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Richard Smith

Richard Smith: Returning health to the people

19 May, 16 | by BMJ

richard_smith_2014For the first two million years of humans there were no doctors. People were born, flourished, became sick, suffered, and then died without doctors. Probably there were healers who danced, sang, rattled skulls, and used herbs but managed without microscopes and randomised trials. “Scientific doctors” appeared recently, and quickly—according to Ivan Illich, the critic of industrial society—“expropriated” health from the people. Now the Creating Health Collaborative wants to hand health back to the people. Can they possibly succeed? more…

Richard Smith: A foretaste of the end of the NHS

11 May, 16 | by BMJ

richard_smith_2014When the NHS began in 1948 dental care was free at the point of delivery, but charges appeared as early as 1951. My current experience with dental services gives me a foretaste of how the whole NHS may begin to crumble.

There is little left of one of my upper molars. My NHS dentist has filled it several times, telling me honestly that the filling has a 50% chance of surviving. The alternatives, he said, were some sort of complicated crowning or extraction. As my many sins do not include vanity (and anyway the tooth is not easily seen), I thought that extraction would be best; and I wish now that I hadn’t gone along with the third filling—but it’s always hard to go against a professional. more…

Richard Smith: Ugandan health—what should be the priorities?

4 May, 16 | by BMJ

richard_smith_2014Uganda, like all low income countries, has formidable health problems and limited resources. If you were the health minister in Uganda what would be your priorities? This question was in the back of my mind as I listened to the presentations at the Uganda Health Summit held in BMA House and organised by the Uganda Diaspora Health Foundation and supported by the BMJ, BMA, and others.

The challenges

Total fertility per woman in Uganda is 5.7, and so, as under 5 mortality fell from 187 per 1000 live births in 1990 to 55 in 2015, the population is growing by 3.2% a year. It is currently around 39 million with 52% of the population under 15. Uganda met its Millennium Development Goal (MDG) for under 5 mortality, but there are still 85 000 deaths a year—14% from pneumonia, 8% from diarrhoea, 7% from malaria, 7% from injuries, 6% from HIV/AIDS, and 23% from “other causes,” showing how only so much can be achieved by targeting particular causes. more…

Richard Smith: The deeper causes of the doctors’ strike—a thought experiment

27 Apr, 16 | by BMJ

richard_smith_2014I’m on my way to walk among bluebells, but my mind is on junior doctors engaging in a total strike, not providing even emergency care, for the first time in the 68 year history of the NHS. How did it come to this? I feel that as “a sort of Doctor” for 40 years and somebody who has written probably a million words on healthcare I ought to know, but I don’t. But let me try. This is a thought experiment.

Immediate causes

The immediate cause is the Secretary of State for Health imposing a new contract on junior doctors. He effectively says, “Sod you. I’m fed up with this. We’ve talked for two years and got nowhere. The government has a democratic mandate to introduce a seven day contract, and you, a bunch of overprivileged brats, have no right to deny the will of the people.” I can feel some sympathy for his position, but imposing the contract is an aggressive act. Good people stand up to bullies, and the junior doctors are mostly good people. more…

Richard Smith: The NHS is a fiction, but what’s the story?

26 Apr, 16 | by BMJ

richard_smith_2014Ask somebody “What is the NHS?” and they are likely to answer to “The people who work in it, the buildings they work in, and the tools they use to do their work.” But it clearly isn’t that. The people who work in the NHS come and go, and none were working in the NHS when it began. Buildings too come and go, and the tools are constantly changing. The NHS is not a thing but a fiction, and none the worse for that. Indeed, if we recognise the NHS as a fiction we are more likely to be able to keep it alive. more…

Richard Smith: What are medical journals for and how well do they fulfil those functions?

19 Apr, 16 | by BMJ

richard_smith_2014Last week I gave a talk to the International Society of Medical Publication Professionals entitled “Medical journals: time for something different.” My core argument was that “Medical journals have played an important role in spreading medical knowledge, but they are now beset with problems. Some will transform, most will disappear. New forms of disseminating medical knowledge are appearing and will continue to appear.” As part of the talk I amused myself by reflecting on the functions of medical journals and then scoring them for how well they do with each function. more…

Richard Smith: Medicine’s need for philosophy

8 Apr, 16 | by BMJ

richard_smith_2014The commonest undergraduate degree of students entering the medical school at University of California Irvine is philosophy. The medical school, traditionally the richest and most arrogant of university departments, has at UC Irvine reached out to the philosophy department for help. At a conference there last month I met a student who is simultaneously studying medicine and doing a PhD in philosophy. I was there at a meeting on social epistemology, feeling a little out of my depth, but I came away with a conviction that healthcare, which is suffering an existential crisis, badly needs the help of philosophers. more…

Richard Smith: Coaching—an essential skill in modern health practice

4 Apr, 16 | by BMJ

richard_smith_2014If you have meningitis how well you do depends on the medical team, whereas if you have diabetes it depends mainly on you, the patient. These days most of healthcare is about patients with long term conditions, usually multiple conditions. So the old style of healthcare when sick patients could be rapidly cured, which many healthcare professionals found deeply satisfying, has been largely replaced by a more complex kind of healthcare that depends on forming a strong, supportive relationship with patients.

Jenny Rogers and Arti Maini call this coaching, and in their new book Coaching For Health: Why It Works And How To Do It they spell out in practical detail how to coach effectively. Some professionals might find this kind of healthcare less satisfying, and more frustrating, than the largely extinct curative form, but the book shows how it can be equally and even more satisfying. more…

Richard Smith: Is the NHS finally going to start taking patient safety seriously?

29 Mar, 16 | by BMJ

richard_smith_2014Jeremy Hunt, secretary of state for health, is embroiled in battles with junior doctors, GPs, and consultants over contracts and patient safety. He thinks that he will improve safety by reducing excess weekend deaths. The doctors think that he’s endangering patient safety through obliging them to work unsafely. Ironically, he’s the first secretary of state since the founding of the NHS to put patient safety at the top of his agenda. Earlier this month he launched a global movement on patient safety and announced developments intended to improve patient safety.

Neglect of patient safety
The sad truth is that patient safety was not an issue at all in the first 50 years of the NHS. This was true of all other health systems as well, and it’s still not an issue for many. more…

Richard Smith: Turning round failing hospitals

23 Mar, 16 | by BMJ

richard_smith_2014The Care Quality Commission has placed 27 health institutions, most of them hospitals, into “special measures,” and so far 11 have emerged. Few jobs can be tougher or lonelier than taking over the leadership of a failing hospital. Regulators may put you under tremendous pressure for quick results, while staff may hope to “see you off.” The Cambridge Health Network heard last week from a chief executive and a chair of the board who are both in the process of turning round failing hospitals. more…

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