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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: Commentary: “I’ve lost count of the times my door has been broken by the police” . 356:doi 10.1136/bmj.j1165

I also (agreeing with Simon Kenwright's response of 20 March) would be interested in an 'audit' of such welfare checks.

It was certainly historically true, that with respect to 'best interests' our courts applied 'concern about “preservation of life” trumping all else'. But this is no longer the case - see for example the ruling by Mr Justice Charles about the withdrawal of CANH (see ref 1) and some of the court rulings I discuss in reference 2.

The problem, seems to be that some people do wish to be 'safeguarded': they are aware of their own mental health problems, and when less-affected by what I shall call 'periods of poor decision-making' those people would effectively request this 'safeguarding'. But other people, know they are careless of their own health and safety, but neither wish to be 'safeguarded' nor are they legally 'lacking in mental capacity' [nor demonstrably afflicted by a mental illness which is affecting their decision-making].

On the front-line, professionals seem to find it easier to 'safeguard first, and justify the intervention later': but, if that is out-of-line with legal rulings, and it probably is out of line with recent legal rulings, the behaviour appears to be flawed. However, especially as the media invariably spotlight cases where 'safeguarding has gone wrong', it is not at all obvious how to achieve behaviour which is properly-balanced between respecting 'the right of the careless but unusual capacitous individual who is reckless [with his/her own health] or even deliberately self-destructive' and 'protecting the individuals who we should be protecting'.

I strongly suspect, that the balance at present is distorted towards the protection of the people charged with doing the safeguarding.

But I have no good idea(s), as to how to remove that distortion.

Ref 1 http://www.bmj.com/content/355/bmj.i6829/rr-0

Ref 2 http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj...

Competing interests: No competing interests

20 March 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: The scandal of generic drug pricing: drug regulation policies need review Karim Meeran, Sirazum M Choudhury, John Wass. 356:doi 10.1136/bmj.j947

I agree with the principle that the NHS should be free to safely manufacture generic drugs where this represents cost saving.

I also wonder whether it would be possible for the NHS to manufacture its own Blood Glucose Monitoring Systems.
There are many different testing kits on the market currently. Meter reading devices are often sold at a discount by pharmacies - a 'loss leader' that will more than recoup its costs through the subsequent NHS prescriptions of testing strips.

Primary care organisations are frequently tasked with the role of sticking to whichever testing system is currently deemed cost effective. These can then rapidly become no longer the most cost effective.

I do not know the true cost of manufacturing testing strips, but my suspicion is that they are likely to be very cheap once a suitable economy of scale has been achieved.

If the NHS had its own prescribable/issuable systems they could then become the only ones that are prescribed throughout primary and secondary care. The potential cost savings could be massive.

Competing interests: No competing interests

20 March 2017
David J Lee
GP
Lister House Surgery, Wiveliscombe
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Re: Pregnancy after bariatric surgery: screening for gestational diabetes Safwaan Adam, Basil Ammori, Handrean Soran, Akheel A Syed. 356:doi 10.1136/bmj.j533

We thank Dr Banerjee and colleagues for their comments on our editorial and we wish to take this opportunity to clarify one or two points. Our premise that the oral glucose tolerance test is the common screening test for gestational diabetes in women who have had bariatric surgery is readily borne out by personal experience that includes follow-up of a large cohort of bariatric surgical patients, discussions with colleagues with a specialist interest in bariatric management nationally and online discussion boards that bear witness to patient testimonies. Whereas surveys are not always completely representative of the full range of clinical practice, the report by Whyte and colleagues provides corroborative insights [1]. In this survey, 26 of 27 respondents had managed pregnant women post-bariatric surgery and therefore encountered this clinical scenario; 18 respondents answered about their preferred diagnostic test for gestational diabetes; 11 of the 18 (61%) opted to use the oral glucose tolerance test, leading to the authors’ conclusion that this was the most performed test.

Dr Banerjee and colleagues urge screening for gestational diabetes at the earliest in those women with a viable second trimester pregnancy that did not have raised glycated haemoglobin (HbA1c) at the antenatal booking appointment. They quote early pregnancy loss of 39% in support of their assertion [2]; however, this paper, which is more than twenty years out of date, reported on vertical banded gastroplasty, a long obsolete bariatric procedure, and did not prove a link between glycaemia and early pregnancy loss. We would offer reassurance to Dr Banerjee and colleagues that pregnancy outcomes with modern bariatric management are often superior to that seen in women matched for level of obesity and arguably comparable to the general obstetric population [3-5]. Our comment (within the editorial) regarding delay in diagnosis when using HbA1c was in reference to diagnosing gestational diabetes, not laboratory processing times. Whilst HbA1c can give an indication of chronic glycaemia, rises in HbA1c will lag behind those of glucose in more acute hyperglycaemia [6], despite an expedited red blood cell turnover rate in pregnancy (from a usual 120 days to approximately 90 days [7]), and is not recommended for diagnosing gestational diabetes [8].

Our recommendation for a safer alternative to the oral glucose tolerance test for screening of gestational diabetes in women who have had bariatric surgery was borne of pragmatism. Capillary blood glucose testing pre- and post-meals starting from the early second trimester and continuing throughout the pregnancy would require considerable personal investment of time and commitment on the part of patients and healthcare professionals and not insignificant healthcare costs. Whilst individual patients may choose to opt for this strategy in discussion with their antenatal and bariatric healthcare professionals, it is idealistic when placed in the context of a reduced risk of gestational diabetes in these women [5, 9]. The second approach of capillary blood glucose testing for a week between 24 to 28 weeks’ of gestation reflects the peak time of onset of hyperglycaemia in pregnancy. Screening for gestational diabetes at this point in pregnancy is well entrenched in antenatal practice supported by national guidance [8]. Arguably a week’s worth of blood glucose monitoring better reflects glucose handling in all pregnant women requiring screening for gestational diabetes, let alone those that have undergone bariatric surgery, than a snapshot oral glucose tolerance with all its foibles and fallibilities. We would urge that a comprehensive discussion between healthcare professionals and patients about all safe gestational diabetes screening approaches is carried out at the first antenatal booking appointment before mutually deciding on a method.

Finally, we concur that specific guidance is needed for diagnosing and managing gestational glycaemia in women post-bariatric surgery. We hope that our editorial and any debate that it has stimulated will enrich the development of a comprehensive clinical guideline.

References

1. Whyte M, Johnson R, Cooke D, Hart K, McCormack M, Shawe J. Diagnosing gestational diabetes mellitus in women following bariatric surgery: A national survey of lead diabetes midwives. British Journal of Midwifery. 2016;24(6):434-8.
2. Bilenka B, Ben-Shlomo I, Cozacov C, Gold CH, Zohar S. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity. Acta Obstet Gynecol Scand. 1995;74(1):42-4.
3. Narayanan RP, Syed AA. Pregnancy Following Bariatric Surgery-Medical Complications and Management. Obes Surg. 2016;26(10):2523-9.
4. Alatishe A, Ammori BJ, New JP, Syed AA. Bariatric surgery in women of childbearing age. QJM. 2013;106(8):717-20. Epub 2013/04/12.
5. Johansson K, Cnattingius S, Naslund I, Roos N, Trolle Lagerros Y, Granath F, et al. Outcomes of pregnancy after bariatric surgery. N Engl J Med. 2015;372(9):814-24.
6. Kilpatrick ES, Atkin SL. Using haemoglobin A1c to diagnose type 2 diabetes or to identify people at high risk of diabetes. BMJ. 2014;348(apr25 3):g2867-g.
7. Radin MS. Pitfalls in hemoglobin A1c measurement: when results may be misleading. J Gen Intern Med. 2014;29(2):388-94.
8. Diabetes in pregnancy: management from preconception to the postnatal period. London: National Institute for Health and Care Excellence; 2015; Available from: https://www.nice.org.uk/guidance/ng3/.
9. Yi XY, Li QF, Zhang J, Wang ZH. A meta-analysis of maternal and fetal outcomes of pregnancy after bariatric surgery. Int J Gynaecol Obstet. 2015;130(1):3-9.

Competing interests: No competing interests

20 March 2017
Safwaan Adam
Clinical Research Associate
Dr Akheel A Syed
3rd Floor, Core Technology Facility, University of Manchester, 46 Grafton St., M13 9XX
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Re: David Oliver: Why shouldn’t nurses be graduates? David Oliver. 356:doi 10.1136/bmj.j863

I completely agree with Dr Mandlik that safe staffing and skillmix are crucial to patient care and that the percentage of graduates in a nursing team is only one factor alongside staff patient ratios. I have written about this before in the BMJ, with some key references and links in the piece below. Indeed workforce recruitment, retention and workforce planning are crucial across all clinical disciplines and are a major issue right now in UK health systems

http://www.bmj.com/content/353/bmj.i2665

I also agree that there should be a variety of routes along a skills escalator to encourage and support a diverse range of applicants into nursing, medicine and professions allied to medicine. And that it's especially important to give people who aren't school leavers and have played other roles in our outside healthcare a chance to enter the caring professions at a later stage.

None of this invalidates the premise of my argument - namely, that nursing is a skilled endeavour requiring a theoretical underpinning and a research base and doesn't just rely on some kind of innate traditionally "womanly" virtues of care, compassion, commonsense and communication. And therefore a degree in nursing should have just as much weight as one in an Allied Health Profession or Pharmacy or Social Work, not least because nurses are the people in most frequent daily contact with patients and the largest and arguably most visible staff group.

Most of all, i have yet to see a shred of evidence to support the notion that somehow higher education or qualifications make people unempathetic. or unable to care. Look no further than the work of skilled palliative medicine doctors working in hospices after 5 years undergraduate and 8-10 years postgraduate training, or caring speech or occupational therapists and you can see that its a bizarre assertion.

Many of the attitudes to degree level nursing are I suspect ingrained in good old fashioned sexism and snobbery and undervaluing of the role and its skill.

David Oliver

Competing interests: No competing interests

20 March 2017
David Oliver
Consultant Physician
NHS
Berkshire
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Re: GP training in mental health needs urgent reform Elizabeth England, Vicki Nash, Kamila Hawthorne. 356:doi 10.1136/bmj.j1311

Suicides and self-harm traumatisms are the sixth leading cause of death, but GPs could not reduce them [1], probably because recent evidence reveals that administered antidepressants actually increase suicide risks by 2-5 times. [2][3][4][5][6]
A recent meta-analysis, level I evidence, clearly demonstrated that SSRIs double the risk of suicide and violence in adults. [4]
Another meta-analysis published in the British Journal of Psychiatry has found that even patients with the most severe depression can expect to get as much benefit from cognitive behavioural therapy (CBT) as those with less severe symptoms. [7]
Even Behavioural Activation effectively decreases depressive symptoms. [8]
References
[1] http://www.bmj.com/content/355/bmj.i6761
[2] http://journals.sagepub.com/doi/pdf/10.1177/0141076816666805
[3] http://www.bmj.com/content/348/bmj.g3510
[4] http://www.bmj.com/content/352/bmj.i65
[5] http://nordic.cochrane.org/sites/nordic.cochrane.org/files/public/upload...
[6] http://www.bmj.com/content/355/bmj.i6103
[7] http://bjp.rcpsych.org/content/210/3/190.long
[8] http://www.bmj.com/content/356/bmj.j914

Competing interests: No competing interests

20 March 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Thessaloniki, Greece
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Re: GP training in mental health needs urgent reform Elizabeth England, Vicki Nash, Kamila Hawthorne. 356:doi 10.1136/bmj.j1311

Dear authors

Whilst it is admirable and desirable that GPs should have a working knowledge and understanding of Mental Health issues, and be able to signpost patients to the relevant services, the service is extremely overstretched as it is, and we cannot possibly be expected to be able to devote the time required to provide the in depth care required for these patients.

Just as an Orthopeadic surgeon called to a patient with multiple trauma would expect to manage the fractured femur and pelvis, they would not get involved in the liver trauma in the same patient, but would know to call the General surgeon to deal with this aspect of the patient's care.

There are specialist services for appropriate management of patients with Mental Health problems, and they have the training and expertise to best manage these patients, just as there are other services available to help with benefits, housing and employment issues, and again these are not areas in which we need to have detailed knowledge, but should be able to advise patients in which direction to turn for this help.

General Practice should not be the "Back Stop" when the Health and Social Services do not provide adequate funding to perform as intended - if more and more is landed on General Practice due to inadequate service provision elsewhere, the whole system will collapse and then patients will get no care at all.

Please be very careful what you wish for!

Competing interests: No competing interests

20 March 2017
James MacHugh
GP
Pitlochry
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Re: Resuscitation policy should focus on the patient, not the decision Zoë Fritz, Anne-Marie Slowther, Gavin D Perkins. 356:doi 10.1136/bmj.j813

Reference 2 in my previous response (18 March 'It seems clear that ...') is incorrect. It seems to be a duplication of ref 1.

The correct link is:

http://nmcforum.ning.com/discussions/must-the-public-be-made-aware-of-th...

The comment by Claud Regnard appears in his post timed at March 16, 2017 at 6:24pm.

Competing interests: No competing interests

20 March 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: Commentary: “I’ve lost count of the times my door has been broken by the police” . 356:doi 10.1136/bmj.j1165

A full formal audit of these welfare checks by the police would interesting. I have heard how they can be frightening, burdensome and inappropriate. The victim does not have to be ill, physically or mentally, nor does the person informing the police have to be one of the caring professions. At least here it is the GP who seems to have put the wheels in motion. In some instances it may just be an anxious neighbour – and perhaps acting from questionable motives – and the victim essentially a somewhat frail and elderly person who has chosen to live alone.

As with doctors, the police too seem at times to be able to exonerate themselves by claiming to act in “best interests” with concern about “preservation of life” trumping all else. But is there an alternative that a Society that likes to see itself as caring - whatever the reality - would see as acceptable?

Competing interests: No competing interests

20 March 2017
Simon Kenwright
Rtd Physician
Stowting, Ashford KENT
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Re: All emergency departments must have GP led triage by October Gareth Iacobucci. 356:doi 10.1136/bmj.j1270

Dear Editors

So the chancellor Philip Hammond says, “Experience has shown that onsite GP triage in A&E departments can have a significant and positive impact on A&E waiting times.”

On what basis and evidence are his beliefs based?

Other than some limited research on local conditions in London, I am not aware of anything that is close to demonstrating this.

Much like the empirically set "4-hour rule" (4HR), there was really no good evidence that a 4-hour target to Emergency Department (ED) presentations (by 2004) in the NHS made any real difference to patient outcome when it was introduced in 2002-3; much of the 4HR literature was written AFTER the introduction.

Australia has a nasty habit of taking up tried-and-failed ideas from the mother country, often at a time when the fashion is on its way out. The introduction of Australia's version of 4HR: National Emergency Access Target (NEAT) in 2011 coincided with the NHS's exit from 4HR standard after 7 years.

We are still (re-)learning the lessons that drawing a line with 4HR does nothing to help anyone without actually addressing the hospital access block issue.

Now, Mother England is proposing GP clinics co-located next to hospital ED and expecting GP-led triage will direct appropriate traffic next door. Perhaps the NHS leaders want to relearn Australia's mistake?

Since 2010, Australian authors have pointed out the poor cost-benefit ROI related to after-hours GP clinics next to major hospital EDs (an Australian phenomenon since the mid-2000s), that only 10% ED presentation are truly suitable for GPs (Ref 1) and that the ED traffic was reduced by 10% (Ref 2). Such is the scale of waste and misdirected funds involved, the Australasian College for Emergency Medicine submitted the After Hours Primary Health Care Review (Ref 3) appealing to the government to rethink its strategy and funding framework.

Perhaps the NHS can avoid its own failures by considering what the Aussies have learnt; much like Aussie's cricket team's disastrous Test year of 2016 at rock bottom.

References:

1. doi:10.5694/mja12.11754 https://www.mja.com.au/journal/2013/198/11/quantifying-proportion-genera...
2. MJA 2010; 192: 448–451 https://www.mja.com.au/journal/2010/192/8/effect-general-practice-after-...
3. https://acem.org.au/getattachment/0a5194c7-7785-44fa-9431-1294eb0ac3f2/S...

Competing interests: No competing interests

20 March 2017
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia
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Re: Emergency care and resuscitation plans David Pitcher, Zoe Fritz, Madeleine Wang, Juliet A Spiller. 356:doi 10.1136/bmj.j876

Mr Stone states that the in-depth understanding of a family carer cannot be transferred to a suddenly-involved 999 paramedic by means of any written information. We agree with him, but his implication that the ReSPECT process may attempt to do this is incorrect. What the ReSPECT process aims to do is promote and support more advance planning by people and their health professionals, to guide immediate clinical decision-making in a future emergency. The process starts with a conversation that aims to achieve a shared understanding of the person’s situation, including their current health, of their goals of care and of their wishes and preferences for aspects of care and treatments that may be considered for them in a future emergency in which they are unable to make or express decisions at the time. The ReSPECT form summarises the resulting recommendations for those aspects of emergency care and treatment that would be wanted as well as those aspects that would not be wanted or that would not work for the person in their specific situation. The ReSPECT form is not a substitute for discussion with family or other carers who may be present at the time of an emergency. However, it can provide support for those family members or other carers at a stressful time by giving professionals responding to the emergency (in some instances paramedics) a clear, succinct summary of recommendations that have been discussed and agreed in advance with the person themselves and/or with people concerned about their welfare.

Furthermore, a ReSPECT form is not a substitute for an Advance Decision to Refuse Treatment (ADRT), but is complementary to an ADRT. A ReSPECT conversation (or any other advance care planning discussion) provides an important opportunity to offer people (in England and Wales) the chance to make an ADRT or (in England, Wales or Scotland) to give someone power of attorney for their future welfare, should they lose capacity. It is because a ReSPECT form contains a summary of recommendations for clinical care – and is neither an ADRT nor a ‘consent form’ – that it does not require signature by the person themselves or, if they already lack capacity when it is completed, by their representatives.

Mr Stone asks what specific wording is required on an ADRT to ensure that a person’s wish not to receive CPR in the event of cardiorespiratory arrest will be respected by paramedics responding to a 999 call. In addition to wording required by the Mental Capacity Act 2005 (MCA) section 25, subsection (5), the wording of an ADRT should reflect the specific individual wishes of the person. There is provision in the MCA (section 25, subsection (4) (c)) for an ADRT to be considered ‘not applicable’ if there are reasonable grounds for believing that circumstances exist which the person did not anticipate at the time of the advance decision and which would have affected his decision had he anticipated them. Some people may wish to refuse CPR regardless of the circumstances of a cardiorespiratory arrest, whereas others may wish to specify that their refusal would not apply if they – for example – stopped breathing as a result of choking. This emphasises the fundamental importance of dialogue between a person and their health professionals in developing any type of advance care plan, including an ADRT. Our recommendation is that a person making an ADRT should develop their individual document in discussion with a healthcare professional, to make sure that they use wording to record clearly and exactly what they want to refuse and in what circumstances.

Mr Stone observes correctly that some people who wish to refuse CPR may wish also to record a wish to receive other types of appropriate treatment in an emergency other than cardiorespiratory arrest. What is needed is a recognisable and immediately accessible way of documenting such preferences and advance decisions. An ADRT makes no provision for this and focuses only on refusal of treatment. Furthermore, an ADRT is available currently only in England and Wales. Where it has been implemented across a health and care community the ReSPECT process provides a clear way of discussing, agreeing and recording – in a recognisable and immediately accessible format – recommendations about emergency care and treatment that should be considered, as well as treatments that are not wanted or will not work.

For many people the precise circumstances of a future emergency cannot be predicted with confidence. When a crisis occurs, no document – be it an ADRT, DNACPR form or ReSPECT form – will be of benefit to a person unless it is accessible immediately. For that reason, we advise people to keep such documents with them, in a place where they will be easy to find in a crisis. We encourage them to make family, friends and other carers aware of these documents and where to find them, so that they can be used – not instead of clinicians listening to family, friends and other carers – but to support those people in ensuring that emergency decision-making respects a person’s previously discussed and recorded preferences, including any legally binding refusal of specific treatment.

Competing interests: We are two of the authors of this paper.

19 March 2017
David Pitcher
Retired consultant cardiologist
Juliet A Spiller, Consultant in palliative medicine, Marie Curie Hospice, Edinburgh EH10 7DR, UK
Immediate past president, Resuscitation Council (UK)
Tavistock House, Tavistock Square, London WC1H 9HR, UK
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