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Richard Smith

Richard Smith: Commissioning needs to be about all public services not just health

5 Feb, 16 | by BMJ

richard_smith_2014Parliament has three times relegislated the commissioner provider split—in 1990, 2002, and 2012, said Stephen Dorrell, secretary of state for health from 1995-97, in a talk to the Imperial College Centre for Health Policy this week. Every health secretary for the past 26 years—with the exception of Frank Dobson—has believed in commissioning. But, he asked, how does it work, how should it work, and how might it work in the future?

The concept, Dorrell said, is simple: the commissioners should start not with existing institutions and ways of doing things but with the needs of individual citizens. They should then set priorities and find the best way to meet those needs paying attention to quality and value for money. They should be open minded and not bound to existing providers. Commissioning, argued Dorrell, provides our best chance of reshaping the care system, which we badly need to do and have so far failed to do. more…

Richard Smith: Calculating our debt to the old

21 Jan, 16 | by BMJ

richard_smith_2014My mother, who has had no short term memory for nine years, has lived in a nursing home for almost three years. I visit her most weeks, but I constantly fret if I should visit her more or less. What, I ask you, reader, is the way to calculate the right amount of time to visit? In most countries the old are increasing and the young decreasing (I’m on the border): most of us will face calculations on how we deal with the old, and many of those calculations will be much more difficult than mine.

If I was living in a low or middle income country my question wouldn’t arise. People from those countries, perhaps Africans or Bangladeshis, would never put their mother into a home. They have great respect for the elderly, and an elderly parent, no matter how infirm, would live with them, probably in an extended family. They see it as a moral failing of our society that we will hand over the care of our parents to others, people who have never known them when young and active. more…

Richard Smith: Gawping at death

15 Jan, 16 | by BMJ

richard_smith_2014Around 4000 people a day visit El Museo De Las Momias (The Mummy Museum) in Guanjuato, making it one of the most popular tourist sites in Mexico. Some queue for an hour or more. Why do they go? Why did I go with my family?

The museum contains about 100 mummies. These are not mummies wrapped in bandages but desiccated corpses with skin, hair, teeth, wounds, and the remnants of clothes. Most look as if they are in agony with their mouths screaming. Their look is probably caused by the processes of death rather than agony, but the museum speculates proudly about one woman being buried alive because her catalepsy was misdiagnosed as death. Several of the corpses have been identified, including the French doctor Remigio Leroy, who was the first exhibit in the museum in 1865 and is still the first mummy you see. more…

Richard Smith: Does the NHS meet the needs of junior doctors?

12 Jan, 16 | by BMJ

richard_smith_2014Bain, the global consultancy, produces what it calls “a pyramid of employee needs,” and on the day when junior doctors are striking it’s instructive to see how well the NHS is doing in meeting their needs.

The bottom of the pyramid is “satisfied employees,” and the very fact that junior doctors are striking suggests that they don’t even reach this level. The first requirement for satified employees is to have a safe work environment. Hospitals are certainly not safe for patients in that they are famously riskier than bungee jumping, and they are not entirely safe for junior doctors in that the work is stressful and risky. The fear is not so much that junior doctors will be harmed themselves but that they will harm patients and suffer disciplinary, legal, and emotional consequences. I’m assured that it’s not like when I was a junior doctor and would be the first to arrive at a cardiac arrest without any training, but “safe” may be a bold claim. more…

Richard Smith: Learning from ruins

8 Jan, 16 | by BMJ

richard_smith_2014Whenever I wander through ruins I imagine people centuries hence picking through the ruins of my world and wondering about the people who lived there. We can learn from ruins, and as I walked through those of the Mayan city of Chichen Itza last week I learnt not only about the Mayan world but also our world and its likely fate.

Chichen Itza, which is situated in the jungle of the North of the Yucatan peninsula, flourished between 600 AD and 1200 AD. Mayan culture was dominated by priests and warriors. The biggest of the ruins is El Castillo, a pyramid (actually a zigerat) that stands 100 feet high and at the top has a box like temple. A staircase runs all the way up the pyramid to the temple. It was the site of human sacrifice, something that ran through all the Mesoamerican cultures. The priests would remove the heart of those who were sacrificed and offer it to the gods. Human sacrifice was necessary to appease the gods, which were angry gods. more…

Richard Smith: Why are we doing so badly with hypertension?

21 Dec, 15 | by BMJ

richard_smith_2014Forty years ago at medical school I learnt the “rule of halves” that states that among those with a chronic disease, like hypertension, half are diagnosed, half of those diagnosed are treated, and half of those treated are treated adequately. Last week I learnt at a meeting organised by Public Health England that England has five million people with hypertension that is undiagnosed and that of all those with hypertension only 37% are adequately treated compared with 66% in Canada. Why, I wondered, are we doing so badly with an age old problem? more…

Richard Smith: QMUL and King’s college should release data from the PACE trial

16 Dec, 15 | by BMJ

richard_smith_2014Several times when I was the editor of The BMJ the journal was declared the worst medical journal in the world by an ME association. Sometimes we shared the award with The Lancet. At another time my wife was telephoned and told that if I didn’t take a different line on ME (which is better known as chronic fatigue syndrome) then “something horrible” would happen to me. So I know something about the emotion that surrounds chronic fatigue syndrome, but I still think that Queen Mary College London (QMUL) and King’s College London are making a serious mistake in refusing to release the data behind a controversial trial of treatments for chronic fatigue syndrome. more…

Richard Smith: Does it take a “bad” patient to make a good doctor?

14 Dec, 15 | by BMJ

richard_smith_2014Trying to define a good doctor is as elusive a task as trying to define a good life or a good death. Like good lives and deaths, good doctors will come in many forms, and I search for them constantly as I read. Most doctors in novels are “bad”—fools, crooks, sadists, and cold fish. But doctors shouldn’t feel badly about that because bad characters vastly outnumber good ones in novels because, as Somerset Maugham writes, “vice can be painted in colours that glow, whereas virtue seems to bear a hue that is somewhat dun.” But I have found a good doctor, an outstanding one, and it is a “bad” patient who has made him a good doctor. more…

Richard Smith: A 45 minute play on death

4 Dec, 15 | by BMJ

richard_smith_2014Caryl Churchill’s 45 minute play on death at the National Theatre begins with people at a drinks party after a funeral. Nobody is much upset. “The waters close over very quickly after a death,” my friend Vitek said to me last week. People talk across each other. There is no real communication. We learn little about the dead man except that he was “an old goat” and had several wives. There doesn’t seem to be much reason to mourn. more…

Richard Smith: Four reasons why we may not be responding in the right way to hypertension in low and middle income countries

2 Dec, 15 | by BMJ

richard_smith_2014Should we be responding to hypertension in low and middle income countries? Of course we should. Hypertension kills 10 million people a year prematurely, and 80% of those deaths occur in low and middle income countries. Less than 5% of people with hypertension in those countries have their blood pressure well controlled, and yet we have cheap drugs that are highly effective in treating hypertension. But are we responding in the smartest way? This question came up at the Novartis Foundation London Dialogue on responding to hypertension in low and middle income countries, which was held this week.  more…

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