Adopting a more evidence based approach to commissioning health prevention services could yield a bigger return on investment (ROI) each year, an analysis1 has suggested.The report by the NHS Confederation and the consultancy firm Carnall Farrar estimates that in England around £5bn a year is spent across the NHS and local government on public health interventions in primary, secondary, and social settings. The potential ROI from this spending could double from around £11.2bn to £22.4bn if the upper quartile ROI was achieved across all current interventions, the analysts estimate.They said that investment should be targeted at high impact areas such as education, vaccines, employment, interventions to tackle substance misuse, and food insecurity. ROI should be a specific consideration when commissioning services, and all services should be systematically evaluated and benchmarked.Such an approach would help the government deliver its key policy goals of moving more care from hospitals into the community...

bmj;387/oct08_15/q2179/FAF1faLionel was born above the family’s menswear shop in Poplar, east London. He read medicine at Christ’s College Cambridge and completed his clinical training at Guy’s Hospital. As a student he loved playing rugby, and he enjoyed golf and tennis throughout his life. He met his future wife, June, as a student and they married after he qualified. They were married for 72 years and had three children, Alison, Simon, and John, and five grandchildren.Lionel worked as a GP, a Royal Air Force doctor, and then as a paediatrician. Ultimately, he worked as an NHS GP in the morning and spent afternoons at his large private paediatric practice in Harley Street, where he often saw the children of celebrities. He was always popular with patients—but not their dentists—as everyone got a lollipop at the end of their consultation. He had a particular interest in childhood asthma, and carried out research...

The complete lack of specialist care in England for patients with severe myalgic encephalomyelitis (ME or chronic fatigue syndrome) could cause deaths in future unless urgent action is taken, a coroner has warned.The hard hitting prevention of future deaths (PFD) report by assistant coroner Deborah Archer on the death of Maeve Boothby O’Neill, 27, also highlighted the lack of research funding, training, and guidelines on treating the condition.The report, thought to be the first such report on the death of a patient with ME, has been sent to the health and social care secretary, Wes Streeting, and health minister Andrew Gwynne; NHS England; the National Institute for Health and Care Excellence (NICE); the Medical Research Council; the National Institute for Health and Care Research; and the Medical Schools Council.O’Neill, who was bedbound, died at home in October 2021 after three admissions to the Royal Devon and Exeter Hospital, with tube...

In 2021, Hanna Haveri became Finland’s first planetary health physician, a unique role created by her local wellbeing county.“I don’t think there are such positions elsewhere in Finland and I haven’t heard about such positions elsewhere in the world,” Haveri says. “They wanted to establish this role to show that the healthcare sector is truly committed to sustainable development, and to promote planetary health.”In Finland, there are 21 wellbeing services counties that are responsible for organising health, social, and emergency services. Planetary health is a relatively new introduction—one that refers to the idea that human health and the health of the planet are interconnected.1Haveri has worked on several projects across the city of Lahti since taking the role. But one initiative stands out: planetary health prescriptions.In collaboration with experts from local universities, the project set out to see how residents could lead healthier and more environmentally friendly lives through small...

For many of us working in health systems across the world, what connects us is the motivation to help—to care for and improve the health of individuals, communities, and wider society. Because a healthy environment and climate is a building block of health, acting to tackle climate disruption is a core feature of responsible and helpful healthcare systems.But many of us face substantial barriers to contributing to action against climate disruption in our roles. For some, the conditions of work offer us little time or energy to engage. Others who do have time to research and advocate for necessary policy shifts might find that the systems that hold climate damaging conditions in place are not changed by the evidence base.Where does this leave health professionals with a commitment to help? Often frustrated and fatalistic. But we do have the means to drive systemic change. Understanding how systems come to be...

I have always felt different from others, but these differences became more apparent while I was at university and during the pandemic. As my anxiety and obsessive-compulsive disorder became worse, I received a diagnosis of ADHD at the age of 22. For me, ADHD feels like constant restlessness, racing thoughts and overthinking, and a rollercoaster of energy and emotions. I constantly feel that I am racing to keep up with life, yet I’m always behind.About 18 months after the ADHD diagnosis, I also received a diagnosis of autism. My experiences have been affected by both ADHD and autism all my life.How can we help you?I often find it difficult to ask for help and support. A year after my diagnosis of ADHD, I had to have laparoscopic surgery, and during a pre-op call I was asked how ADHD affected me. I was totally stumped, as it affects me in so...

H W FowlerHenry Watson Fowler (1858–1933) was a schoolmaster who turned to journalism and then became a lexicographer. And it is for lexicography that he is justifiably famous.Fowler started his lexicographical career in collaboration with one of his younger brothers, Francis George Fowler (1871–1918). Having previously published a translation of the works of Lucian of Samosata (1905), in 1906 they published The King’s English, a volume for which they had originally suggested the title The new solecist for literary tiros.1 This was followed, in 1911, by the Concise Oxford Dictionary of Current English, an abridged version of the Oxford English Dictionary, or as much of it as had been published by then (A–Sc), supplementing it using entries from other dictionaries.They then began work on a book on English usage, but the first world war intervened, and when Francis died from tuberculosis in 1918, Henry continued the work alone. The first...

US vice president Kamala Harris has condemned the “healthcare crisis” brought on by former president Donald Trump’s abortion bans after reports that two women died “preventable” deaths because they did not receive abortion care.Harris, the Democrat presidential candidate, said, “This story is, sadly, not the only story of what has been happening since these bans have taken place.” In an interview with Oprah Winfrey1 Harris condemned Trump for overturning Roe v Wade and unleashing “Trump abortion bans” that are criminalising doctors and bringing women “to death’s door” before they get the care they need.In 2022 the US Supreme Court overturned Roe v Wade, the ruling that made abortion a constitutional right, and returned the decision to the 50 states.2 About half have either banned or severely restricted abortion. Doctors in these states often fear performing an abortion even if medically necessary because of punishments such as fines, jail time, and...

I’m getting a feeling of déjà vuThis time it’s the Policy Exchange think tank calling for NHS England to be abolished as an independent commissioning body and for its key functions to be delivered by an NHS management board within the Department of Health and Social Care (DHSC).1Isn’t constant reorganisation part of the problem?Yes, Ara Darzi’s recent damning report said the NHS is in a “critical condition,” partly as a result of the “disastrous” structural reforms in 2012.2So it’s all Andrew Lansley’s fault?His 2012 reforms did create NHS England. But the report argues that we now need a “rebalancing,” with less central bureaucracy; a limited number of functions “to be overseen and held more tightly by ministers and others more loosely”; and greater autonomy for managers and clinicians throughout the NHS. There should also be a major overhaul to improve operational performance with more effective procedures to dismiss managers who...

The UK government must take stronger action to protect children from the serious health harms of air pollution, the Royal College of Paediatrics and Child Health (RCPCH) has urged.In an updated position statement,1 the college highlighted the latest scientific evidence showing the impact poor air quality is having on childrens’ health. It said the Westminster government and local authorities must take action to combat sources of two of the most harmful pollutants: fine particulate matter (PM2.5) and nitrogen dioxide.PM2.5 can be breathed deep into the lungs and absorbed into the bloodstream, affecting children’s developing organs, exacerbating respiratory and cardiovascular diseases, and increasing the chance of developing long term health conditions in adulthood.Children are especially vulnerable to air pollution because they inhale more air than adults in proportion to their body weight, breathe closer to ground level sources of air pollution such as vehicle exhausts, and are less able to control...

The plan to introduce and further expand physician associates through the NHS workforce plan has become a clinical, financial, and strategic mess. The royal colleges—including the Royal College of Physicians, the Royal College of Anaesthetists, and the Royal College of General Practitioners—are finally starting to develop national scope for the role.1Problems will arise with having multiple scopes of practice from different royal colleges setting different baselines or ceilings. This would create further conflict and raises questions about what happens if trusts decide to ignore their guidance—and whether doing so would put them at risk of legal challenge. This has opened a can of worms because there was a lack of defined scope for many staff for years, allowing local scope to develop without quality control. My advice to the colleges is to recognise that trust between their members and leaders is frayed, and pushing through scope for physician associates without...

The World Health Organization has officially verified Jordan as the first country in the world to have eliminated leprosy.1Also known as Hansen’s disease, leprosy still occurs in more than 120 countries, with more than 200 000 new cases reported every year, WHO said. Most new cases are reported in Southeast Asia.Saima Wazed, WHO’s regional director for Southeast Asia, and who heads WHO’s global leprosy programme, congratulated Jordan on the milestone. “The fight against leprosy around the world is more than a fight against a disease. It is also a fight against stigma and a fight against psychological and socioeconomic harm.”Jordan has not reported any autochthonous cases of leprosy for more than two decades. A WHO independent verification team carried out an extensive review to confirm that leprosy had been eliminated in the country.WHO’s regional director for the Eastern Mediterranean, Hanan Balkhy, said, “As the first country to achieve this target...

The number of working age people in England and Wales receiving health related benefits has risen sharply over the past four years, an analysis by the Institute for Fiscal Studies (IFS) has shown.1Some 3.9 million people (10% of the working age population) got health related benefits in 2023-24 compared with 2.8 million (7.5% of the working age population) in 2019-20. Every local authority in England and Wales apart from the City of London saw an increase in claims, and the official forecast is for further growth by 2028.For the whole of Great Britain, real terms spending on health related benefits increased from £36bn in 2019-20 to £48n in 2023-24, found the report, which was funded by the Joseph Rowntree Foundation and the Health Foundation. The analysis found that comparable countries have generally seen falls or little change in the number of people on health related benefits, suggesting a particular problem...

bmj;386/sep19_9/q2024/FAF1faCDCJean Kakuru Biyambo, a father of six from the Muja camp for internally displaced persons in the Democratic Republic of the Congo, gestures outside Goma general hospital, where he is receiving treatment for mpox. Across the DRC at least 16 000 cases of mpox have been reported, including more than 500 deaths.This week the World Health Organization has added the MVA-BN mpox vaccine to its prequalification list,1 making it accessible to UN agencies and therefore low income countries.Yukiko Nakatani, WHO’s assistant director general for access to medicines, said, “This will help accelerate ongoing procurement of the mpox vaccines by governments and agencies such as Gavi and Unicef to help communities on the front lines of the emergency in Africa and beyond.”The vaccine is currently not licensed for anyone aged under 18 years, but WHO said it may be used off label in these age groups in an outbreak. Last month...

bmj;386/sep19_7/q2033/FAF1faFor Peter Cole, an anaesthetist at St Bartholomew’s Hospital in London, the life of a conventional hospital consultant would never have satisfied his intellectual curiosity. He had a busy brain and was keen to push scientific boundaries, and so alongside his clinical work he embarked on a long academic career—at a time when few anaesthetists were engaged in research.Described by Charles Hinds, one of Cole’s trainees and now emeritus professor of intensive care at Barts, as an “original thinker and true pioneer,” Cole established an innovative research laboratory with “no visible, to us at least, source of funding; his enthusiasm and determination overcoming all the many obstacles he encountered along the way.”His research covered both anaesthesia and many other topics that interested him, including studying the effects of air pollution and cigarette smoking by measuring carbon monoxide levels in the blood.“He performed these measurements in smokers and non-smokers, police on...

A 24 year old student who was visiting his hometown of Malappuram, in the southern Indian state of Kerala, has become the second person to die from Nipah virus infection in the state this year, the country’s national laboratory confirmed on 15 September. The first was a 14 year old boy who died in June within days of testing positive for Nipah.The World Health Organization lists Nipah as a priority pathogen, with a high potential to cause pandemics.1 The virus spreads through bodily contact.Officials in Kerala have been struggling to contain Nipah in recent years. Last September they closed schools, offices, and public transport in the Kozhikode district in response to a re-emergence of the virus.2 The current outbreak is the sixth spillover event since 2018, and the second outbreak this year, they said. Since 2018, 22 people have died from Nipah in Kerala and outbreaks are becoming more frequent....

The BMA and the UK government have finally agreed about something—two things, in fact: a new pay deal and the need for major reform of the NHS.After 44 days of strike action over the past two years, resident doctors (as junior doctors will now be known) have voted to accept the government’s latest pay offer, with two thirds of those who voted backing the deal (doi:10.1136/bmj.q2038).1The BMA and the government also agreed that Ara Darzi’s report on the state of the health service in England underlines the fact that far reaching change is needed (doi:10.1136/bmj.q2001 doi:10.1136/bmj.q2032 doi:10.1136/bmj.q2009).234 “Without radical action, the NHS won’t survive,” said the BMA’s council chair, Philip Banfield, in response to the review, while the prime minister, Keir Starmer, said that the health service must “reform or die.”One of many failings that Darzi highlights is the wellbeing of health service staff. “Every day, more than a million...

Diagnostic yield from gastroscopyAnalysis of the results of nearly 400 000 gastroscopies carried out in the UK for common gastrointestinal symptoms shows that only one in 10 reveals anything other than normal findings or minor pathology. The chances of finding cancer were greatest in older male patients, those over 50 with dysphagia, and those with weight loss in addition to symptoms, but the overall likelihood of diagnosis of malignancy was 1%. Among patients under 50, less than 1% were diagnosed with cancer, regardless of symptoms (Gut doi:10.1136/gutjnl-2024-332071).Food allergyFood allergy is becoming commoner, according to an analysis of 8 million individual records in an English primary care database. Between 2008 and 2018, the prevalence increased from 0.4% to 1.1% and was highest in children under 5. For most people with food allergies, management was exclusively within primary care, but the proportion of people who had been prescribed autoinjectors for adrenaline—even in...