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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: NHS managers should face the same regulation as doctors, says Francis Abi Rimmer. 357:doi 10.1136/bmj.j2055

Dr Anand does not need to ask for permission to disagree with me.

I cannot read the article (subscription) and I am not at all sure of what Sir Robert has actually said. But based on what he has said previously, I suspect it will amount to doctors being subject to rules about 'transparency and honesty' and that doctors have a duty to serve their patients. If managers are not subject to similar duties of 'transparency', then if their duties involve things which conflict with 'the patient comes first' (for example, if 'orders from above stress money saving as a priority') and managers effectively force clinicians to provide a worse service, it is possible for 'management' to 'try to put the blame on the clinicians'. Nurses - from reading Nursing Times discussions - are definitely not happy about that.

I feel sure that Sir Robert is fully aware of the potential of such 'buck passing' and blurring of who is responsible for what - making a 'guess in the dark', my suspicion is that he is now trying to deal with that. I might be wrong: at the moment I do not have the online time to study what Sir Robert has recently said, because at the suggestion of a doctor I joined Twitter last week and that is currently consuming a lot of my online time.

Competing interests: No competing interests

27 April 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: David Oliver: From acute ward to care home—a journey fewer should take? David Oliver. 357:doi 10.1136/bmj.j1915

Editor

In response to David Kerr, he can find several links to key references about the question he raised in my recent BMJ Column "taking carers for granted". The link is here

http://www.bmj.com/content/357/bmj.j1523

In essence, the vast majority of personal care and support for older people IS provided by their loved ones in the UK. As the population has aged and need has grown, we have lost care home beds and far fewer people are receiving home care than was the case in 2010, leaving family caregivers to do more of the heavy lifting (literally and figuratively). And it is rare for them to receive any formal support. The caring role often has detrimental effects on their own health

With regard to cultures and communities which are not white British, it's certainly true that respect for and family obligations to elders are a stronger part of traditional cultures in South and South East Asia, meaning that what older people might expect as they age, what roles their families might expect to play and the wider societal values or pressures to make continuing to care the norm have all tended to make the use of care homes less likely in those cultures. And those of us (me included) treating patients from these communities can see how ready they often are to continue supporting people.

However, just as the stereotype of White Indigenous Britons "Granny Dumping" (whereas in fact we have more carers giving more care than ever before) doesn't really ring true; its also the case that as societies urbanise, as the role of women changes and more women work outside the home, and as economic pressures change work life balance, there are more older people in some of those countries now socially isolated and not necessarily supported by their families.

Gender equality is also an important consideration. So often it has traditionally been a daughter or daughter in law taking on the bulk of the caring and therefore having her own life choices or opportunities or wellbeing compromised. Keeping very frail older people at home relies on a huge amount of goodwill, sacrifice and often harms the carer's physical or mental health.

In the UK in 2017, unless you have considerable means, it is impossible to get into a residential or nursing home without being very frail, often with severe dementia, often with complex multiple long term conditions and age related disability. And generally it's a last resort when there are no other viable options available.

It is absolutely the case that if we invested adequately in community health and social care services, in support for family caregivers (or "carers" as we tend to call them in England), in age friendly "halfway house" housing options, in telecare and equipment, in proper support for people living with Dementia and in ensuring we don't railroad people into premature decisions about long term care whilst still recovering from acute illness or injury, we would be able to place fewer people in care homes or delay their entry.

All this said, even European Countries regarded as paragons for high performing well integrated age friendly health and social care such as the Netherlands and Sweden do have and use care homes.

And we have to move away from the notion that living in a care home is a tragedy to be avoided at all costs. A well run adequately staffed, well designed care home may be preferable in many cases to a life of social isolation in poor housing stock dependent on occasional short visits from care agency staff for company and care.

The point of my article was really that we make the decision too often, too early in acute beds for want of adequate step down facilities and due to time and bed pressure. Not to blame patients' families.

David Oliver

Competing interests: No competing interests

27 April 2017
David Oliver
consultant physician
NHS
Berkshire
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Re: Association between active commuting and incident cardiovascular disease, cancer, and mortality: prospective cohort study Lewis Steell, Yibing Guo, Reno Maldonado, Daniel F Mackay, et al. 357:doi 10.1136/bmj.j1456

We are encouraged to see such robust data showing a significant reduction in all cause mortality from active commuting.[1] Active commuting can also reduce greenhouse gas emissions, which has been named as a health co-benefit of climate action.[2] We would support further active commuting studies to also consider quantifying the reduction in greenhouse gas emissions in order to better characterize overall benefits. Despite residual questions on the health effects of active commuting, given the overall co-benefits, there is an even more appealing case for strong public policy.

References:
[1] Association between active commuting and incident cardiovascular disease, cancer and mortality: prospective cohort study. Celis-Morales CA, Lyall DM, Welsh P et al. BMJ 2017;357:j1456 http://dx.doi.org/10.1136/bmj.j1456

[2] Health co-benefits of climate action. Haines A. The Lancet Planetary Health , Volume 1 , Issue 1 , e4 - e5 http://dx.doi.org/10.1016/S2542-5196(17)30003-7

Competing interests: No competing interests

26 April 2017
ENRIQUE DE BARROS
family doctor
Juliana Barbosa de Barros
WONCA (WORLD FAMILY DOCTORS ORGANIZATION) Working Party on the Environment Chair
Rua Pedro Boufleur, 135
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Re: Exploring thoughts of suicide Lindsey Sinclair, Richard Leach. 356:doi 10.1136/bmj.j1128

Dear Editor,

I note Dr Sinclair's recent letter about risk assessment.

I think the point is possibly missed. If risk assessment doesn't work (as evidenced by the meta-analyses mentioned by Dr Large and colleagues), then doing it is pointless, and may well be harmful.

I don't see that the prevalence of suicide affects any decision making about whether or not risk assessment works. If suicidal thoughts affected 50% of the population, or 0.5%, that has no effect on the utility of risk assessment as a tool. It either works, or it doesn't. The fact that this is a difficult clinical call for many clinicians in patients is frustrating, but doesn't mean that we should not apply evidence based principles.

If it doesn't work, then there is no role for it.

Thanks
Fergus Hamilton

Competing interests: No competing interests

26 April 2017
Fergus W Hamilton
Medical Trainee
Weston Area Health Trust
Weston Area Health Trust
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Re: NHS managers should face the same regulation as doctors, says Francis Abi Rimmer. 357:doi 10.1136/bmj.j2055

Amendments to the Health and Social Care Act 2008 created a requirement that the chair of all NHS provider organisations ensure that all their directors are “fit and proper persons”. Such persons must have never “been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement” in a heath care organisation.

The CQC can, via the provider registration process, require the removal of directors if they have been involved in such “serious misconduct or mismanagement”.

The RCN has warned that directors with a professional role are, in effect, subject to “dual regulation” - the Nursing and Midwifery Council or GMC and the CQC.

This may be why, speaking to BMJ Careers, Robert Francis said that there had been some difficulties with the fit and proper person test and that there should be professional regulation of all NHS managers. However it is not clear to me which organisation would be responsible for such regulation.

This issue could easily be resolved by arranging that all executive directors of NHS provider organisations were registered with one of the 12 health and social care regulators. This reform would also address the Francis’ main finding that senior clinicians at Mid Staffordshire NHS Foundation Trust lacked “a suficient sense of collective responsibility, or engagement, for ensuring that quality care was delivered at every level”.

Competing interests: No competing interests

26 April 2017
Keith E Dudleston
Retired Consultant Psychiatrist
Modbury, Devon
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Re: Active commuting is beneficial for health Lars Bo Andersen. 357:doi 10.1136/bmj.j1740

I am an avid bicyclist and used to bike to work, but I don't advocate people biking to work unless they have safe roads (preferably bike paths) to ride on. I have been hit by a car before (I was lucky to survive) and occasionally see where people in KC are killed on bicycles going to work at young ages (thinking they are doing the right thing for their health). People in vehicles are in hurry trying to get to and from work, on their cell phones, and texting. This really isn't a good recipe for longevity on a bicycle. People are probably better off riding in a park before or after work. Depending on the city in which you reside, your mortality risk may be higher by riding a bicycle to work.

Competing interests: No competing interests

26 April 2017
Mike J Feldkamp
Nuclear Cardiology Director
Kansas City, Kansas
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Re: Avoid missing a rare condition by colouring your judgment purple Aaron Wernham, Georgina Fremlin, Stephen Orpin. 357:doi 10.1136/bmj.j1489

This case report is quite chilling for anaesthetists as careful, cautious and well considered care might have resulted in major unintended harm for the patient. The acute presentation could easily have been misinterpreted as a surgical emergency and resulted in an operative intervention under general anaesthesia. Without porphyria being suspected as the diagnosis, the use of a standard rapid sequence intravenous induction with the barbiturate thiopentone would have been both very reasonable - and very hazardous.

We too should avoid missing a rare condition by colouring our judgement purple.

Competing interests: No competing interests

26 April 2017
Emma L Simpson
CT1 Anaesthetist
Mark W Davies, Consultant
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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Re: Making the NHS and social care system sustainable Jennifer Dixon. 357:doi 10.1136/bmj.j1826

A Lords select committee will not take the NHS out of the political cauldron or be able to make the required difficult decisions about what can or should be funded. Politicians, doctors and health care workers will never be able come to consensus about what the NHS should and should not fund (after all, that is the nub of the problem). All healthcare workers will shout loudly for their area of special interest and are unlikely to reach consensus, and politicians cannot make difficult healthcare decisions at local or national levels because they will lose their seats and 'power'. Only a Royal Commission can balance the conflicting calls on the health care pound. It will not be quick and it will be costly, but there is no alternative. STPs may fix the acute problems but we must look to the future. I set up a GOV.uk poll last year to garner support for an NHS Royal Commission but it failed to gain traction but with BMA support it would become a reality.

Competing interests: No competing interests

26 April 2017
Nigel S G Mercer
Plastic Surgeon
Past President of the British Association of Plastic, Reconstructive and Aesthetic Surgeons
Bristol
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Re: NHS managers should face the same regulation as doctors, says Francis Abi Rimmer. 357:doi 10.1136/bmj.j2055

Might I be forgiven for disagreeing with Sir Francis and Mr Stone?
NHS managers serve the Secretary of State.
Doctors serve, OR should serve, only their patients. The S o S is only their pay-master.

Competing interests: No competing interests

26 April 2017
JK Anand
Retired doctor
Free spirit
Peterborough
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Re: David Oliver: From acute ward to care home—a journey fewer should take? David Oliver. 357:doi 10.1136/bmj.j1915

Anecdotal for sure but one observation from many years of dealing with this is that the British tend to dislike their relatives as they age and prefer to off-load them to the State or failing that to anyone else. Much rarer to see minority families doing this. Any data out there?

Competing interests: No competing interests

26 April 2017
David Kerr
Director of Research and Innovation
William Sansum Diabetes Center
Santa Barbara, California
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