BMJ - British Medical Journal

Private equity’s ownership of US hospitals has led to patient suffering, understaffing, reduced care quality, and health and safety violations, while investors have earned millions, a year long Senate Budget Committee investigation has found.1The bipartisan committee looked at more than a million pages of documents, including emails, board meeting minutes, financial reports, spreadsheets, and loan agreements, relating to two major private equity firms, Apollo Global Management and Leonard Green & Partners.Through studying these documents the committee “uncovered troubling patterns of prioritising profits over patients and of unfulfilled promises.” It identified “systemic issues” such as underinvestment in critical hospital infrastructure and the “pursuit of financial gains through leveraged buyouts and dividend extractions—often to the detriment of patients and hospital operations.”Apollo owns around 220 hospitals through the rural hospital operator Lifepoint Health and a second operator ScionHealth, and Leonard Green & Partners held a majority stake in Prospect Medical Holdings from 2010...

A controversial scheme in which midwives paid by a leading formula milk company have been providing infant feeding advice to new parents has been axed after an outcry.The initiative, hosted by the supermarket giant Tesco and revealed by The BMJ last week,1 drew criticism for its parallels to disgraced activities by formula milk companies that took place many decades ago.Midwives hired by Danone, which owns the UK’s leading formula brand, were being paid nearly double NHS rates to work at Tesco offering infant feeding advice. The service breached the International Code of Marketing of Breast-Milk Substitutes, established by WHO and Unicef, which clearly advises against marketing personnel seeking direct or indirect contact with pregnant women or mothers. As the midwives were working for Danone they are seen as marketing personnel.Tesco originally said it intended to continue the pilot in its flagship Hertfordshire store and roll out the service to two...

In recent years, the NHS has faced numerous drug shortages, with serious consequences for both patients and healthcare professionals.12 These ongoing shortages have affected a wide range of drugs, including antibiotics, diabetes medicines, ADHD medications and hormone replacement therapy.34 As the NHS grapples with drug scarcity, it is necessary to understand the causes and prioritise solutions to tackle this recurrent problem.Medicine shortages doubled between 2022 and 2024, with 101 drug supply disruption notifications in February 2024 compared to 52 in the same month in 2022.567 In 2023, healthcare providers received an average of 137 monthly notifications about supply disruptions, signalling a worsening crisis which is affecting patient care.7The current drug shortages in the UK arise from global and local factors.2 Disruptions in worldwide supply chains—triggered by events such as the covid-19 pandemic, the Ukraine war and increased energy costs—have impacted the manufacturing and transport of essential pharmaceutical ingredients.8 Manufacturing problems...

A 44 year old man with epilepsy who died following a fall had been left without his anti-epileptic medication carbamazepine (Tegretol) after his pharmacy could not supply the drug, a prevention of future deaths report has said.1The coroner’s report was addressed to both the Midway Pharmacy, Pudsey, and the General Pharmaceutical Council (GPC). It said that David Joseph Crompton had not received his medication twice last year, first for 10 days in April and then again in December, when his pharmacy left him an “IOU” for Tegretol when delivering his other medications to his home.According to the report, Crompton and his family were then left to “contact other pharmacies to see if they could obtain it.”The coroner said, “Without his medication his epileptic condition was likely to destabilise and give rise to fits. His falls both in April and December 2024 occurred when he was left without his essential medication....

New roles in healthcare provision, such as physician associates (PAs), have been introduced too quickly and without proper preparation, a review has found.The review of new staff roles in the NHS in England,1 carried out by the health think tank the Nuffield Trust, found that too often they had been introduced before agreement on issues such as regulation, training, supervision, and communication.The study, commissioned by NHS Employers, looked at the history of how different roles have been introduced, how the mix of staff skills in the NHS compares with other countries, and what needs to be tackled if the government’s plans to expand the workforce and invest in new roles are to succeed.The NHS has a long history of introducing new roles, said the authors—recently including PAs, nursing associates, and advanced nurse practitioners to tackle staff shortages, financial constraints, and changing health needs.The report drew on published data throughout England...

An employment tribunal has ordered an NHS trust to pay just over £100 000 to a trauma surgeon with post-traumatic stress disorder (PTSD) after deciding that he was unfairly dismissed.1The Cambridge tribunal found a “wholesale failure” by East and North Hertfordshire NHS Trust to follow its own illness policy when it decided to dismiss Vladimir Filipovich, who worked at the Lister Hospital in Stevenage, at the age of 60.Filipovich, who represented himself at the tribunal, had worked for the trust for nearly 20 years when he was sacked in July 2019. He had conducted over 25 000 operations without any deaths. Before coming to the UK he had been a trauma surgeon in the Bosnian war, exposed to severely injured and dying patients.He experienced an inability to concentrate, memory loss, exhaustion, and flashbacks. In November 2016 a psychiatrist made a preliminary diagnosis of PTSD.In January 2017 Filipovich turned up for...

Reports that a “mysterious” covid-like virus is overwhelming Chinese hospitals have made international headlines. Is human metapneumovirus (HMPV) a common winter bug that is following an expected seasonal outbreak pattern or something more serious?Could it be the next pandemic?That is extremely unlikely. HMPV is not a new virus like SARS-CoV-2 and has been circulating in its current form for decades.12 The Dutch researchers who first isolated it in 2001 found antibodies in almost all of the children they tested aged 5 and older.3Unlike respiratory syncytial virus (RSV), from which it is almost clinically indistinguishable, there is no vaccine against HMPV. But patients usually recover after a few days of mild illness. Immune treatment and antivirals are occasionally used, but bed rest and fluids are the primary treatment.HMPV can be more serious in infants, elderly people, and people who are immunocompromised, who may develop bronchiolitis or pneumonia. It kills at about...

The true number of people who have died directly from war in Gaza is around 41% higher than the official figures reported by Palestine’s health ministry, a study published in the Lancet has found.1The health ministry reported that 37 877 people had died during the first nine months of Israel’s air and ground operations in Gaza, but the real figure is closer to 64 260, the researchers estimated after analysing several overlapping datasets.The estimated total would mean that nearly 3% of Gaza’s population was killed between October 2023 and June 2024.“The UN Human Rights Office has already condemned the high number of civilians killed in the war in Gaza, and our findings suggest that the traumatic injury death toll is underreported by around 41%,” said Zeina Jamaluddine, an epidemiologist at the London School of Hygiene and Tropical Medicine (LSHTM) and the study’s lead author. “These results underscore the urgent need...

AbstractObjectiveTo assess whether intra-arterial tenecteplase administered after successful endovascular recanalisation improves outcomes in patients with acute arterial occlusion of the posterior circulation.DesignMulticentre randomised controlled trial.Setting31 hospitals in China, 24 January 2023 to 24 August 2023.Participants208 patients with successful recanalisation (grade 2b50-3 on the extended thrombolysis in cerebral infarction scale) of an occlusion in the V4 segment of the vertebral artery; proximal, middle, or distal segment of the basilar artery; or P1 segment of the posterior cerebral artery: 104 were randomly allocated to receive tenecteplase and 104 to receive standard care.InterventionsIntra-arterial tenecteplase (0.0625 mg/kg, maximum dose 6.25 mg) administered proximal to the residual thrombus (if still present) or distal to the origin of the main pontine perforator branches over 15 seconds, or endovascular treatment only (control group).Main outcome measuresThe primary outcome was freedom from disability (modified Rankin scale score 0 or 1) at 90 days after randomisation. Primary safety outcomes included symptomatic intracranial haemorrhage within 36 hours and all cause mortality at 90 days. All efficacy and safety analyses were conducted by intention to treat and adjusted for age, pre-stroke modified Rankin scale score, time from onset of moderate to severe stroke (National Institutes of Health stroke scale score ≥6) to randomisation, hypertension, and baseline stroke severity.ResultsAt 90 days, 36 patients (34.6%) in the tenecteplase group and 27 (26.0%) in the control group had a modified Rankin scale score of 0 or 1 (adjusted risk ratio 1.36, 95% confidence interval 0.92 to 2.02; P=0.12). Mortality at 90 days was similar between the tenecteplase and control groups: 29 (27.9%) v 28 (26.9%), adjusted risk ratio 1.13, 0.73 to 1.74. Symptomatic intracranial haemorrhage within 36 hours occurred in eight patients (8.3%) in the tenecteplase group and three (3.1%) in the control group (adjusted risk ratio 3.09, 0.78 to 12.20).ConclusionsIn patients with acute ischaemic stroke due to acute posterior large or proximal vessel occlusion, intra-arterial tenecteplase administered after successful recanalisation was not associated with a statistically significant reduction in combined disability and mortality at 90 days.Trial registrationClinicalTrials.gov NCT05684172.

The government has reportedly ceased further funding of the controversial doctor apprenticeship programmes.1 The scheme has faced considerable opposition from the medical community and lobbying by the BMA from the start. Proponents initially argued that these programmes would widen access into medicine, but this argument began to fall apart as further details emerged. Medical doctor apprenticeships would not have delivered on the aim of expanding access into medicine, instead we need effective widening participation schemes in medical education.The timelines to deliver the medical apprenticeships were always tight. In 2022, NHS England set out a tender for medical schools to develop a new programme offering the use of the apprenticeship levy funding for the first time to medical degrees. The pilot medical schools were confirmed in January 2023. NHS England then needed to find willing local employment providers, adapt a medical curriculum, seek regulatory scrutiny for the degree and apprenticeship aspect,...

The BMA has called on the agency responsible for issuing NHS pensions savings statements to urgently rectify “completely unacceptable” errors that are making it impossible for doctors to accurately report their tax status to HM Revenue and Customs.At least 757 doctors have received inaccurate statements for 2023-24 from the NHS Business Services Authority (NHSBSA), which potentially prevents them from being able to complete self-assessment tax returns before the deadline at the end of this month, the BMA said.Examples of errors include miscalculations of pension savings that were distorting total amounts, the BMA added.In light of the situation the association has urged the NHSBSA to report itself to the pensions regulator over the mistakes.In a letter to the NHSBSA sent on 10 January, Vishal Sharma, chair of the BMA’s pensions committee, said, “This is completely unacceptable. Failing to provide accurate pension savings information to scheme members in a timely fashion means...

A coroner has questioned whether enough information is provided about the risk of suicide associated with selective serotonin reuptake inhibitors (SSRIs) after the son in law of Prince and Princess Michael of Kent shot himself after taking the antidepressant drugs.Thomas Kingston, 45, died of a self-inflicted shotgun wound to the head last February while visiting his parents in Kemble, Gloucestershire.Katy Skerrett, senior coroner for Gloucestershire, has sent a regulation 28 report, intended to prevent future deaths, to the National Institute for Health and Care Excellence (NICE), the Medicines and Healthcare Products Regulatory Agency (MHRA), and the Royal College of General Practitioners. The bodies must respond by 3 March with proposals for action.Her report questions if there is adequate communication of the risks of suicide associated with SSRIs and if “the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has...

Gabriela Alvaro’s blood was flowing through a dialysis machine when the power in Ecuador went out nationwide.“Generators can take up to a minute and a half to start,” says Alvaro, 31, whose kidneys stopped functioning eight years ago. She relies on dialysis three times a week. “That minute and a half felt eternal. I remember being afraid that my blood would clot and they wouldn’t be able to return it to my body. That would kill me, of course. I don’t remember much else—I fainted.”It was 5 August 2024, and the latest in a series of scheduled blackouts that left the country in darkness for at least 70 days, with some outages lasting 14 hours. Every Friday the government announces the power outages scheduled for the following week. Life is planned around the affected areas and times.By government mandate, public healthcare facilities are exempt from power cuts, although private hospitals...

Establish boundaries earlyAshley Simpson, medical education fellow, NHS Lothian, says, “Being asked to undertake a task you believe is outside your role can be challenging. Navigating these situations is often context dependent, requiring a balance between your professional responsibilities, team working, and patient safety.“Delivering healthcare is a team effort, with each professional holding specific responsibilities. There is often overlap in competencies, however, meaning that some tasks can be undertaken by multiple team members.“As a resident doctor rotating though departments, it’s important to clarify the typical responsibilities of team members in each setting. A task outside your role in one department may fall within it in another. Establishing role boundaries can empower you to handle situations like this more effectively.“Occasionally you may be asked to complete tasks typically assigned to others—for example, phlebotomy—because of workload or staffing pressures. In these instances, working collaboratively may be the best approach for patient care....

A group of UnitedHealth Group shareholders has asked the company to report costs and patient risks related to denial of medical care. The demand comes in the wake of the murder of Brian Thompson, head of the firm’s health insurance business, on 4 December 2024.12Thompson’s murder evoked widespread public criticism of the US healthcare industry and even praise for the man accused of the murder, Luigi Mangione.3“Shareholders recommend that the report evaluate how company practices impact access to healthcare and patient outcomes, including analyses of how often prior authorisation requirements or denials of care lead to delay or abandonment of medical treatment, and serious adverse events for patients,” said the shareholders in their request.The proposal could be voted on at UnitedHealth Group’s annual meeting later this year.News stories about denials of care are common in the US. Reports include that of a man who was denied a replacement for his...

bmj;388/jan13_1/r24/FAF1faObstetrician and gynaecologist Rupert Fawdry was an original thinker, dismissed by some as a Luddite and acclaimed by others as a maverick genius. If computers had been invented first, he suggested, paper and pen might have been considered the greatest IT breakthrough since the dawn of civilisation.This may seem an odd and even illogical observation by a charming eccentric who had an “affair” with the computer, according to his Canadian born first wife Judy. This passionate, obsessive affair reflected a love of structure and an overwhelming desire to organise the world—in particular, medical records.Fawdry highlighted dozens of inconsistencies in some 70 maternity datasets. The Körner model, for example, lacked an option for a breech birth by caesarean, he said, while the “place of birth” option seemed to differ in each dataset.Perhaps it was the depth of his knowledge and experience that ultimately made him appreciate the limitations of computerised medical...

The US Food and Drug Administration (FDA) has published draft guidance aimed at improving the performance of pulse oximeters across all skin colours, following research suggesting the medical devices may be less accurate in people with darker skin.1Once finalised, the guidance could see a prominent label added to the packaging of pulse oximeters proven to perform “comparably across groups of individuals with diverse skin pigmentation.”It also provides manufacturers with actions they can take to better assess their products, such as increasing the number of clinical trial participants and using the Monk skin tone scale2 alongside other methods for classifying skin pigmentation.Pulse oximeters became more widely used during the covid-19 pandemic as a way for people to monitor blood oxygen levels while at home. But research published in the New England Journal of Medicine in 2020 found that the devices may be missing three times as many cases of occult hypoxaemia...

“Eco-anxiety” is growing worldwide, especially among young people.1 Considerable anxiety about the climate crisis is rational, particularly for young people, for whom even 2100 is a tangible date. Deep concern for future human and ecological wellbeing is justified among all ages, not only because of the disturbing evidence of climate breakdown, but also because of the apparent climate change policy paralysis, especially in so-called developed countries—the global North. Climate policy paralysis and hypocrisy are stark given the disturbing evidence of rising global temperatures in the last 18 months. The primary responsibility for climate change lies with the lifestyles and intransigence of the world’s most affluent people, most of whom live in high-income nations including Europe, the US, Canada, and Australia. Although these populations have, to date, been comparatively insulated from the harm caused by climate change, more extreme climate related weather events are becoming increasingly frequent, such as wildfires in...

The 10 winners of the 2024 Shkreli awards, given annually to the worst examples of profiteering and dysfunction in US healthcare, have been announced by the Lown Institute, a non-profit US think tank.1The winners include an oncologist who subjected a healthy patient to cancer treatment for profit, a hospital accused of demanding upfront payments from patients with cancer, and UnitedHealth, the insurance company that has faced a storm of public indignation after one of its executives was murdered in New York.2This is the eighth year in which the awards have been given. Winners are chosen by a panel including doctors, public health experts, journalists, and patient advocates. The awards are named after Martin Shkreli, the “pharma bro” who became infamous when he bought the maker of the anti-parasitic drug Daraprim and increased the price 50-fold.Speaking at the ceremony, Lown Institute president Vikas Saini said, “All these stories paint a picture...

One of England’s largest hospital trusts has ordered an independent review of its international medical training programmes because of concerns, first highlighted in The BMJ, that overseas doctors were paid substantially less than domestic peers working at a comparable level.University Hospitals Birmingham NHS Foundation Trust (UHB) has already carried out an internal review “following concerns raised by staff members” about the international medical training programmes.A message sent to UHB staff on 8 January from Kiran Patel, the trust’s chief medical officer, said that the internal review had “highlighted a number of issues, including pay parity . . . We will therefore undertake an independent review of each of the international training programmes we are involved in.”Foreign doctors come to English hospital trusts as “fellows” as part of the Academy of Medical Royal Colleges’ medical training initiative scheme.1 The scheme provides experience in the NHS for up to two years for...