More important than life and death

时间：2016-02-25

发布：Kamran Abbasi, International Editor, The BMJ

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It is an interesting time to propose collaboration as a solution for the NHS. The United Kingdom may decide to leave the European Union, with unknown consequences for science and health (doi:10.1136/bmj.i1117). A state of emergency exists in primary care, where GPs are stressed (doi:10.1136/bmj.i693). Health and social care remain dysfunctional (doi:10.1136/bmj.i458). England’s health secretary has imposed a new contract on junior doctors (doi:10.1136/bmj.i1129; doi:10.1136/bmj.i1124). You might then reasonably conclude that collaboration isn’t in the air. Nor is the cup of goodwill overflowing. “Sustained effort” might not be the cleverest rallying cry for a demoralised workforce. Yet Hugh Alderwick and Chris Ham argue that collaboration, goodwill, and sustained effort are essential ingredients to rescue the NHS in England from the “biggest crisis in its history” (doi:10.1136/bmj.i1022).

This alarming scenario has come quickly, considering that the Health and Social Care Act was passed a little over three years ago. Few readers will dispute the editorialists’ diagnosis of a crisis, but they might question our ability to resolve it. NHS organisations are producing “place based plans,” multiyear proposals to meet the needs of local populations. The central challenge is to replace competition, beloved of the Health and Social Care Act, as the main driver of change and to allow collaboration to flourish instead. Alderwick and Ham warn that it is hard for collaboration to succeed in a legislative environment built for competition.

One solution is new care models that integrate services and promote place based collaboration between NHS providers and commissioners, local authorities, and third sector organisations. The logic seems sound, but why should today’s new models of care be any more viable than yesterday’s? And even if they are, a challenge remains in translating successful small scale initiatives to larger geographies and populations. These collaborations require goodwill and sustained effort. But in an environment where staff are already making sustained effort, and where goodwill has run dry, how likely are we to reach the light at the end of this tunnel?

Perhaps this is an issue of communication? We might be better served adopting the language of football. “The NHS is a funny old game,” writes David Barer (doi:10.1136/bmj.i1023), whose home team, incidentally, sits near the bottom of the English Premier League. Just as with football, new formations must be tried, the consequences of any tactical change are impossible to predict, and, importantly, everyone is an expert. To paraphrase Liverpool’s legendary manager Bill Shankly, some people believe that health is a matter of life and death, but we can assure you that it is much, much more important than that.

In an environment where staff are already making sustained effort, and where goodwill has run dry, how likely are we to reach the light at the end of this tunnel?

BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i1122 (Published 25 February 2016)
Cite this as: BMJ 2016;352:i1122

Innovation now

时间：2016-02-18

发布：David Payne, Digital Editor, The BMJ

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BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i994 (Published 17 February 2016)
Cite this as: BMJ 2016;352:i994

Eight thousand taxis gridlocked central London last week as drivers protested at the rise of the cab hailing app Uber 1, the latest in a series of similar demonstrations in the UK and other cities around the world. Opponents claim that Uber undercuts traditional licensed cabs and is less regulated. But can Uber’s technology be successfully applied to medicine? Nigel Hawkes (p X) reports on the emergence of companies claiming to be “the Uber of healthcare” and asks whether such innovation will ultimately reinvent home visits, which in the UK now account for less than one in 25 GP consultations. This reinvention includes private paid “virtual” home visits, as Ingrid Torjesen outlines (p X). Is there a market in the UK? Many have their doubts, but the kidney specialist Renee Dua, founder of the US startup Heal, which in its first year has treated 2000 patients in Los Angeles and Orange County, says that the Uber model can be applied globally.

London taxi drivers were not the only ones demonstrating last week. Gareth Iacobucci’s live blog covered the junior doctor strike across England (bmj.co/strike) and the subsequent contract imposition by England’s health secretary, Jeremy Hunt. Our GP columnist Margaret McCartney (p X) accuses Hunt of choosing the nuclear option and jeopardising the “moral contract” between clinicians and patients, effectively setting the NHS up to fail. As far as primary care is concerned, she warns: “It’s easy to see how the proliferating private GP companies will profit.”

Politicians do have a tendency to seize on technology, often prematurely, as the £10bn spent a decade ago on the National Programme for IT showed. The Nuffield Trust’s chief executive, Nigel Edwards (p X), says that paperless technology is now at the stage where it can revolutionise healthcare and outlines four lessons from previous rollouts. His conclusion? Involve clinicians to avert a digital disaster.

Technology’s revolutionary influence was also felt last week when the owners of the UK newspaper the Independent announced that it would cease daily print publication after 30 years. Its former editor Andrew Marr 2 said that the move to an online only format marked the loss of a community of “similarly minded, but not identically minded, people who argue, debate and together fashion a view of the world which is distinctive.” The BMJ’s experience is that such communities straddle both print and online, which Marr would see if he read the open letter (p X) from 83 academics from 12 countries and our response to it (p X). The authors are challenging the journal’s policy on qualitative research. Join the live (and lively) debate as it unfolds, digitally of course, on thebmj.com.

References
1 Black cab protest: London gridlocked by taxi demonstration against Uber Wednesday. Evening Standard 10 Feb 2016 www.standard.co.uk/news/transport/black-cab-protest-cabbies-set-to-bring-gridlock-to-central-london-with-demonstration-against-uber-a3176746.html
2 Marr A. The loss of the Independent means the loss of a community. Guardian 13 Feb 2016 www.theguardian.com/media/2016/feb/13/the-independent-gave-me-some-of-the-most-exciting-times-of-my-career 

Zika, and rapid diagnostic tests for malaria

时间：2016-02-14

发布：Fiona Godlee, Editor in Chief, The BMJ

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A year ago few people outside French Polynesia had heard of Zika. Now few people in the world will not have heard of it. This relatively benign and largely asymptomatic infection has spread to 25 countries, apparently bringing with it microcephaly, a condition now haunting thousands of families in—and travelling from—Latin America, the Pacific islands, and elsewhere (Cape Verde).

As Daniel Lucey explains in his editorial (doi:10.1136/bmj.i781), the guidance is clear and unanimous on what precautions people should take to prevent transmission to an unborn child. But the absence of an effective diagnostic test bedevils efforts to contain and respond to the virus.

The world is responding, though never quickly enough, says Lucey. The Ebola virus epidemic taught us many lessons, but “this time our response must be faster and smarter—to control the Zika epidemic, and in preparation for the many other infectious disease epidemics surely to come,” he says.

The BMJ and other journals are doing what we can to support research and provide reliable and up to date information for health workers in affected areas. We have pulled together relevant resources from across the BMJ publishing house and other sources (bmj.com/freezikaresources). In concert with the other members of the International Committee of Medical Journal Editors (icmje.org), we are making all Zika related research freely available and waiving publication fees. And The BMJ has joined other organisations such as the Wellcome Trust and the Bill and Melinda Gates Foundation in an initiative to share data on Zika (www.wellcome.ac.uk/News/Media-office/Press-releases/2016/WTP060169.htm).

With Zika understandably dominating the headlines, other mosquito-borne diseases have, of course, not gone away. Prevalence of the world’s most burdensome of these, malaria, is falling in many countries, say Eleanor Ochodo and colleagues (doi:10.1136/bmj.i107). But with this success come other challenges, notably the harms caused by presumptive overtreatment of fever as malaria.

The policy of presumptive treatment made sense when the prevalence of malaria was high and antimalarials were cheap, and it dominated the approach to fever in malarial regions of the world. Now the ingrained belief among health workers that missing a case of malaria is more dangerous than treating a fever as malaria is fuelling an epidemic of its own, with adverse effects of drugs, rising costs, and resistance to the drugs.

Despite the development and scaling up of rapid diagnostic tests for malaria, presumptive overtreatment of fever as malaria still goes on: a test may not be done for various reasons; the test may deliver a false positive result; or antimalarials may still be prescribed despite a negative test.

Ochodo and colleagues outline strategies to tackle these problems. But they conclude that changing behaviour is rarely easy and that malaria experts will need to learn from efforts to tackle antibiotic resistance in other illnesses.

BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i841 (Published 11 February 2016)
Cite this as: BMJ 2016;352:i841