Early exponents of evidence based medicine put forward an optimistic view of future healthcare, where the availability of robust information would allow clinicians to select the most effective treatments—and to stop doing things that were shown not to work. But this last part has proved elusive.

A recent paper by Sarah Garner and colleagues from NICE tested out the use of Cochrane reviews to identify low value practices which might inform local disinvestment decisions. NICE was criticised by the Health Select Committee in 2008 for lack of progress in supporting the NHS drive for efficiency savings. Very few technologies were identified as absolute candidates for disinvestment. Indeed, the authors noted that only two topics featuring low value practices had been selected in the last six years for full NICE guidance development. A really interesting contention was explored in this paper—greater certainty and levels of evidence were required for a “do not recommend” decision by NICE, than a treatment option left to the discretion of the clinician. This is because of the inevitable challenge (in the courts) if existing treatments are discontinued. more…

The NHS is in the middle of the transition from a publicly funded and publicly provided health service towards a publicly funded but increasingly privately provided service. It is thus following the course adopted in social care, with the closure of local authority owned care homes and the contracting out of service provision to commercial, charity, and other voluntary sector providers.

The management costs for commissioners involved in running the new model successfully are very substantial.  I have previously written about the costs involved in running tender processes, and warned that the NHS has not budgeted for the management costs involved in such processes.  However, the disclosure that Harmoni had been failing to provide sufficient doctors to staff its out of hours contract in north London raises an entirely different problem. more…

I spent yesterday at St George’s Hospital in Tooting, south London, talking to readers of the BMJ. The medical school library had organised an open day and a sales colleague had organised a BMJ stand, so I joined him to discuss our plans for the BMJ website with both qualified doctors and medical students. more…

The Royal College of Surgeons of Edinburgh (RCSEd) team has been here before, yet nothing from past experience can possibly prepare for being swept up by overwhelming excitement of entering the Augusta Victoria Hospital (AVH) on the Mount of Olives, towering over East Jerusalem. AVH is our host again for the third Basic Surgical Skills (BSS) Course for Palestinian surgical trainees.

The intensity of all the preparation work done by the UK and Palestinian members of the team is sealed with the joy of meeting old friends. Not only are we greeted with heartfelt hospitality, but every effort is made to obtain all materials for the course, despite difficulties inconceivable in the UK.   more…

I was fortunate to have the opportunity to attend a national summit on arts, health, and wellbeing across the military on 10 April 2013. It was held at Walter Reed National Military Medical Center (WRNMMC) just outside of Washington, DC.

I did not know a great deal about creative arts therapies prior to the event so I did some reading. They include creative arts like music, dance, painting, sculpting, poetry, drama, and writing. In the US there is a National Coalition of Creative Arts Therapies Association (www.nccata.org). Their mission is to promote the use of creative arts therapists who use arts modalities and creative processes to ameliorate disability and illness while optimizing health and wellness. The dividing line between art activities and art therapy is that the latter is done by licensed counsellors who seek to use art as a modality for psychotherapy and counselling, as a tool in improving communication and expression, as well as increasing physical, cognitive, and social functioning. So, it is art with a behavioral health component and/or outcome. more…

When buses in Glasgow started to come with posters asking if people were “Concerned about diabetes?” with an image of an older woman, a freephone number, and webpage for people “to find out about our health screening programme,” I wondered what was going on. Another bus advert said, “Do you have asthma? Register for a complimentary health check today and you could be part of our research into the future of asthma.” more…

Field Marshall Mannerheim of Finland is one of the giant, if relatively under fêted, figures of European history. Called out of retirement at the age of 72 to lead tiny Finland against the might of the Soviet Union in the Second World War, his achievements were not only to win two wars, but also to know when and how to sue for peace. It is this latter aspect which is almost certainly the most significant reflection of the wisdom of ageing and experience. more…

Recently in preparing a talk I was giving in Bologna I found a copy of a talk I’d given to WONCA, the world meeting of general practitioners, back in the era before Powerpoint existed, and it contained information on a study that has stuck in my head for 20 years, but which I couldn’t find. (And after 20 minutes of searching I still can’t find the study, but perhaps you can.) It’s a study that suggests that patients are regularly misled, even abused, because they are not given full information. more…

JAMA 15 May 2013  Vol 309
2016    I got into a bit of a muddle with this paper, but I blame JAMA. Let me test you out: the abstract says “Long-term follow-up of the randomized, masked 2-year Colpopexy and Urinary Reduction Efforts (CARE) trial of women with stress continence who underwent abdominal sacrocolpopexy between 2002 and 2005 for symptomatic POP and also received either concomitant Burch urethropexy or no urethropexy.” Then in the first section of the full text the cohort is described as from a “multicentre, randomized, masked trial in women without stress urinary incontinence (SUI).” Because I’ve never before heard women described as being “with stress continence,” and then randomized to incontinence surgery, my mind supplied the prefix “in.” Did yours? Anyway, let’s get this quite clear: the women in this study had pelvic organ prolapse without stress incontinence and they all got a procedure called abdominal sacrocolpopexy, by which the vaginal vault is fixed to the sacral anterior longitudinal ligament. Half of them also got the procedure called Burch urethropexy to support the urethra and hopefully prevent stress incontinence. They were asleep during the procedures and not told whether or not they had the Burch procedure. Stay with me—we are nearly there. At seven years, a lot of the sacrocolpopexy procedures had come adrift anatomically and the women who had the concomitant Burch procedure had less stress incontinence. So are you now clear about the message of this paper for patients and general clinicians? I can’t say that I am, but it is a nice piece of work and I hope that it will be of interest to urogynaecologists and those in the IDEAL collaboration who study surgical trial methods. more…

This is a serious blog about death, about what can go wrong in the dying process and how it can be put right. It arises out of an inquest where I represented a family member who found the medical and caring profession had misunderstood what was meant by a “duty of care” and tried to impose futile treatment on a dying elderly woman when she ought to have been allowed to die in peace and dignity.  I urge you to read on if you have the time because this is a case which shows what should not happen and, as a result of the decisions of the coroner to write formal letters under Rule 43 of the coroners rules, it might lead to changes in practice in this vital area of care. more…