david oliver helen salisbury the bottom line partha kar … 2019-09-12 · announced that prue...

The NHS always polarises opinion, and many who work there are constantly divided over whether we should highlight its faults or champion it as a great place to work. If we dwell on its faults we can seem like

shroud wavers, set on deterring the next generation from following in our footsteps. But, if we champion it unreservedly, we risk coming across as blindly optimistic evangelists.

I interact with enough junior doctors to know that they’re as dedicated to working hard and helping people as the doctors I trained with. It’s not their fault if today’s working hours are different and training shorter. Do today’s juniors moan more than their predecessors? Well, it’s more public now because of social media: on Twitter you can immediately offload your angst and frustration, which many people see as moaning. When I was in training two decades ago, when we complained about the system we did so in a pub, among friends. If we’d had social media would we have been any different from today’s junior doctors? Probably not.

Being a registrar was tough—never more so than when acting as medical registrar on call. Consultant coverage was rare, referrals were rubbish, we sometimes lost our cool, and the pay wasn’t great. (Anyone remember those additional duty hours?) But I suspect that we all knew where we were heading: we worked our time, the pay improved, and, in general, we had fun. The pressure of the working environment and the long working hours created a sort of trench mentality, and the concept of a team was ingrained. Does it still exist? A lot of people now would suggest this mentality is a rarity rather than the norm.

Then I became a consultant, and what can I say? Things get better. I do a job I love (the one I wanted to do), and I have amazing colleagues. The frustration you hear about from colleagues isn’t necessarily the work

itself but the lack of basic things such as tea and coffee or team lunches—compounded in no small measure by national bodies pontificating about which yoga mats to buy, while the basics aren’t dealt with. “How do you make your workplace better?” isn’t something to be discussed at a conference: it’s right in front of us, if we choose to look.

I know that some will disagree and tell you how rubbish life can be as an NHS doctor. But, having worked in other health systems, I’d say no, it’s not rubbish. It’s not Disneyland, but neither is it Mordor. There are ups and downs and frustrations, but, in the main, it isn’t bad. To anyone unsure of a future in medicine or the NHS, I’d say this: don’t leave. You’d miss out on the best part of the career you’ve worked so hard to build.Partha Kar is consultant in diabetes and endocrinology, Portsmouth Hospitals NHS Trust [email protected] this as: BMJ 2019;366:l5451

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the bmj | 14 September 2019 315

The NHS is not Disneyland, but neither is it Mordor. There are ups and downs, but in the main, it isn’t bad

THE BOTTOM LINE Partha Kar

The NHS really isn’t a bad place to work

“Several trusts spend less than £4 per patient per day on food” DAVID OLIVER “It seems lies are so commonplace it’d be naive to believe an MP” HELEN SALISBURY PLUS Tackling suicide among medical students; digital literacy in medicine

As a profession, we need to discuss suicide openly, and extend these discussions to include our colleagues and students. While there is

a tentative but increasingly emboldened literature around mental health problems and suicide in senior and junior doctors, there is little specifically about medical students.

Suicide is the most common avoidable cause of death in young people. There is currently no evidence to show that the prevalence of death by suicide in medical students is higher than in the general population (or indeed the wider student population), but there is an allied and growing literature around medical student perfectionism, anxiety, depression, burnout, and suicidal ideation. The data suggest that stigma and fear of fitness to practise sequelae inhibit medical students from seeking help.

There is little written about those students who actually end their lives and the impact

that this has on the medical education community. Anecdotally, clinical academics at medical schools who have been affected describe the devastating effects on family, but also on friends, faculty, and society. They talk about the legacy of the suicide of a student—shame, guilt, helplessness, sadness. While the scale of the problem is hard to quantify, the impact, precipitating factors, and potential solutions are difficult to tackle if we don’t acknowledge the problem.

Doctors are beginning to be more confident in role modelling their vulnerability, and discussing or writing about their mental health problems in an honest way. Like seasoned clinicians, students are vulnerable to stresses inside and outside of medicine. They can be affected by the uncertainty and powerlessness that clinical practice can engender.

In addition, students are subject to other stressors arising from their specific circumstances. Particularly in big cities and

large medical schools, some report feeling anonymous or that they don’t belong or aren’t valued. Many talk about isolation and feeling superfluous, especially in clinical placements where they can feel like spare parts.

Intense competition and pressureStudents enter medical school as laypeople and emerge as fledgling professionals, expected to navigate scary terrain. They can be affected by intense competition in an assessment driven climate where many medical schools rank students’ performance. Other contributors include financial pressures, as well as having to adjust to being “average” among their high achieving cohorts, having previously stood out as exceptional. Moving frequently between hospitals and wards on placement can generate anxiety too. There can be additional pressure to author publications and other CV building achievements from early on in medical school.

Increasing attention has begun to be paid to student wellbeing. Some medical schools are working with students and specialist services to co-produce suites of interventions including focusing on suicide, mental health weeks, and conversations about how to broach difficult topics and widen their reflective opportunities.

There is as yet no comprehensive longitudinal evaluation of whether these improve mental health, wellbeing, or even attrition rates at medical school or beyond

316 14 September 2019 | the bmj

PERSONAL VIEW Faye Gishen

Suicide among medical studentsWe have a duty of care to our future doctors

History often shows us the importance of adopting developments in healthcare. In the 19th century, for example, surgeons who didn’t use new antiseptic techniques had higher rates of infection than those who did.

Today, the newest medical tools are coming from computer science, yet few doctors have any programming skills and many workplaces are still waiting to update to Windows 10, let alone electronic notes or prescribing.This presents a strategic problem.

Doctors have a much bigger part to play in guiding technological developments and encouraging new systems to become more

user friendly, patient centred, and efficient. As things stand, however, much of this work is being left to commercial and political forces. I worry the profession, and patients, will be at the mercy of these forces until more doctors can combine clinical acumen with advanced software and programming skills.Is it really for doctors to tackle this? There are some good reasons why they should.

It’s important for senior doctors to engage more closely with the evidence base behind the interventions they use, shaping their development and contributing to a better understanding of the context in which we care for patients. My generation won’t be

BMJ OPINION Zack Hassan

Is digital literacy a blind spot in medical education?Medicine seems to lag behind other sectors on digital knowhow

able to do this effectively if we lack the skills to understand research generated by machine learning, or if we’re unable to manipulate the large datasets we’ve collected to see if it’s worth spending time on a research question.

The BMJ is running a wellbeing campaign, which you can follow at www.bmj.com/wellbeing. Take part on social media by sharing examples of things that are changing for the better or where more needs to be done using #giveusabreak.

into clinical practice. However, several higher education institutions still adopt the view that pastoral care is not part of their “core business,” and that adult learners should take full responsibility for their physical and emotional health. This mirrors the narrative that physicians—as opposed to healthcare institutions and systems—should take responsibility for their own health and wellbeing.

Profound effect of a kind commentThis is a difficult subject to discuss, and I acknowledge that it may resonate with and elicit sadness and other emotion. Indeed, a personal experience has made me want to write about this for some time. To many students—and indeed to any of us—the profound effect of a kind, encouraging comment from a clinician role model can be deeply affecting. I wish to ignite a conversation that in my experience as an undergraduate medical educator is rarely had.

We have long been told by our psychiatry colleagues that asking somebody if they are depressed or experiencing suicidal thoughts is not a catalyst for suicide and can be a simple and effective intervention. I suggest we acknowledge the problem, name it, and tackle it where appropriate as part of our wider citizenship roles and duty of care to our future doctors.Faye Gishen is consultant physician and associate head of MBBS, UCL Medical School, London [email protected]

Boris Johnson recently announced that Prue Leith, a judge on the Great British Bake-Off, would join the government’s review of

hospital food. He claimed that better food would aid recovery and “fuel patients.” Leith added that millions were wasted on “unpalatable” hospital food.

But the health secretary, Matt Hancock, had announced a “root and branch review” of hospital food back in June, before Johnson became prime minister. This will be chaired by Philip Shelley, ex-head of the Hospital Caterers Association.

Hancock’s original plan was in response to nine confirmed cases of listeria, which killed six patients. The cases were traced to pre-packed sandwiches and salads from one catering company, which supplied 43 hospitals. Crucially, Public Health England has followed up its investigation with a more detailed one focusing on foodborne infections. This is ongoing, separate from any grandstanding by Johnson or Hancock about the wider issue of quality.

We’ve been here before: governments hiring celebrity chefs and critics to demonstrate their commitment. Back in 2013 the BBC reported that this had wasted millions and had little impact. Last year the i newspaper described a long history of public concern over NHS hospital food and chronicled 21 initiatives to tackle it from 1992 to 2015.

Nutrition and hydration feature heavily in calls to the Patients Association and were central to its CARE campaign. Previous government reports, as well as the response to the Francis inquiry and the NHS Confederation’s Delivering Dignity, recommended better nutritional assessment and help with eating and drinking. In 1994 the National Audit Office recommended national standards for hospital catering. The issue remains of intense interest to voters and the media. What might be a more meaningful approach than a cycle of negative news

stories, set piece announcements, and failed or forgotten initiatives?

NHS catering has been privately outsourced at scale. I can’t see it being brought back in house at more than a few organisations. Even if it is, trusts increasingly put these staff into subsidiary companies for tax purposes. Many staff preparing and delivering food for wards are on low wages. NHS Digital data from 2016-17 showed that, for 144 million inpatient meals each year, hospitals spent on average £11 per patient per day (but with wide variation). In several trusts it was less than £4.

The Sunday Times journalist Jenny McCartney recently quoted another former head of the Hospital Caterers Association who praised centralised mass catering, with pre-cooked meals delivered to hospitals for reheating. Whatever we think of this, surely experienced caterers—delivering thousands of meals each day to a tight budget in NHS hospitals and drawing on local advice from dietitians—have as much relevant expertise as food critics or high end chefs with far higher budgets.

If we’re serious about hospital food we should fund, value, and regulate it better.David Oliver is a consultant in geriatrics and acute general medicine, Berkshire [email protected] Twitter @mancunianmedicCite this as: BMJ 2019;366:l5369

Psychiatry colleagues tell us that asking if somebody is experiencing suicidal thoughts is not a catalyst

If we’re serious about hospital food we should fund, value, and regulate it better

ACUTE PERSPECTIVE David Oliver

Publicity stunts and hospital food

BMJ OPINION Zack Hassan

The medical profession seems to be lagging behind other sectors when it comes to digital knowhow. When budgets are strained ever tighter, this is to our detriment—a lot of time and money could be saved by exploiting big data, automation, and machine learning. Medical education and training in the 21st century needs to promote higher levels of digital literacy. After all, it is the medical profession who are best placed to realise the potential applications of new technology and to decide how they should be implemented.Zack Hassan is a foundation year 1 doctor, colorectal surgery, Western General Hospital, Edinburgh


When my patients tell me their symptoms they put their trust in me: they trust me to listen attentively,

to examine carefully, and to investigate thoroughly. They trust me to keep their confidences and to follow up as promised.

Above all, when they ask me a question they trust me to tell the truth as far as I know it. If I fall short in any of these areas I am likely to lose their trust—and then I’m not much use to anyone. I also risk losing my medical registration.

The same applies to all doctors, and we guard our reputations carefully, so it is a big deal to be accused of deliberately misleading the public—as David Nicholl, a consultant neurologist, was accused by the Tory MP Jacob Rees-Mogg last week on LBC radio. Nicholl had been involved in planning to mitigate the adverse effects of Brexit on pharmaceutical supplies. His well informed worries were dismissed as “scaremongering” by the politician.

Worse still, under cover of parliamentary privilege, which averts the possibility of being sued for defamation, Rees-Mogg then compared Nicholl to the disgraced ex-doctor Andrew Wakefield, who was struck off the medical register in 2010 for falsifying his research and fraudulently claiming that the measles, mumps, and rubella (MMR) vaccine caused autism.

Rees-Mogg eventually apologised for this calumny, but

not before he had been roundly rebuked by Sally Davies, the chief medical officer for England.

When members of the public are asked whether a given professional is likely to tell the truth, doctors are considered to be significantly more honest than politicians: (92% versus 19% ). As that particular poll by Ipsos MORI was done a year ago, the public’s trust in politicians may now have fallen further.

In science and in medicine we assume the veracity of our colleagues—it’s difficult to see how else we could operate—and it’s still a shock when we discover fraud and lies. In politics, meanwhile, it seems that lies are so commonplace that it would be foolish or naive to believe a politician.

The informal system of gentlemen’s agreements and codes of honour, which in previous decades led to resignations if a politician was found to have lied, no longer seem to be working. Perhaps what we need now is a register, as in medicine, with some minimum competences required for anyone to be eligible to be a member of parliament. Politicians who are dishonest or corrupt could then be struck off, becoming ineligible to stand for further elected office.

There is a long way to go, but perhaps that could start to rebuild our trust in

politicians.Helen Salisbury is a GP in Oxford

[email protected] x.ac.uk Twitter @HelenRSalisbury

Cite this as: BMJ 2019;366:l5477


Catch up on all of The BMJ’s latest podcasts at bmj.com/podcasts

Perhaps what we need is a register, as in medicine, with some minimum competences for anyone to be eligible to be an MP

Edited by Kelly Brendel, deputy digital content editor, The BMJ

Planning for BrexitAs uncertainty over Brexit grows, The BMJ’s Duncan Jarvies talks to Natasha Azzopardi Muscat, president of the European Public Health Association, about what it means for the whole of European public health. Here, she talks about the implications for the mutual recognition of doctors’ qualifications in EU countries:“We do know that the British NHS is quite reliant on a pipeline of doctors and nurses from EU countries. The reciprocal side to that is that Britain, for many years, has acted as a fertile training ground for EU nationals—they spend time providing a service in Britain, but also gaining exposure to some of the top medical centres in Europe. If common sense and goodwill prevail, then it would be in everyone’s interest to allow those qualifications, which are not going to change overnight, to continue to be recognised.But we haven’t seen much common sense or goodwill prevailing, which would have given us the confidence that these kinds of barriers can be overcome quickly or easily.”

Tackling burnout in the Netherlands“Hospitals are not hiring ill employees or ill physicians. No, they're hiring healthy physicians that become ill by their work and the system they are in.” So says Karel Scheepstra, a psychiatrist and researcher who is working on a new programme in the Netherlands to see whether an intervention to prevent burnout or other mental health problems in doctors can be implemented. He joins this podcast to discuss what we know about burnout in Dutch doctors, and what this new research hopes to uncover.

PRIMARY COLOUR Helen Salisbury

Trust and truth tellingLATEST PODCASTS


The independent inquiry into Liverpool Community Health NHS Trust announced in June 20191 is the

culmination of a well worn path. Concerns about care are raised

and ignored, staff are denigrated or bullied, the situation escalates into whistleblowing to outside authorities, and eventually—often years later—a formal inquiry is set up to get to the bottom of things.

The long line of inquiries in the UK and elsewhere highlights the sentinel role of staff “speaking up” when they see unsafe or poor quality care.2‑4 But exhortations to speak up (encapsulated by the statutory duty of candour introduced in the NHS after the Francis inquiries into failures at Mid Staffordshire NHS Trust4 5) belie the complexity and ambiguity that it creates for staff.

KEY MESSAGES

• Frontline health professionals are often best placed to identify substandard care and alert colleagues and managers if patients are at risk

• Staff can be afraid to raise legitimate concerns and have sometimes been bullied and victimised for doing so

• Managers need to redouble efforts to create the right organisational environments where frontline voices can be aired and responded to appropriately

• Management education and leadership training must find ways to encourage this

ANALYSIS

How to raise and respond to concerns in healthcare settings

Frontline staff are well placed to identify failings in care, but speaking up requires a supportive organisational culture to be effective, say Russell Mannion and Huw Davies

Individuals voicing concerns should be commended for their insights, but sometimes their observations are unwelcome


Ambiguity

Raising concerns about care can be as simple and everyday as making an observation or suggestion to colleagues while delivering care. Informal commentary or intervention, gentle reminders, humour, or sarcasm may be used to draw attention to perceived concerns.6

If this doesn’t work, staff have the option of stronger measures such as more explicit conversations; drawing the attention of coworkers and line managers to the concerns; placing critical observations “on the record” within formal accountability, appraisal, or performance management systems; or seeking remedial action plans.

If the problem still remains they can leapfrog traditional line management hierarchies to report to someone more senior. As a last resort staff may decide to “blow the whistle”7 to outside authorities (such as regulators, professional bodies, or trades unions), political representatives, or the media.

Individuals voicing concerns should be commended for their insights and challenge, but sometimes their observations are unwelcome because they draw attention to personal and collective failings or to irresolvable problems and tensions. Staff raising concerns may then be perceived as unhelpful—denigrating services, fracturing organisational relationships, and damaging professional and organisational reputations.

As the stakes get raised, competing narratives begin to form and harden

around what can be quite ambiguous circumstances or events. These narratives can quickly extend to impugn motives, competencies, and even sanity, personalising disputes and making them harder to resolve. Crucially, decisions about whether concerns affect safe and high quality care are often not clear cut. In pressured systems, differentiating “sufficient but stretched” resources (such as staffing) from “insufficient and unsafe” resourcing is complicated. Local narratives about “coping under pressure” may stop staff from identifying risk, and a lack of objective standards can lead to the gradual expansion of what is seen as acceptable.8

Moreover, it would be naive to assume that all those voicing concerns are driven entirely by genuine concerns: some may be motivated, at least in part, by work grievances or personality clashes. Allegations may even be malicious. Importantly, the motivations behind actions (both of raising and of responding to perceived concerns) may be partially obscured, even to the protagonists.

Speaking up is thus complex. There is no simple binary choice between voicing concerns and keeping silent, and lack of visibility has given rise to the pejorative notion, sometimes promoted in the media, that healthcare professionals are culpable bystanders who tolerate poor standards of care. Instead, we need to focus on what can be done to support healthcare professionals in speaking up and ensuring they are listened to.

Supporting and inhibiting speaking up

Although some research suggests that there are relevant individual factors that can promote clearer articulation of frontline concerns, situational factors are also important (box). Many of these relate to the local organisational culture,9 especially the presence (or absence) of “psychological safety” and the normative expectations about the giving and receiving of feedback.

Also important are the degree of social cohesion in the care team, the attitudes of senior leaders,10 and the presence (or absence) of authority gradients, professional demarcations, and deference.

Expectations about responses within the system are especially powerful. An open culture where transparency, participation, and feedback are encouraged can be conducive, whereas expectations of inaction or retaliatory action are clearly inhibitory. In this, the expectations around speaking up can be difficult to disentangle from the broader managerial culture around performance and accountability.

Factors influencing speaking up11

INDIVIDUALConfidence in personal knowledge The more staff trust their judgment the more likely they are to report poor carePersonal control Perceptions of autonomy at work can improve the likelihood of speaking upCommunication skills The ability and confidence to speak assertively and critically is important for speaking up and can be learntSeverity of (perceived) risk The higher the perception of the potential harm to patients the greater the likelihood of reportingNature of the concerns Some studies suggest that doctors are more likely to speak up about traditional threats to patient safety (eg, staffing and equipment shortages or organisational disruption) than about a colleague’s unprofessional behaviour or substandard performancePerceptions of effectiveness of speaking up When health professionals believe their concerns will be acted on they are more likely to report

SITUATIONAL FACTORSNational context Government policy, media coverage, the action of interest groups, ethical codes and guidelines promoted by professional bodies, and the care standards expected by national regulators all affect willingness to speak up and how people respondReliance on colleagues for educational or professional advancement This can be a powerful inhibitor of speaking upBoard and managerial cultures and competencies10 Confidence that an organisation will respond affects decisions about speaking up

Hierarchies and job specialisations can contribute to a tendency to downplay or sidestep unwelcome news


Speaking up is only the first step; concerns also need to be heard and addressed. Senior clinicians and hard pressed managers may be reluctant to acknowledge, accept, and act on concerns from the frontline, especially when these are relayed by staff with less seniority.

Sometimes the concerns raised simply do not register, being lost in the daily hurly burly; at other times they may be noted but downplayed or considered as misplaced, unimportant, or irrelevant. Hierarchies and job specialisations can contribute to this tendency to downplay or sidestep unwelcome news, as can pre-existing narratives of success or competing priorities or crises that monopolise managerial attention. In extreme cases, those that raise concerns may be harmed by their actions, including being disciplined or reported for misconduct to professional bodies.12

Attempts to use speaking up as a means of improving services need to attend to these organisational dynamics that resist the emergence of bad news. In highly stratified and hierarchical organisations, such as most healthcare facilities, the entrenched status and power differences between different professional and occupational groups (eg, between nurses and doctors, or between frontline staff and managers) are a key part of this. Moreover, just as the actions of those voicing concerns may be complex, variably motivated, ambiguous, and contested, so too can be the responses of those in authority (within and outside the organisation).

While an unwillingness to hear and resistance to change are common, positive responses include openness to further inquiry, shifts in attitudes and understanding, and direct actions that support beneficial change. Understanding how to encourage these positive actions is essential.

It is widely recognised that speaking up takes courage, but it is less obvious that it may also require courage to accept that the concerns raised have merit. When a manager acknowledges the need for change, they are taking on the responsibility of acting. This may require challenging colleagues,

changing routines, redirecting resources, and speaking up to higher authorities, with all the risk and exposure that that entails.

The notion of “shooting the messenger” extends to those who have to convey frontline concerns to other parts of the system, so supporting “hearer courage” and protecting those who relay unwelcome messages may be as important as supporting speaking up in the first place.

A study of senior managers identified two broad categories of behaviour that the authors termed “problem sensing” and “comfort seeking.”13 In problem sensing, managers seek out issues and concerns, drawing on a wide range of hard data and soft intelligence. In contrast, comfort seeking arose when managers limited their purview to reassurances from limited sources that systems were compliant with regulatory standards and that everything was fine. When comfort seeking behaviours predominate managers can disassociate themselves from the raising of frontline concerns. Moreover, powerful systematic biases in group and team decision making, such as strong group affiliation and groupthink, can make healthcare professionals less willing to hear and respond to concerns about unsafe care.14

Encouraging people to listen, supporting courageous actions through protective policies, and countering inward looking and self comforting dynamics can help support an effective response to frontline concerns. The key is to create space for engaged and curious dialogue.15

Positive agenda

It is important to recognise the diversity in the willingness of frontline staff to speak up and of organisational actors to listen. The figure below shows how this diversity can give rise to different dynamics. Too often, healthcare organisations reside in the bottom left quadrant of the figure, where staff are unwilling to speak up and more powerful people in the organisation are unwilling to hear troublesome messages. Such a dynamic can be heavily self reinforcing.

In organisations where speaking up has been encouraged, or even mandated (as in the NHS), unless the local organisational dynamic is also changed those speaking up may be vulnerable and speaking up is unlikely to be maintained.

A longer term goal of both policy and operations management should be to move to a virtuous dynamic of local learning that would obviate the need for powerful but cumbersome legal safeguards. It remains to be seen whether the creation of freedom to speak up guardians in the NHS will alter the entrenched dynamics we have described. Recent exploratory work in the US aimed at supporting such a transition used confidential interviews to identify the reasons why staff were reluctant to speak up, followed by carefully tailored interventions to encourage voice and build local capacity for holding difficult conversations.16 Such intervention strategies hold great promise but need further development and testing.11

In summary, speaking up cannot simply be mandated by policy diktat or ensured through legislative change, although both may play important supporting roles. Reform is needed in all parts of the system, but better encouragement of diverse frontline voices and sustained managerial support for effective response to those voices are paramount.Russell Mannion, professor, Health Services Management Centre, University of Birmingham, [email protected] Davies, professor, School of Management, University of St Andrews, FifeCite this as: BMJ 2019;366:l4944

Virtuouslearning

Vulnerablevoices

Disengagedworkforce

Collusionin silence

Organisationalopenness to

frontline voice

Speaking upencouraged

Speaking updiscouraged

Organisationalresistance tofrontline voice

Dynamics of speaking up and being listened to in healthcare organisations. The aim should be to move to a truly learning organisation with an open culture

A longer term goal of both policy and operations management should be to move to a virtuous dynamic of local learning

Refocusing on hearing and acting


LETTER OF THE WEEK

Preventing institutional abuseMurphy’s editorial on Whorlton Hall describes the institutional abuse of vulnerable patients that continues despite improved safeguarding training, care home environments, and regulatory systems (Editorial, 27 July).

Beadle-Brown et al argued that just moving people out of institutions into community settings does not improve quality of life, especially for people with more severe intellectual disabilities and complex needs such as challenging behaviour. Community services are needed close to vulnerable patients’ homes and families, particularly accessible positive behavioural support. There remains little substantial evidence of effective interventions for preventing abuse of people with learning disabilities and elderly people.

We support Murphy’s call for substantial investment in community services. We call on the National Institute for Health Research to fund research in safeguarding and preventing abuse in institutional care. NHS England’s Transforming Care programme needs an ongoing replacement that includes enhanced emphasis on the care of children and young people and on managing transition to adulthood, with the Care Quality Commission to evaluate measures such as quarterly corrective and preventive action plans.

The situation has been compounded by multiple delays in publishing the government green paper on social care, which seems to have intensified local councils’ rationing of much needed community care. In addition to central changes, all healthcare professionals visiting institutions must be vigilant to detect signs of abuse and take responsibility for raising safeguarding concerns early. The Royal College of General Practitioners’ adult safeguarding toolkit is useful guidance for primary care health professionals

Inevitably further abuses will come to light at other care institutions, but we must continue to minimise the risks and work at both a system and an individual level to improve the quality of life of all vulnerable people.Matt Hoghton, GP, BristolKirsten Lamb, retired GP, Harpenden


LETTERS Selected from rapid responses on bmj.com

GAMBLING

Lacking longitudinal dataOur knowledge on the numbers affected by gambling related harm, the types of harm, and how these change over time is hampered by the absence of data (This Week, 27 July). The last British Gambling Prevalence Survey was conducted in 2010 and questions about gambling participation and behaviour are not regularly included in the Health Survey for England.

The Gambling Commission collects and publishes statistics about gambling participation and problem gambling, but we lack longitudinal data about the trajectory of individuals’ gambling participation and behaviour over time and their help-seeking behaviours.

Local authorities could be encouraged to engage with similar

initiatives given their role in licensing gambling environments and their responsibility for improving public health and wellbeing. Insights into gambling related harm affecting local communities will help to identify unmet needs, which could inform commissioning of treatment services and help develop professional expertise in prevention and response.Stephanie Bramley, research associate;Jill Manthorpe, professor of social work;Caroline Norrie, research fellow, London


Capturing “decision regret”Kar asks whether genuine choice is possible in the NHS (Partha Kar, 27 July). Consenting clinicians do not always explain the treatment options and choose the one that they think is right for the patient. This is usually what the multidisciplinary team or the guidelines recommend. But most recommendations don’t consider the patient’s preference.

Patients might be prepared to accept less successful outcomes to avoid surgery or a stoma. They might not know what is best for them, but they know what they don’t want and what they can’t cope with. They are the ones who must live with the consequences of the treatment they receive.

We are trying to capture this “decision regret” in our national database of patient reported outcome measures for contact x ray brachytherapy (Papillon technique), which is supported by NICE. We do not need level one evidence or a randomised trial for this. Arthur Sun Myint, lead clinician, Papillon, Wirral


Ethical duty to taxpayersKar expresses a dilemma that is well recognised, but often ducked, by medical sociologists. In 1951 Talcott Parsons said that the claims of sick people were conditional on their compliance with the recommendations of recognised experts and on their demonstrated commitment to recovery, or at least the minimisation of their needs or demands for care.

Fundamentally, however, the care that sick people receive, whether funded by tax or insurance, depends on the extent to which those who are well are prepared to pay for it. In a system like the NHS, health professionals are morally obliged to provide care that is efficient, effective, equitable, and reasonably humane—not to meet every patient wish. This is their minimum ethical duty to the taxpayers who fund the service. Should patients want something different, they can pay for it or seek to raise funds to pay for it—which is a potential, but legitimate, source of inequality.Robert Dingwall, professor, Nottingham


PATIENT CHOICE IN THE NHS


TALKING ABOUT DEATH

Normalising conversations about death and dyingOur healthcare system does not create an environment in which professionals can easily talk about death and dying with patients, their families, and those important to them. As Salisbury says, this process that requires care, delicacy, and time (Helen Salisbury, 6 July). In our stretched system, this is difficult to accommodate.

We are all trying to do our best. Harbouring the expectation that someone else—the GP, the hospital specialist, or the palliative care team—is best placed to hold these difficult conversations will not help patients and can create friction in collaborative care.

Health professionals alone should not be expected to begin discussions about end of life care and people’s wishes. Our wider societal attitudes need to change and normalise conversations about death and dying.

Improving the care we can provide for those at the end of their lives is everyone’s

Clinicians need time, not videoconferencing

ECHO (extension for community healthcare outcomes) seems to be less disruptive innovation and more a product patented in the United States being sold to the NHS as “something new” (New Models of Care, 20 July). We used to have fantastic liaison with outreach education from hospitals by specialists. We still have hospital based education sessions, but fewer of us are able to attend, largely due to relentless escalation of non-clinical meetings for management, commissioning, audit, referrals, pathways, prescribing, and more.

Perhaps hailing ECHO is an acknowledgment that we have lost something vital to medicine: the cohesion of clinical networks where clinicians support and educate each other to keep pace with evidence, to inspire debate, and to achieve the best outcomes for patients.

ECHO might have better functional videoconferencing than the NHS, but that just highlights the lack of will to develop the best technology for, and by, the NHS.Nick Mann, GP, LondonCite this as: BMJ 2019;366:l5156

ECHO director: “We are committed to building support and trust”Mann highlights concerns about liaison between primary and secondary care expressed by general practitioners across the United Kingdom in these days of ever increasing pressure.

As a GP, I hugely valued the opportunity to learn from and be supported by my colleagues at the local district general hospital on Friday lunchtimes. Sadly those days have all but disappeared across the UK as the demands on practice have exploded. My hope is that, for some, ECHO could provide an opportunity to regain a little of that major loss by enabling regular contact and helping rebuild trust between primary and secondary care.

One of our recently started ECHO networks, called Mind the Gap, links a district general hospital with its primary care community with the specific goal of improving understanding of problems on either side of the referral-discharge interface. ECHO is committed to building trust and support through collaborative problem solving across such interfaces rather than any particular software package.

There is no financial cost of engaging with Project ECHO, which has been supported by philanthropic and government funding in the UK. The approach has been helpful in a wide range of countries and healthcare systems across the globe.

The ECHO patent, about which Mann expresses concern, is not linked to any particular videoconferencing software nor is it focused on preserving the commercial success of Project ECHO. The patent was taken out to prevent ECHO from being used by those who would seek to make commercial capital out of the methodology.

If in the future nobody remembers the name ECHO but the movement has encouraged a more collaborative, networked, and less siloed way of caring for patients in our hard pressed NHS, that will be a huge success for ECHO in the UK.Max Watson, director of Project ECHO and consultant in palliative medicine, Hospice UK, London


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responsibility—clinicians, managers, commissioners, politicians, and society.Christina Chu, palliative medicine registrar, LondonCite this as: BMJ 2019;366:l5041

DO WE NEED INTEGRATION?

No basis for integration in the NHSThere is little rationale for more “integration” in the NHS, and the choice of word reflects an error in understanding the problem (Helen Salisbury, 20 July).

When we talk about integration we think of removing the barriers between separate organisations. But this assumes that organisational boundaries are the reason why patients don’t get coordinated care. This is a serious and misleading error.

If the barriers to coordination of care were external, then care inside single large NHS organisations, like major hospitals, would be smooth and well coordinated. It isn’t. Most hospitals can’t even organise coordination between their pharmacies and discharge teams; delays to prescriptions and

drugs to take home often add long delays to discharges.

The biggest, most harmful, barriers to coordinated care are operational, not organisational. To assume—as the drive for more integration seems to—that merging organisations will improve coordination is not just wrong, it is harmful as it diverts scarce management talent away from operational improvement into futile organisational restructuring.

If the NHS was right that integration is required for coordination, the world would look very different. Mobile phone users wouldn’t be able to call a friend on a different network. The internet would not work, and Apple customers would not be able to use services built on Android or Microsoft systems.

The rest of the economy is based on competitors working out how to make their competing systems work smoothly together. The NHS is pursuing a goal that is not just wrong but harmful.Stephen Black, data scientist, Biggleswade Cite this as: BMJ 2019;366:l5163


OBITUARIES

Vijyarangam Senthilkumar ShanmugamSenior neurology registrar (b 1975; q Madurai Medical College, India, 2000; MRCP (UK), MRCP (Neurol)), died from renal carcinoma on 1 June 2019Vijyarangam Senthilkumar Shanmugam (“Kumar”) was an incredible, brave, and sincere doctor. On the eve of his finals, while visiting the temple, he broke his arm, swerving his motorbike to avoid a child who had run into the road. He eventually had it plated in hospital (but only under light anaesthesia and eschewing painkillers that could affect his concentration). In the UK, he obtained a national training number in neurology and passed the national exit examination first time. In January 2019 he secured a national stroke training fellowship. He attended that interview only two weeks after undergoing major abdominal surgery for what proved to be renal carcinoma. He leaves his wife, Rajeswari, a GP in training; and two sons.Damian Wren, Camilla Blain, Niranjanan Nirmalananthan, Anthony Pereira Cite this as: BMJ 2019;366:l4883

John Kenneth RobertsFormer general practitioner and orthopaedic clinical assistant (b 1934 q Manchester 1959), died from chronic obstructive pulmonary disease on 29 June 2019After house posts John Kenneth Roberts (“Ken”) joined a singlehanded practice in Llanfair PG. He also worked four sessions a week in orthopaedics as a clinical assistant. The work became too onerous after 10 years, and he moved to a practice in Timperley, where he spent four years. He then received a call from Victoria Terrace, Holyhead, offering immediate partnership, so he moved back to Anglesey. He spent many happy years with his partners and working at the local cottage hospital. Because of ill health Ken took early retirement in 1994. He was involved with archaeological digs, travelled, and conducted tours of St Cybi’s Church in Holyhead. He leaves his wife, Margaret; two children; and four grandchildren.David Williams Cite this as: BMJ 2019;366:l4900

John WalesConsultant general and respiratory physician, Leicester (b 1940; q Cambridge/Barts 1965; MA, FRCP), died from vascular dementia and stroke on 11 April 2019John Michael Wales undertook junior posts in Warwick and Southampton before being appointed consultant physician at Groby Road Hospital, Leicester. Respiratory medicine was then still associated in many minds with tuberculosis officers working in isolation in sanatoriums. John arranged, against some opposition, for the hospital to share in the general medical take with the other hospitals in the city, thereby raising the tenor of both the hospital and the specialty. Later he was instrumental in the development of Glenfield Hospital. He was regional adviser and a member of council for the Royal College of Physicians. He had an encyclopaedic knowledge of railways, closely followed by snakes and the Titanic. He leaves his wife, Caroline; two children; and six grandchildren.John Cookson Cite this as: BMJ 2019;366:l4879

Barry BrayGeneral practitioner Guernsey and Lewes (b 1940; q Guy’s Hospital 1963), died from a cerebral haemorrhage on 13 March 2019After his preregistration jobs, Barry Bray obtained his diploma in anaesthetics, but then followed his love of general medicine and paediatrics. He worked at Hither Green Hospital, where he met his future wife, Angela, and passed his membership examination for the Royal College of Physicians. Subsequently he moved to Guernsey, Channel Islands, where he worked in general practice and in hospital, incorporating all his special medical interests. As his family grew older, he moved back to the mainland near Lewes, where he worked as a singlehanded practitioner until his retirement. In retirement he studied for and obtained a degree in law (LLB London) and served on the East Hoathly Parish Council. Predeceased by one grandchild, he leaves his wife, five children, and eight grandchildren.Edward Bray Cite this as: BMJ 2019;366:l4881

Thomas Gruffydd DaviesConsultant psychiatrist Cefn Coed Hospital, Swansea (b 1931; q Welsh National School of Medicine, Cardiff; 1960; MD, FRCPsych, DPM, FSA), died in his sleep on 26 January 2019Thomas Gruffydd Davies (“Tom”) was a consultant psychiatrist at Cefn Coed Hospital, Swansea, from 1972 to 1990. His post was in general psychiatry, and for most of this time he was responsible for the lower Swansea valley. He gave this post-industrial area an excellent psychiatric service and was committed to postgraduate education. After stepping down from the NHS he channelled his considerable energies into his abiding passion—the Welsh language and its culture, local history, and the history of medicine. Regular publications appeared up to the last year of his life. Tom remained an unassuming modest man, true to his Welsh roots. He died after a period of gradual physical decline and leaves his wife, Rosina; two children; and two grandchildren.Donald Williams Cite this as: BMJ 2019;366:l4884

Hugh Shuter PlattChemical pathologist and diabetologist Basingstoke and Southampton (b 1933; q 1958; OBE, MD, FRCPath, FRCOphth, FRCP), died from cardiac failure on 4 February 2019Hugh Shuter Platt was a lecturer in histopathology at University College Hospital in Ibadan, Nigeria, in the 1960s. He considered his time there as the most formative of his life and gave his two daughters Nigerian names. He returned to England in 1965 and was appointed consultant chemical pathologist at London’s University College Hospital in 1971. In 1974, attracted by the prospect of helping to set up a new hospital and working in the new medical school in Southampton, Hugh was appointed consultant in Basingstoke and pioneered a community diabetes service. In 1992 Hugh became the postgraduate dean for Wessex. After retiring in 1999 he became part time director of studies for the Royal College of Pathologists. He leaves his wife, Christine, and two daughters.Gifford Batstone Cite this as: BMJ 2019;366:l4880

Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]


Racism was a fact of life in the southern US in the mid-20th century. There were stores downtown that you knew you couldn’t go in as a black person, LaSalle Leffall recounted in an oral history interview with the US Library of Congress. Public accommodations such as drinking fountains and bus waiting rooms were clearly labelled for either “white” or “colored” people.

EducationStill, he began life with several advantages. His father had graduated from college at a time when less than 5% of Americans had access to higher education; for minorities the number was smaller still. His father, LaSalle Doheny Leffall

Sr, was principal of the blacks-only high school in the town of Quincy, near Tallahassee, Florida. That position ensured the family largely avoided the direct ravages of the Great Depression. Interest in medicine was cultivated by his godmother, Annie Kent Stevens, wife of the only black physician in town. But what clinched the deal was finding an injured bird, at the age of 9 or 10, splinting its broken leg, and seeing it recover.

But the path was blocked for the talented young man. All of the medical schools in the south were segregated, not open to blacks, and the northern medical schools that accepted a few black students generally

chose from among their own undergraduate university ranks.

Leffall applied to the two medical schools that at that time trained the overwhelming majority of black physicians in the US, Meharry in Nashville, and Howard University Medical School in Washington, DC. Both turned him down, largely because of a poor showing on one section of a standardised test, subject matter his schooling had not covered.

A college mentor, William Gray, travelled to Washington to plead his case, and Leffall was accepted. It created a bond that would last more than half a century and prompt Leffall to say,” I owe Howard a debt that I can never repay, I can only make instalments.”

One of his teachers there was Charles R Drew, who was responsible for many of the innovations that made the modern blood bank possible. Leffall was at the last lecture Drew would deliver before dying in a fatal car accident that night, in 1950, at the age of 45; decades later Leffall would be honoured with the first endowed chair in Drew’s name at Howard.

Leffall excelled at Howard and in his residency. Drawn to surgery because “you took it out and the patient got well,” rather than treatment of chronic conditions, he secured a coveted fellowship in cancer surgery at Memorial Sloan-Kettering Cancer Center in New York, just the second African-American to train there. It was an exciting time, with innovations being made in radiation and chemotherapy.

Leffall was drafted and served as chief of general surgery at the US Army Hospital in Munich, Germany, where he became proficient in German, to add to the French he already spoke. Howard welcomed him back in 1962,

where he quickly rose to become chairman of the department of surgery, in 1970, a position he held for 25 years.

Over the decades he taught more than 6000 medical students and 300 surgical residents, influencing several generations of doctors who were drawn to Howard as the crown jewel of America’s historically black colleges and universities.

Champion of minority healthLeffall served as the first black president of the American Cancer Society, where he championed issues of minority health. He had a similar role as president of the American College of Surgeons and as chairman of the board of the large charity then known as the Susan G Komen Breast Cancer Foundation. In 2002 he was appointed to and later chaired the President’s Cancer Panel, which advised the White House on policy matters.

Leffall was a large man with movie star good looks, a willing smile, and vestiges of the deep south in his voice. “He was larger than life. He could impress you with being a nerd in many respects, but he was also a nerd with a personality and a tremendous sense of humour,” Otis Brawley told The BMJ. The former chief medical officer of the American Cancer Society worked with Leffall on numerous projects over the decades.

While Leffall retired from performing surgery in his 70s, he continued to teach and mentor students until near the time of his death. Services were held at the Washington National Cathedral. He leaves his wife, the former Ruth McWilliams; a son; and a sister.Bob Roehr, Washington, DC, USA [email protected] this as: BMJ 2019;365:l4342

Leffall was drawn to surgery because “you took it out and the patient got well,” rather than treatment of chronic conditions

OBITUARIES

LaSalle LeffallGroundbreaking American surgeon and educator

LaSalle Doheny Leffall Jr (b 1930; q Howard University College of Medicine 1952), died from cancer on 25 May 2019

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