bmj;390/sep10_1/r1891/FAF1faIn the late 1960s and early 1970s a series of scandals shed much needed light on the plight of people with learning disabilities. Many were living in large institutions, removed from society, and were often treated appallingly by the people meant to care for them.In 1972 Oliver Russell, a child psychiatrist, was asked to provide two sessions a week at Farleigh Hospital in Bristol. The psychiatric hospital had been brought back under the health authority’s control in 1968 after three nurses were jailed for abusing patients. Hospital managers were resistant to the new regime, however, and it took Russell two years to persuade them to allow him to take charge of a single ward. When he eventually took over he found that 10 out of the 22 male patients were detained under the Mental Health Act 1959. Russell and a colleague interviewed the men and reviewed their notes.“By the end...

An industrial action ballot of first year doctors has been launched by the BMA, just days after the union said the majority of its senior doctor members are willing to strike over pay.Faced with the barrage of disputes, Health Secretary Wes Streeting has urged doctors not to let the union “derail” their careers.The ballot, open to BMA members who are foundation year 1 (FY1) doctors in England from 8 September until 6 October, demands the government “act to fix the unemployment crisis affecting resident doctors.”1In July a BMA survey of 4401 resident doctors with a response rate of around 5.7% found that a third of respondents had no planned substantive employment or regular locum work from August.2BMA Resident Doctors Committee co-chairs Ross Nieuwoudt and Melissa Ryan have called the unemployment figures a scandal, saying, “Thousands of doctors have been left in career limbo while patients desperately need them. We are...

People seeking assisted dying should undergo an assessment with a palliative care specialist, experts have argued ahead of the official Lords debate on the Terminally Ill Adults (End of Life) Bill on Friday 12 September.At a roundtable event organised by The BMJ and hosted on 9 September by the Conservative politician and former health minister James Bethell and the Labour MP Simon Opher of the All Party Parliamentary Health Group, experts from across the NHS and social care, as well as peers, discussed the challenges posed by the current bill and amendments that could improve its implementation.While some raised concerns over adding unnecessary layers of bureaucracy to the system, others argued the need for a specialist palliative care assessment as part of the process to ensure that patients can make an informed decision. Experts also discussed whether assisted dying should be considered a treatment or a service, reaching a consensus...

The Conservative Party leader’s career could have taken a very different turn had she snapped up a place nearly 30 years ago to study medicine at the elite Stanford University in the United States. But what sounds like a potential Sliding Doors moment may not be as straightforward as it seems.Media reports have raised doubts over Kemi Badenoch’s claims that she was offered a place and a partial scholarship to study in California at 16 years of age but couldn’t take up the “pre-med” owing to family circumstances.Politicians in the UK have urged Badenoch to clarify the record and provide documentary proof after former Stanford admission staff told the Guardian that they couldn’t recall such an offer having been made and described such a scenario as impossible.1Medicine at Stanford—where competition for places is intense—is for graduates only, and the university’s website suggests that there was no pre-med degree at the...

AbstractObjectiveTo determine the effect of a prepregnancy lifestyle intervention on glucose tolerance in people at higher risk of gestational diabetes mellitus.DesignSingle centre randomised controlled trial (BEFORE THE BEGINNING).SettingUniversity hospital in Trondheim, Norway.Participants167 participants with at least one risk factor for gestational diabetes mellitus who contemplated pregnancy.InterventionThe participants were randomly allocated (1:1) to a lifestyle intervention or a standard care control group. The intervention consisted of exercise training and time restricted eating, started before pregnancy and continued throughout pregnancy. Exercise volume was set using a physical activity metric that translates heart rate into a score (personal activity intelligence, PAI), with the goal of ?100 weekly PAI points. Time restricted eating involved consuming all energy within ?10 hours/day for at least five days a week.Main outcome measuresTwo hour plasma glucose level in an oral glucose tolerance test at gestational week 28. The primary analysis used an intention-to-treat principle.Results167 participants were enrolled from 2 October 2020 to 12 May 2023: 84 in the intervention group and 83 in the control group, out of whom 111 became pregnant (56 in intervention group and 55 in control group). One participant in the intervention group was excluded from the analysis because of prepregnancy diabetes. Pregnancy data from one participant in the control group were excluded from the analysis because of twin pregnancy. The intervention had no significant effect on two hour plasma glucose level in an oral glucose tolerance test at gestational week 28 (mean difference 0.48 mmol/L, 95% confidence interval ?0.05 to 1.01, P=0.08). In the prepregnancy period, 31/83 participants (37%) in the intervention group adhered to prespecified criteria, whereas 24/55 participants (44%) in the intervention group who became pregnant fulfilled these criteria. During the prepregnancy period, the average eating window was 9.9 hours/day (standard deviation 1.2) and the average number of weekly PAI points was 111 (standard deviation 54), but the adherence to both intervention components decreased during pregnancy.ConclusionsA combination of time restricted eating and exercise training started before and continued throughout pregnancy had no significant effect on glycaemic control in late pregnancy.Trial registrationClinicalTrials.gov NCT04585581.

Each year brings variations to the GP contract, and one hotly debated tweak this year was the stipulation that patients should be able to contact their practice online throughout core hours (8 am to 6 30 pm). On the face of it this doesn’t sound very onerous, but if a patient sends an online query at 6 29 pm, someone has to be there to read it and decide whether it needs an urgent response.This is because, mixed in with requests for a repeat “fit note” and advice on which vitamin supplement the GP would recommend to a patient with acne, there will be a query about whether a parent should be worried about their child who has a rash and a fever. No matter how clearly you signpost that this communication channel isn’t for urgent medical questions, patients will still use it for these. So, most practices currently turn...

I fully support the government investing in new IT and artificial intelligence (AI) for the NHS,1 but I think that it needs to fix the current IT problems in the NHS first.My hospital is one of a handful in the country that still does not have a proper electronic patient record (EPR) system. Unfortunately, this has been delayed as the trust cannot afford to pay for even the cheapest EPR system. Before investing in the NHS app and other new IT based solutions, I think the government needs to put forward the cash to get my hospital, and the others, an updated EPR system. It is hard to deliver the efficient care the government requires with our current systems.

In the US, few healthcare experiences are as universally resented (and feared) as an unexpected medical bill. Such “surprise” medical bills arise when patients receive care from clinicians who they did not authorize to care for them and do not participate in their insurance plan. These situations occur because most adults in the US have private health insurance, typically obtained through their employer. For each private insurance plan, the insurer negotiates a specific fee schedule with healthcare providers included in its insurance network. If insurers and healthcare providers cannot agree on reimbursement rates—or a contract is never pursued—the clinician or hospital will be excluded from the insurance plan’s network (out of network).Before the No Surprises Act legislation, evaluated in the linked study by Liu and colleagues (doi:10.1136/bmj-2025-084803),1 out-of-network providers could charge patients whatever they chose. Insurers were under no obligation to pay the full charges, and if they paid less,...

A recent review into the role of physician assistants has had a catastrophic effect on their mental health, with some even considering suicide, a survey indicates.It follows the landmark review of PAs by Gillian Leng, which recommended sweeping changes to the role. These included a name change from physician associates and that PAs must no longer see undifferentiated patients, except within clearly defined protocols.Concerns over possible job losses,1 uncertainty over the future of the role, and reported hostility towards them among some doctors have prompted concerns about PAs’ mental health.2In the new survey the PAs’ trade union, United Medical Associate Professionals (UMAPs), asked members about their mental health, using questions from the patient health questionnaire 9 (PHQ-9). This self-administered questionnaire is used in NHS talking therapies to screen and measure the severity of depression but does not provide a definitive diagnosis.3The survey was conducted over 24 hours, 8-9 August 2025....

Researchers have urged the World Health Organization not to scrap a landmark report on the commercial determinants of health amid concern that it is at risk from the financial crisis engulfing the agency.WHO’s first ever global report on the commercial determinants of health,1 analysing the effect of corporate industries on peoples’ health and recommending policy, was due to be published this year. But after rumours that the report could be scrapped in the wake of US aid cuts, 12 academics, experts, and former employees of WHO wrote its director general, Tedros Adhanom Ghebreyesus, last month to express “extreme concern” that work in this area “may be entirely lost.”Financial crisisIn their letter to Tedros, seen by The BMJ, the experts claimed that the report has been threatened by the “financial crisis that WHO is facing following the withdrawal of the USA and its funding from the organisation.”In March the Trump administration...

Countries should move towards banning all forms of surrogacy, a new UN report has said.1The UN’s special rapporteur on violence against women and girls, Reem al Salem, called for a ban on the grounds of the “exploitation and violence against women and girls” that characterises surrogacy arrangements, as well as health risks to the mother and baby.Al Salem will present the report to the UN General Assembly in October 2025. It will call for the 193 UN member states to “take steps towards eradicating surrogacy in all its forms.” Pending its abolition, states should adopt a legal and policy framework for surrogacy that is modelled on the Nordic model for prostitution and includes penalties for commissioning parents and surrogacy agencies alongside decriminalisation and exit support strategies for surrogate mothers.The report cites higher rates of caesarean section, gestational diabetes, hypertension, preeclampsia, and placenta previa in surrogate births, and lower birth weights...

NHS England has issued a 10 point plan to improve the working lives of the 75 000 resident doctors it says form the “backbone” of the health service.The plan, sent to NHS trusts on 29 August, emphasised the importance of fixing “unacceptable working practices” that younger doctors too often face during their employment.1These include tackling “basic issues” such as payroll errors, poor rota management, lack of access to rest facilities and hot food, and unnecessarily repeating training, it said (box 1).Box 1NHS England’s 10 point plan to improve resident doctors’ working livesTrusts should take action to improve the working environment and wellbeing of resident doctorsResident doctors must receive work schedules and rota information in line with NHS England’s resident doctors rota code of practice4Resident doctors should be able to take annual leave in a fair and equitable way and which enables wellbeingAll NHS trust boards should appoint two named leads:...

The “publish or perish” doctrineBeing interested in why people write, and having surveyed the musings of several well known writers, including Alphonse Daudet, Joan Didion, E M Forster, Neil M Gunn, Rayner Heppenstall, Stephen King, George Orwell, and Alfred Perlès, I have come to the conclusion, following the trail of the cacoethes scribendi, first laid by the Roman poet Juvenal, that the main reason for the itch to write is the need for self-comprehension. Or, as Stephen King put it, “I write to find out what I think.”1Among others who have tackled the question of why they write, the Canadian writer Mordecai Richler repeated Orwell’s quartet of reasons (egoism, aesthetic enthusiasm, historical impulse, and political purpose) and recognised being “driven by some demon whom one can neither resist nor understand.” However, he might have seemed to have failed to realise the source of this as a need to know what...

More than half a million people in Gaza are now “trapped in famine,” as food and clean water continue to be used as weapons of war as part of Israel’s “genocidal campaign,” aid agencies have said.The latest report from the Integrated Food Security Phase Classification (IPC) system has confirmed that famine is now widespread in Gaza. This is the first time a famine has been officially declared in the Middle East region.1 It means that three critical thresholds have been met: extreme food deprivation, acute malnutrition, and deaths related to starvation.Save the Children’s international chief executive officer, Inger Ashing, said, “All of Gaza is being systematically starved by design, and children are paying the highest price. The world has failed to act as their tiny, emaciated bodies have been overcome by hunger and disease and shut down.“This engineered famine is the ultimate and inevitable result of the government of Israel’s...

Public health experts have warned that inadequate policies on conflicts of interest in government commissioned research into gambling “will only lead to more harm” for members of the public.Last year the government announced that gambling operators would have to pay up to 1.1% of their profits as part of a new levy, to generate £100mn for the “research, prevention, and treatment of gambling harms.”1A fifth of the cash has been set aside for research, led by UK Research and Innovation (UKRI) and its arts and humanities arm, the Arts and Humanities Research Council. The move came after decades in which gambling researchers had to apply to industry funded charities for funding.UKRI opened its call for researchers to work on its “gambling harms research coordination centre” in June.2But a group of researchers have told The BMJ that the call threatens the “opportunity for a fresh start” offered by the levy funds...

Leading urologists have called for an end to the routine use of the digital rectal examination, but it is still an important part of the holistic assessment of patients.1 As access to diagnostic tests in the NHS continues to be a problem, the combination of a borderline concentration of prostate specific antigen together with a prostate that feels abnormal on examination should help fast track a patient for further investigation.Jones et al report the sensitivity and specificity of digital rectal examination as a predictor of prostate cancer in symptomatic patients to be “28.6 and 90.7%, respectively.2 The positive and negative predictive values were 42.3 and 84.2%, respectively.” These numbers are not insignificant and shouldn’t be discounted.A rectal examination can help diagnose many conditions, including prostatitis, constipation, and colorectal cancer, and it is still recommended in NICE guideline NG12: “People with a rectal mass, an unexplained anal mass, or unexplained...

The global south, home to 85% of the world’s population, has disproportionately high disease burden and fragile healthcare systems. Mass net emigration of doctors to the global north—known as “medical brain drain”—is of existential concern to global healthcare and equity. For the countries that raised and educated these doctors, this loss is tied to poor population health and reflects a failing state.1Nigeria exports the most health workers in Africa—13 609 in 2021-22—and is second globally only to India (42 966), with the Philippines third (11 021).23 At least 16 000 doctors have left Nigeria in the past 5-7 years—around nine a day—leaving just 3.9 doctors per 10 000 population (India has 7.3, the Philippines 7.8, the US 36, and the UK 32).45 These doctors largely go to high income economies, where there is a growing demand for primary care physicians for ageing populations.6 On average, it costs $21 000-$59 000...

The author and barrister John Mortimer once quipped that “no brilliance is required in law, just common sense and relatively clean fingernails.”1 I was reminded of this quote on a visit to my GP for a check-up. A medical student was present, and, when the doctor asked them to examine my cubical fossa, I noticed their long, dirty fingernails that lingered on my skin.Medical students who are present at patient consultations may believe they blend into the background, but the opposite is often true. The consultation room, like the courtroom, is a peculiar setting that amplifies actions and words and where a look, a sigh, or a pause can take on great significance. As the student watches the patient, the patient observes them in response, especially during those silent moments when the doctor’s attention is focused elsewhere.In the GP consultation room, I noticed how the student sat with a wide...

United Medical Associate Professionals (UMAPs) has lost its High Court bid to temporarily prevent NHS England from carrying out the recommendations outlined in the Leng review last week (15 August) but insists the “fight goes on.”1The union for physician assistants, known as physician associates before Gillian Leng’s independent review recommended a name change,2 sought an injunction to halt NHS England from rolling out this name change and barring PAs from seeing undiagnosed patients.UMAPs said that the case, although it “did not result in injunctive relief,” had clarified that it was up to individual NHS employers to decide whether to implement the changes. The union has urged “all NHS trusts and primary care networks to await the outcome of our upcoming judicial review before making any changes to medical associates’ job roles.”In response a spokesperson for NHS England said, “We will continue to work with partners across the NHS and the...

When consultant psychiatrist Suhana Ahmed gave birth in 2013 she had a long difficult labour followed by little sleep for months as her baby struggled with colic and reflux.“I can see now there were a number of things that contributed to my postnatal depression (PND),” says Ahmed, who is deputy chief medical officer at West London NHS Trust. “But by the time Daniel was 6 months old I was suicidal. I had written suicide notes and I was probably days away from ending my life.”Talking about this personal and deeply traumatic experience has not been easy—but she has found that when she shares what she has been through, other doctors open up about their own challenges.Even for those working in psychiatry, there remains stigma around doctors having mental health problems, says Ahmed, who is also a north west London higher trainee leadership and management tutor and Royal College of Psychiatrist...