BMJ - British Medical Journal

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...

Targeted NHS retention schemes have helped to reduce the number of doctors and other staff leaving the health service, NHS England has reported.NHS data show that one in 10 (10.1%) hospital and community healthcare workers left the NHS in the 12 months up to September 2024, nearly 21 300 fewer than in the same period up to September 2022 when one in eight (12.5%) left the health service.12 In the same period, one in seven (13.9%) doctors working in hospital and community services left the NHS, 771 fewer than in the 12 months up to September 2022, when one in six (15.9%) doctors left.NHS England said that the fall in leavers had been aided by a pilot scheme to find new ways to improve retention, which was trialled in 23 trusts from April 2022 and is now being extended to a further 116. An NHS England evaluation of the initiative...

International women’s day falls on 8 March every year. As the outgoing president of the Medical Women’s Federation, I want this year’s celebration to be followed by action. The number of women doctors in the UK has doubled in the past 20 years.1 This is a large but undervalued workforce, so improving their working lives would have the additional benefit of improving health across the population.The key to this change is to talk about sexism and systemic barriers in medicine.23 We must challenge sexist generalisations about individual women doctors while also understanding that some general systemic factors are more likely to limit their careers than those of men. Pregnancy, child rearing, caring for elderly parents, or being overlooked for opportunities and development are factors affecting women doctors at critical phases, preventing career progression.The prevailing model of healthcare—a continuum of symptoms, investigations, diagnosis, treatment, and cure—doesn’t fit our increasingly complex population...

Within hours of being sworn in, President Donald Trump signed an executive order withdrawing the United States from the World Health Organization (WHO).1 On 30 January 2025, just 10 days later, a deadly outbreak of the Sudan strain of the Ebola virus was reported in Kampala, Uganda.2 By 10 February, nine cases of the virus had been confirmed.3 This marks Uganda’s sixth Ebola outbreak since 2000, following the late 2022 outbreak that resulted in 143 infections and 55 deaths.4The US contributes roughly 14% of the WHO’s $6.9bn biennial budget, so its withdrawal would strip WHO of a major funder, leading to budget cuts that will affect both the current response in Uganda and global health efforts broadly.5Historically, WHO has had a crucial role in managing outbreaks in sub-Saharan Africa. In Uganda in 2022, WHO provided essential equipment like testing kits and isolation centres for patients with Ebola, enhancing disease containment...

Last month NHS England published its priorities and operational planning guidance for 2025-26,12 outlining key improvement objectives for the NHS for the first time since Labour took office in 2024. Meanwhile, the government’s 10 year plan for the NHS3 is due to report this spring. Whatever the 10 year plan concludes won’t be enacted immediately. If we’re looking for actions to improve, stabilise, or protect services—and to navigate our way out of our current crisis—this operational plan is our only short term roadmap. But is it helpful?In January, Wes Streeting’s Road to Recovery,4 his first mandate to the NHS as health and social care secretary, emphasised the need to “cut waiting times for elective care,” “improve urgent and emergency care,” “improve access to primary care,” “reduce the amount of time spent in ill health,” “tackle health inequalities,” and “reduce lives lost to the biggest killers—cancer, cardiovascular disease, and suicide.” It...

Hospital consultants have demanded action to tackle the “unacceptable” treatment delays, avoidable harm, and excess deaths resulting from the number of patients being treated in corridors and other inappropriate settings.Doctors at the BMA’s UK consultants annual conference on 4 March said that they were “deeply concerned” by the crisis in emergency care which has resulted in unprecedented crowding in emergency departments and delays in ambulance responses.The conference carried a motion urging the BMA and medical royal colleges to lobby the government to urgently rectify the situation by tackling understaffing and under-resourcing in NHS trusts and social care. The BMA should also work with other unions and colleges to “increase pressure on the government to manage this crisis,” it said.In January1 a report from the Royal College of Nursing highlighted the scale of the problem.Denise Langhor, an emergency medicine consultant from Wirral University Teaching Hospital, who proposed the motion, described the...

Heart attacks and strokes rise exponentially with age and make a major contribution to increasing healthcare costs and lost productivity. In the UK more than 7 million people are living with cardiovascular disease. Around 100 000 people have a heart attack and more than 100 000 people have a stroke every year. Direct healthcare costs relating to cardiovascular disease are estimated at £10bn a year, with a cost of £25bn to the UK economy from lost productivity.1Preventive medication to reduce blood pressure and low density lipoprotein (LDL) cholesterol can have a major effect in avoiding most cases of heart attack and stroke.23 This opportunity has been neglected and should form part of an overall preventive strategy that also includes the avoidance of smoking or being overweight and keeping active. The polypill, which combines blood pressure lowering agents, statins, and anti-platelet agents, and its application in preventing heart attacks and strokes...