a profit driven private equity firm takes over a hospital. In the years since, several other hospitals bought by private equity firms have abruptly closed, leaving their communities’ health, economies, and resident...

Over the past year, a firestorm of debate has been swirling around the role of physician associates (PAs) in the NHS. Many commentators have used the lack of regulation of PAs and oversight of their education as evidence that PAs are trying to hide their practice or escape the consequences of their actions. Nothing could be further from the truth.PAs, like doctors, nurses, physiotherapists, pharmacists, and all NHS professionals, want to ensure that only highly qualified people are admitted to their profession and that there is a mechanism to manage those who are not performing to standard. Just as all doctors do not bear responsibility for the mistakes of other doctors, nor do all PAs bear responsibility for every mistake made by another PA. Yet the government has been slow to respond to the need for regulation.The lack of statutory regulation has meant that the PA profession took the initiative...

The BMA has announced plans to take legal action over an exam error that left some doctors facing the risk of unemployment.The error affected nearly 300 candidates who sat part 2 of the membership of the Royal College of Physicians (MRCP) exam in September 2023.1 A total of 61 doctors who were originally told they failed were informed 18 months later that they had passed, while 222 doctors who had been told they passed were belatedly informed that they had failed.Some doctors who thought they had passed were in the process of applying for higher specialty training when the error was announced in February. They have now had their applications withdrawn from the process, as they no longer meet the eligibility criteria for the roles.2 Doctors who have been affected told The BMJ they were concerned about becoming unemployed when their current training programmes end in August.The decision to withdraw...

Nottingham University Hospitals NHS trust is investigating allegations that healthcare staff illegally accessed medical records of the victims of a stabbing attack that left three people dead.Barnaby Webber and Grace O’Malley-Kumar, both 19 year old university students, and Ian Coates, a 65 year old school caretaker, were stabbed to death by Valdo Calocane in June 2023.The claims that their medical records had been accessed illegally were first reported by the Daily Mirror.1 In a joint statement the families of the three victims described the news as “distressing and traumatic.”The statement said, “These are not just alleged data breaches but gross invasions of privacy and civil liberty. For individuals to choose to access information regarding the vicious attack and murder of Barney, Grace, and Ian with no reason to do so is sickening. It’s gross and inexcusable voyeurism at the most repugnant level.”The families found out about the potential breach in...

A most beautiful word?During his presidential campaign in 2024 Donald Trump was heard to say that “the most beautiful word in the dictionary today is the word ‘tariff.’ It’s more beautiful than ‘love’. It’s more beautiful than anything. It’s the most beautiful word. This country can become rich with the use—the proper use—of tariffs.”1If President Obama modelled himself on President Lincoln, Trump seems to be modelling himself on William McKinley, who was president from 1897 until his assassination in 1901, having been re-elected in 1900, and whom Trump has called the Tariff King: “He spoke beautifully of tariffs. His language was really beautiful: ‘We will not allow the enemy to come in and take our jobs and take our factories and take our workers and take our families unless they pay a big price, and the big price is tariffs.’” Trump made it sound as if he was quoting McKinley...

Stephen Powis, NHS England’s national medical director and one of the government’s most prominent communicators during the covid-19 pandemic, is to step down this summer.1His departure, announced on 6 March, creates another gap in NHS England’s senior leadership after Amanda Pritchard’s sudden decision to quit as its chief executive.2Powis, who has served more than seven years as national medical director, gave notice of his intentions in January in a letter to Pritchard, NHS England said.The departures come as health secretary Wes Streeting considers overhauling NHS England’s role and how it relates to the Department of Health and Social Care as part of reforms to improve NHS accountability and productivity, amid calls from some critics for NHS England’s abolition.3Streeting praised Powis’s “outstanding leadership” and “professionalism,” saying “his contribution to the NHS and the country was enormous during the pandemic.”“I would like to thank Steve, not only for his pivotal role in...

Hospital consultants have urged the BMA to lobby for a national, anonymous reporting structure for staff who experience sexual harassment at work.Doctors at the BMA’s UK consultants annual conference on 4 March also called for NHS organisations to investigate reports of sexual misconduct using external investigators trained in trauma investigations.A motion carried by the conference also stated that NHS trusts should include active bystander training within mandatory training programmes for all staff.Proposing the motion, perinatal psychiatrist Bhairavi Sapre referenced an investigation by The BMJ and the Guardian which found that more than 35 000 sexual safety incidents were reported to 212 NHS trusts in England between 2017 and 2022.1Figures from the 2023 annual NHS staff survey showed that 9% of NHS staff in England were sexually harassed while at work.2Sapre said that the lack of national reporting structure for sexual harassment left victims “without the support or confidence to report...

The National Institute for Health and Care Excellence (NICE) has decided to reconsult on draft guidance for Alzheimer’s treatments donanemab and lecanemab, six months after initially rejecting the drugs, in light of new evidence provided by the manufacturers.The new draft guidelines, published on 6 March,12 have again not recommended the treatments be available on the NHS as they do not provide “good value” with “relatively small” benefit and high rollout costs, including regular infusions and side effect monitoring.However, the guidelines are now undergoing public consultation during which manufacturers and other stakeholders can “submit new evidence or commercial proposals that might tackle the problems that have so far been a barrier to the use of these new treatments in the NHS.”The consultations will close on 27 March and the NICE committee will consider all responses during a meeting in May, after which their recommendations will be finalised.The re-review of the drugs...

For the first time ever the UK has more female than male doctors, with 164 440 women (50.04%) and 164 195 men (49.96%) registered with a licence to practise, show data from the General Medical Council (fig 1).bmj;388/mar07_2/r458/F1F1f1Fig 1Proportion of doctors able to practise medicine in UK who are womenThe 2024 data show variation across the four UK countries. There are more women than men working as doctors in Scotland (54.8% versus 45.2%) and Northern Ireland (53.5% v 46.5%) but fewer women than men in England (49.7% v 50.3% male) and Wales (47.3% v 52.7%), though it is expected women will outnumber men in all four countries in the near future.One of the factors driving the trend has been more women going to study medicine. Since 2018-19 there have been more female than male medical students in all four UK countries. In 2023-24 the UK medical student intake was 60%...

bmj;388/mar07_1/r449/FAF1faMalcolm Faulk was a pioneering forensic psychiatrist who was instrumental in the development of regional secure units, which were developed to bridge the gap between prisons and the NHS. In 1972 Faulk was appointed consultant psychiatrist to the Home Office and the Wessex regional health authority—these joint posts were new and they were viewed with suspicion by other staff. Prison doctors saw them as a threat to their authority and NHS psychiatrists worried that their hospitals would be filled with dangerous patients.Faulk and his fellow newly appointed psychiatrists met up regularly, and their self-described “dream” was a system of treatment for disturbed offenders “which would permeate the penal system, dealing with the problems there, supported by clinics and outpatients in the NHS—a unified approach rather than a split one.”1 Faulk described the kind of problems he saw in prisons: “We saw neuroses, emotional turmoil, loss of control, pathological anger, and...

In healthcare we trust—or do we? A breakdown in trust, like the schism in the transatlantic alliance, should make us think again about whether the current model requires reinvention. An anonymous scientist continues to reveal the extent of the shocking attack on health and science in the US (doi:10.1136/bmj.r392).1 The professionals and public betrayed by their president’s purge must feel, as Nick Cave sang, like a microscopic cog in a catastrophic plan—designed and directed by his red right hand. Trust and rights (doi:10.1136/bmj.r372)2 are eroding in many if not all health systems worldwide, albeit not as dramatically as in the US. Crises—financial, workforce, and disease burden—strain every sinew of every health system.In the UK, the NHS is no different. Yes, some progress is being made. For example, a newly agreed contract offers hope of a gradual restoration of general practice (doi:10.1136/bmj.r426 doi:10.1136/bmj.r435).34 The alarming events at Moorfields Eye Hospital in...

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...