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BMA wrong to call for repeal of Health and Social Care Act

BMA wrong to call for repeal of Health and Social Care Act

BMA wrong to call for repeal of Health and Social Care Act

BMA wrong to call for repeal of Health and Social Care Act

BMA wrong to call for repeal of Health and Social Care Act

BMA wrong to call for repeal of Health and Social Care Act



by sjhoward

This is the 2,249th post. It was published at 16:38 on Friday, 13th June 2014.

Versions of this post also appear on the BMA website and Medium. It's like it's hunting you down wherever you look, begging to be read.

I took the photo at the top of this post at BMA House in September 2012.

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The BMA is asking members to sign a petition asking Government to repeal the Health and Social Care Act 2012. The leadership’s rationale is that the Act requires providers to compete, while the BMA believes that “collaboration and not competition is more likely to allow a greater integration of community and hospital services”.

I could not agree more: collaboration is more clearly in the interests of individual patients than competition, and collaboration seems at odds with competition. Yet I don’t think the BMA’s position should be to call solely for repeal of the Act: after all, the Act is not solely about competition. The legislation brought about many changes, some of which are working well.

For example, we are beginning to see the value of a new local authority perspective on influencing the wider determinants of health, as shown by the exemplary nominees for NICE’s local government public health award. This sort of progress can be found in many Local Authorities across England. To campaign for repeal of the Act is to surround this progress with a fog of uncertainty: repeal would reject this progress outright and move staff back into PCTs.

The Act limits the Secretary of State’s powers to intervene in the day-to-day running of the NHS. While the success of this has been questionable at best, we are beginning to see push-back against Government diktat. No one, except perhaps Lansley and Hunt, would argue that the NHS benefits from the Health Secretary holding operational control; yet repeal would reintroduce this.

The Act confers new responsibilities on NICE to support evidence-based social care. The Act provides the first (baby) steps towards regulation of healthcare support workers. The Act gives an unprecedented level of legislative support to research in the NHS. These may be small considerations in comparison to the problems of the Act, but outright repeal would (if I may mix metaphors) cast the baby and the bathwater both into uncertain territory.

How quickly the BMA seems to have forgotten the pain inflicted on our profession through restructure, job uncertainty, and redundancy. Excellent professionals left medicine — and especially public health — to pursue other careers, while others lived for years with the stress of the uncertainty of their positions. For the profession’s trade union to argue for yet another overnight reorganisation “so big, it can be seen from space” seems utterly perverse. Perhaps this is why, despite the BMA’s repeated urging, fewer than 4,000 people have signed the petition. Even if every signatory were a BMA member, this would represent less than 3% of the membership.

Repeal represents only a return to the past. It behoves professionals to put forward an alternative vision. For example, politicians refuse to discuss the threat to universal healthcare of having fewer taxpayers per patient as a result of an ageing population; yet the BMA is uniquely placed to devise a considered, collective, professional vision of the future of the NHS. To campaign only for repeal of what exists, and allow the next government propose and introduce yet another short-term model, seems to me to be a sure route to unhappiness.

The BMA should not call for repeal of the Act: this is opposition without a position. The BMA should identify the most insidious parts of the Act, and work tirelessly to scrap or rework them. But, more importantly, the BMA should thoughtfully advocate for the future health of the nation, not for a return to the systems of the past.

Photo-a-day 102: Donation 37

Photo-a-day 102: Donation 37



by sjhoward

This is the 2,230th post. It was published at 22:01 on Wednesday, 7th May 2014.

I'm trying - with limited success - to post a photo each day during 2014, replicating my previous 'Photo-a-day' project from 2012. You can browse the photos so far via this link.

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Drug shortages hamper lethal injections in the USA

Drug shortages hamper lethal injections in the USA

Drug shortages hamper lethal injections in the USA



by sjhoward

This is the 2,225th post. It was published at 10:00 on Saturday, 3rd May 2014. The quotes in this piece have been edited for length.

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I am implacably opposed to capital punishment. There are few issues on which I'm so certain. The state should not kill people. As I've said before, humanity is better than that.

It was only a few weeks ago that I learned that the European Union forbids the export of drugs used for killing prisoners in the USA through lethal injection. For perhaps the first time, I felt a real swell of pride at what seemed a surprisingly strong and principled stand. It is rare to see ethics translated to action on this scale.

But today, Owen Dyer's article in the BMJ (paywalled) has given me pause for thought. This excellently-written article discusses, in some detail, the difficulties drug shortages have caused for the lethal injection programme in several states.

Dyer's article talks through a number of horrendous botched executions, as well as the methods (some illegal) by which states have attempted to procure drugs for lethal injections. I found it a deeply thought-provoking piece. Towards the end, Dyer comes to this point:

Arkansas’ attorney general last year called the state’s capital punishment system “completely broken … it’s either abolish the death penalty or change the method of execution.”

Initiatives are now cropping up in state houses to return to more violent methods. These methods are not so far behind us as some imagine. The last execution by firing squad was in 2010, the last by gas chamber was in 1999, and the last hanging occurred in 1996. The last use of the electric chair was in 2013 in Virginia.

Is it better to bend our principles to supply drugs and assure a more humane death, or to withhold them and ensure a violent death?

The dilemma is complicated by the knowledge that violent methods have less public support, so may – or may not – bring about the end of capital punishment in the USA sooner than non-violent methods.

I tentatively lean in the direction of the greater good, and suggest that drugs are withheld. But it is certainly a complicated issue.

Where will the next pandemic come from?

Weekend read: Where will the next pandemic come from?



by sjhoward

This is the 2,057th post. It was published at 12:30 on Friday, 30th August 2013.

I recommend an article I've read and enjoyed every Friday afternoon. You can browse all previous selections here.

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Varicella zoster virus

My recommended read for this week is a long but very engaging extract from David Quammen’s book Spillover. It was published in PopSci. It reads like some sort of adventure novel, but discusses the reality of tracking where the next pandemic virus might come from, and the work scientists do to prevent it. It’s well-worth reading!

The electron micrograph of a varicella zoster virus at the top of this post is from NIAID’s Flickr feed, and is used under its Creative Commons Licence.

2D: The economics of science & healthcare

2D: The economics of science & healthcare



by sjhoward

This is the 2,039th post. It was published at 12:30 on Wednesday, 17th July 2013.

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The link between the two articles in this 2D is health and economics. It’s a reasonably weak link, granted… but it’s a link nonetheless!

The first article I’d like to recommend is this long and thoughtful interview with Bill Gates by Ezra Klein of the Washington Post, which carries the arresting title “death is something we really understand extremely well”. He talks through some of the financial decisions his Foundation makes, and the economics of disease eradication. I found it quite fascinating.

The second article is really rather different. For Priceonomics, Alex Mayyasi gives a history and economics lesson to explain why articles in scientific journals are, more often than not, behind a paywall. He argues, too, that the system needs to move on and develop in the 21st century. As someone who spends a disproportionate amount of time whining about medical journals and their paywalls, I found this detailed blog post very interesting and informative.

2D posts appear on alternate Wednesdays. For 2D, I pick two interesting articles that look at an issue from two different – though not necessarily opposing – perspectives. I hope you enjoy them! The picture at the top of this post was uploaded to Flickr by Howard Lake, and has been modified and used under Creative Commons licence.

The plane that crashed into the Hudson… and medical safety

The plane that crashed into the Hudson… and medical safety

The plane that crashed into the Hudson… and medical safety



by sjhoward

This is the 2,029th post. It was published at 11:37 on Thursday, 13th June 2013.

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I don’t often post videos on here these days, but this one I really enjoyed. First Officer Jeff Skiles of the flight that ended up in the Hudson, and healthcare safety expert Terry Fairbanks lecture on what healthcare can learn from airline safety.

Some thoughts on GMC social media guidance

Some thoughts on GMC social media guidance

Some thoughts on GMC social media guidance



by sjhoward

This is the 2,008th post. It was published at 13:29 on Friday, 5th April 2013.

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On the 25th March – approximately a lifetime ago in internet terms – the GMC published guidelines for doctors’ use of social media. The guidelines come into effect later this month.

Publication of the guidelines caused something of a social media uproar, particularly around the anonymity clause. The brilliant Anne Marie Cunningham, who has written and spoken a lot about social media in medicine, has hosted a particularly fascinating conversation about this on her blog, with well made points on both sides.

With all the high-quality discussion and carefully thought-through points flying back and forth, I’ve taken a back seat on this one. I’m not sure that I have all that much that’s new to add, and I don’t blog all that much about medical matters any more. But a nagging feeling in the back of my head says that this is exactly the sort of debate I would once have jumped into with both feet, and the focus hasn’t been on the part of the guidelines to which I most object. So here goes.

In all guidelines, I’ve always been lead to believe that definitions are crucial. For a guideline to be effective, let alone for it to be enforced, it must be clear what it covers. And yet, the GMC’s definition of social media is absurdly wide:

Social media describes web-based applications that allow people to create and exchange content.

Later in the guidelines, it is clarified that this definition includes non-public, professional social networks too. As I’ve discussed this issue with tech friends and colleagues over the last couple of weeks, this definition has caused several to – literally – laugh out loud.

It, of course, includes all manner of things that are not social media, and essentially describes any form of cloud-based application. If we interpret this guidance as written, then from 22nd April patient-identifiable information can no longer be uploaded to web-based GP note systems, or to HPZone used by Public Health England to track outbreaks, or indeed transferred via NHSMail, the restricted-level security email system designed exactly for that purpose. Use of Choose and Book will be against the GMC’s rules. All of these are online applications which allow people to create and share content. All are clearly not supposed to be covered by this guidance.

It can be argued that even if the definition as written is unclear, it is perfectly clear to most people what it is supposed to refer to. I don’t buy that, for two reasons. Firstly, what’s the point in publishing the guidance at all if we aren’t to interpret it as written? Some might say that the definition has to be broad in a fast-moving environment, and that the guidance would quickly be outdated if it were too pinned down.

Which brings me to my second problem: you may understand it, but I don’t. I actually don’t know whether this guidance applies in edge cases. Office 365 and Google Drive are both web-based applications which allow the creation and exchange of content. Applications like these are almost certain to replace locally hosted applications like the Word and Excel of today within this decade. Indeed, some organisations have already made the switch.

Is use of these outlawed by the guidance? I can see arguments why it, perhaps, should be. There are inherent risks about patient confidentiality in these systems. But to ban their use for patient identifiable information is a big statement, and I suspect that they didn’t actually mean it. But I’m far from certain.

To me, the nub of the problem here is that this is guidance on using a particular medium – and one that is ill-defined, at that. Publication might feel relevant now, and everyone from the BMA to the RCGP is helping people to understand how to use this medium safely. But I don’t think this is the place of a regulator. I’m acutely aware that others will strongly disagree with this position.

By and large, I think the GMC should stick to outlining principles. I no more expect to see supplementary guidelines on social media use than I would on letter writing or telephone conversations. Although, if – like many hospitals – you’re using a VOIP system, it could be argued that these guidelines apply. Just like the GMC does with those two media, I think case studies would have been a better way to illustrate the application of principles, rather than a list of inflexible “rules”. I don’t think it’s sensible or advisable to try and give over-arching “explanatory guidance” about an area of life which is changing so rapidly.

After all, these are only supposed to be explanatory. They are not intended to introduce new regulation. Though, to my reading, their poor formulation does lead to new regulatory burdens being placed on doctors.

When the last Good Medical Practice was published, Twitter had barely been conceived, and Facebook had yet to open to the general public. These guidelines aren’t clear now, so goodness knows what we’ll think of them in seven years’ time. I think they should be withdrawn.

This is how you healthcare

Weekend read: This is how you healthcare



by sjhoward

This is the 1,991st post. It was published at 12:30 on Friday, 22nd February 2013.

I recommend an article I've read and enjoyed every Friday afternoon. You can browse all previous selections here.

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» Weekend Reads
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Sarah Bee published this moving story earlier this week over at NSFWCORP. Just occasionally, I come across a story that stops me in my tracks, moves me, and makes me think a little bit differently about life and medicine. This powerfully personal article about Sarah Bee’s experience as she watched her own father die in an intensive care unit in London is one of those stories.

How to lecture medical students

How to lecture medical students

How to lecture medical students

How to lecture medical students



by sjhoward

This is the 1,975th post. It was published at 11:44 on Tuesday, 15th January 2013.

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Lectures can, in short, bring a subject alive and make it more meaningful. Alternatively, they can kill it.

A true, but not altogether encouraging, sentiment in this excellent 2001 paper by Brown and Manogue, sent to me by Newcastle Medical School to help me prepare my first big scary lecture for their students.

“There is a lot of blood and unfamiliar aromas”

“There is a lot of blood and unfamiliar aromas”

“There is a lot of blood and unfamiliar aromas”



by sjhoward

This is the 1,969th post. It was published at 14:08 on Thursday, 10th January 2013.

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So given that I’ve stopped posting pictures of my face, I’m trying to record something in my scrapbook each day that means something to me – whether that’s something memorable that I’ve done in the day, something that summarises what I’m up to, something meaningful I’ve read, or something that’s brought back memories.

Today, I’m going for the final category. This article about autopsies* (I’d say post-mortems) from the Student BMJ really reminded me of my time studying Forensic Pathology in Calgary. The description of the autopsy process was particularly redolent of my experience, and the quote above certainly made me smile! The aromas were particularly unfamiliar when dealing with “decomps” – corpses that had lain decomposing for some time before being discovered!

It was a great experience, and I’m really glad I chose to take the opportunity to do something completely different to the rest of my medical career when I had the chance.

*You need to complete a free registration to read the whole of this article. Irritating, isn’t it?

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