BMJ - British Medical Journal

In the past two years we have been involved in an expert panel convened by the Royal Society of Canada and the Canadian Academy of Health Sciences on Canada’s past and future global health role. Our report, published on 27 March 2025, aims to provide strategic insights and advice on Canada’s role in global health for the next two decades.1 The need for global leadership in health is clear: growing economic and climate threats, divisive politics, backlash against human rights, and powerful waves of misinformation threaten past gains in global health and cooperation. As we enter a new era shaped by isolationist geopolitics and the US retreating in global affairs, Canada’s role as a middle power, actively engaged in multilateralism, is more important than ever.2Greater clarity around Canada’s global health role is also relevant to current domestic affairs. The new leader of the Liberal party, Mark Carney, was appointed as...

Vaccination has been so successful in protecting whole populations from disease that it is now an often-repeated phrase that vaccines are victims of their own success. As vaccination rates rise, vaccine-preventable diseases become less common within society, creating the illusion that vaccination against these diseases is no longer necessary. This means that the more successful vaccines are, the harder health authorities must work to make their value apparent. During the covid-19 pandemic the need to vaccinate against SARS-CoV-2 was paramount, but uptake was nevertheless a challenge. It would be wrong, however, to view vaccination failures as being only the fault of those who do not want to vaccinate. Government failings should also be considered.These failings have been highlighted by the ongoing UK covid inquiry. Module four, which focused on vaccines and treatments, concluded in January 2025.1 The inquiry emphasised that the covid-19 vaccination is a success story from the pandemic,...

AbstractIdentifying patients with chest pain that is of cardiac origin is crucial owing to the high mortality and morbidity of cardiovascular diseases. History, electrocardiogram, and cardiac biomarkers are the core elements of the assessment. High sensitivity cardiac troponins (hs-cTn) are the preferred biomarkers for diagnosing acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury. However, elevations in hs-cTn can occur in patients who are not experiencing acute myocardial infarction. Therefore, it is important for clinicians to recognize how to integrate hs-cTn levels into their clinical decision making process. Structured risk assessments, using evidence based diagnostic protocols, should be employed to estimate the risk of acute coronary syndrome and adverse events in patients with chest pain. Clinical decision pathways should be used routinely in emergency departments. Patients at intermediate or high risk of obstructive coronary artery disease might benefit from cardiac imaging and further testing. Patients should be involved in decision making, with information provided about risks, radiation exposure, costs, and alternative options to facilitate informed decision making.

Unlike true experiments that are conducted by researchers for scientific purposes, natural experiments occur when infrastructure, policies, or services are introduced or changed by governments or healthcare systems. Interventions of this kind are sometimes amenable to randomised controlled trials, for example, if the advantages of randomisation can be negotiated with policy makers or providers at the planning stage and the findings are likely to be transferable across several contexts. Although the randomised controlled trial remains an important method, there are occasions when a trial will not be appropriate or feasible for answering questions about infrastructure, policy, or service changes. However, provided that the intervention divides a population into groups that are otherwise similar, researchers can evaluate the health effects of the changes in a natural experimental evaluation. Natural experiments therefore generate valuable opportunities for evaluating population health, health systems, and other interventions, including those that are, for practical or ethical...

BiographiesJohn-Arne Røttingen was appointed chief executive officer (CEO) of the Wellcome Trust in October 2023. A doctor-scientist, he was previously Norway’s ambassador for global health, chief executive of the Research Council of Norway, and was the founding CEO of the Coalition for Epidemic Preparedness Innovations. His research encompasses epidemiology, clinical trials, and global health policy.Victor Adebowale has been chair of the NHS Confederation in a personal capacity since April 2020. He is the former CEO of Turning Point, a social enterprise, and has been a crossbench peer at the House of Lords since 2001. He has led commissions on mental health and housing. He holds an MA in advanced organisational consulting from City University and the Tavistock Institute of Human Relations and founded the Race and Health Observatory.VA: You’ve had a distinguished career in research funding, including leading Norway’s research efforts. How did issues of race, diversity, and equity play...

In November 2024, the Terminally Ill Adults (End of Life) Bill was passed in the UK House of Commons by a majority of 330 to 275. One key consensus in the debates surrounding the bill was that while palliative care in the UK can be excellent, its provision and funding are often inconsistent, inadequate, and must be improved. In response, a commission on palliative care has been established by Rachael Maskell MP to drive improvements in palliative and end-of-life care in the UK. More recently the Expert Panel of the parliamentary Health and Social Care Committee has announced it is undertaking an independent evaluation of the state of palliative care in England. The 1946 NHS Act established a health service focused on improving physical and mental health and treating illness. This wording led many to assume that palliative care, which puts the person and their concerns before their illness,...

A group of whistleblowing doctors who raised the alarm about patient safety in the emergency department at Scotland’s largest hospital have had their concerns upheld.An investigation by Healthcare Improvement Scotland (HIS) into conditions at Glasgow’s Queen Elizabeth University Hospital concluded that NHS Greater Glasgow and Clyde seemed “to have allowed an abrasive culture to develop, with evidence of poor and disrespectful behaviours, which makes it very difficult for staff at all levels of the organisation to feel safe to challenge and appropriately address this culture.”1Staff complained of insufficient capacity to meet demands for emergency care, leading to long delays in treatment and patients being cared for in unsuitable areas such as corridors. After two years of trying and failing to get senior management to act a group of 29 doctors raised their patient safety concerns directly with HIS.HIS decided to review conditions at all three of the health board’s emergency...

A rise in antibiotic resistant cases of gonorrhoea, including extensively drug resistant (XDR) strains, risks making the sexually transmitted infection (STI) “untreatable” if the problem is not tackled, health officials have said.While most gonorrhoea infections can be treated effectively, increased resistance to ceftriaxone—the most common antibiotic used to treat it in injection or tablet form—poses risks, the UK Health Security Agency (UKHSA) said.Katy Sinka, a consultant epidemiologist and head of the STI section at the UKHSA, called for people to use condoms to protect against STIs and to get tested after unprotected sex, including after having sex abroad.Figures from the UKHSA show that there were 17 cases of ceftriaxone resistant gonorrhoea recorded between January 2024 and 20 March 2025 (13 in 2024 and four in 2025 so far). This compares with 16 during the whole of 2022 and 2023. There were nine cases reported between 2015 (when ceftriaxone resistant gonorrhoea...

Decades of improvements in mortality are coming undone as public health funding is eroded and trust in evidence based treatment is undermined. At the same time, commercial interests are pushing people away from healthy lifestyles, as companies work to ensure that government policies don’t undermine their business models (doi:10.1136/bmj.r487).1 And millions of the most powerless people in the world will be harmed in the wake of the US’s sudden withdrawal of foreign aid (doi:10.1136/bmj.r518).2Can some of the new ideas and technological advances discussed in this week’s articles on bmj.com help us turn the tide and progress towards a new age of enlightenment? Should we, for instance, do away with the ancient practice of cadaveric dissection and embrace modern training tools—or will we then miss an essential aspect of the way in which students learn human anatomy (doi:10.1136/bmj.q2829)?3In other areas of medicine, the advantages of new tools and techniques may be...

AbstractClinical questionIn adult patients undergoing colonoscopy for any indication (screening, surveillance, follow-up of positive faecal immunochemical testing, or gastrointestinal symptoms such as blood in the stools) what are the benefits and harms of computer-aided detection (CADe)?Context and current practiceColorectal cancer (CRC), the third most common cancer and the second leading cause of cancer-related death globally, typically arises from adenomatous polyps. Detection and removal of polyps during colonoscopy can reduce the risk of cancer. CADe systems use artificial intelligence (AI) to assist endoscopists by analysing real-time colonoscopy images to detect potential polyps. Despite their increasing use in clinical practice, guideline recommendations that carefully balance all patient-important outcomes remain unavailable. In this first iteration of a living guideline, we address the use of CADe at the level of an individual patient.EvidenceEvidence for this recommendation is drawn from a living systematic review of 44 randomised controlled trials (RCTs) involving more than 30 000 participants and a companion microsimulation study simulating 10 year follow-up for 100 000 individuals aged 60-69 years to assess the impact of CADe on patient-important outcomes. While no direct evidence was found for critical outcomes of colorectal cancer incidence and post-colonoscopy cancer incidence, low certainty data from the trials indicate that CADe may increase positive endoscopy findings. The microsimulation modelling, however, suggests little to no effect on CRC incidence, CRC-related mortality, or colonoscopy-related complications (perforation and bleeding) over the 10 year follow-up period, although low certainty evidence indicates CADe may increase the number of colonoscopies performed per patient. A review of values and preferences identified that patients value mortality reduction and quality of care but worry about increased anxiety, overdiagnosis, and more frequent surveillance.RecommendationFor adults who have agreed to undergo colonoscopy, we suggest against the routine use of CADe (weak recommendation).How this guideline was createdAn international panel, including three patient partners, 11 healthcare providers, and seven methodologists, deemed by MAGIC and The BMJ to have no relevant competing interests, developed this recommendation. For this guideline the panel took an individual patient approach. The panel started by defining the clinical question in PICO format, and prioritised outcomes including CRC incidence and mortality. Based on the linked systematic review and microsimulation study, the panel sought to balance the benefits, harms, and burdens of CADe and assumed patient preferences when making this recommendationUnderstanding the recommendationThe guideline panel found the benefits of CADe on critical outcomes, such as CRC incidence and post-colonoscopy cancer incidence, over a 10 year follow up period to be highly uncertain. Low certainty evidence suggests little to no impact on CRC-related mortality, while the potential burdens—including more frequent surveillance colonoscopies—are likely to affect many patients. Given the small and uncertain benefits and the likelihood of burdens, the panel issued a weak recommendation against routine CADe use.The panel acknowledges the anticipated variability in values and preferences among patients and clinicians when considering these uncertain benefits and potential burdens. In healthcare settings where CADe is available, individual decision making may be appropriate.UpdatesThis is the first iteration of a living practice guideline. The panel will update this living guideline if ongoing evidence surveillance identifies new CADe trial data that substantially alters our conclusions about CRC incidence, mortality, or burdens, or studies that increase our certainty in values and preferences of individual patients. Updates will provide recommendations on the use of CADe from a healthcare systems perspective (including resource use, acceptability, feasibility, and equity), as well as the combined use of CADe and computer aided diagnosis (CADx). Users can access the latest guideline version and supporting evidence on MAGICapp, with updates periodically published in The BMJ.

A new deal for GPs in Scotland which promised to transform their working lives has been a failure, says a damning report from Audit Scotland.A contract agreed with the Scottish government in 2018 envisaged GPs working at the head of expanded primary care teams to deliver improved services.1 It sought to tackle the financial pressures and growing workloads facing family doctors and improve access to care for patients.Audit Scotland analysis found, however, that the contract failed to deliver on several of its commitments.2 Pressures on general practice have increased, investment as a proportion of overall NHS spending has fallen, the number of full time GPs has reduced, patients report finding it more difficult to access care, and proposals to support GPs with more nurses, physiotherapists, and other specialists have not materialised as originally intended.The report says that the Scottish government’s commitment to increase the number of GPs in Scotland by...

The “Hello, my name is” campaign, set up by geriatrician and cancer patient Kate Granger in 2015, encourages all staff to introduce themselves to patients.12 The campaign stemmed from her experience as a patient and the lack of introductions she received from the healthcare staff looking after her.3 It reflected the simple need to know who was providing her care. However, it is now often conflated with use of the first name of healthcare professionals, both in introductions and on name badges, which can cause confusion about names, titles, and roles. The “Hello, my name is” campaign needs updating.Names matter for patients, but introductions using first names alone are insufficient. Introductions and badges should include a healthcare professional’s full name, title, and role. Healthcare delivery has diversified, so role recognition is more difficult and important than ever. Like Kate Granger,1 my usual introduction is “I am Professor Tim Cook, consultant...

Doctors in Gaza have been “abandoned by the world” as they continue to struggle to provide basic healthcare amid renewed Israeli airstrikes, a lack of staff and supplies, and under threat of violence and death, a US doctor working at the recently bombed Nasser Hospital has said.Feroze Sidhwa, US trauma surgeon who is volunteering in Gaza with MedGlobal, told a press conference on 26 March that the horrors he has witnessed since entering Gaza on 6 March far exceed anything he has seen during his humanitarian career, including during his three stints in Ukraine since the Russian invasion.“Doctors feel alone. They feel abandoned by the world, and I think rightly so. When Russia bombs a children’s hospital in Kiev, everybody loses their mind, and rightly so,” Sidhwa said. “But what’s going on here is far more severe and they see that the world, and especially the West, just doesn’t seem...

The treatment of around 800 patients by a now suspended consultant paediatric orthopaedic surgeon at Addenbrooke’s Hospital in Cambridge is to be examined by a panel of expert clinicians, after an initial review of complex hip surgery cases over the past two and a half years found that nine children had received substandard care.The external retrospective review will be chaired by Andrew Kennedy KC, an independent barrister who represented the Countess of Chester Hospital NHS Foundation Trust in the Thirlwall inquiry into the circumstances surrounding the crimes of nurse Lucy Letby.Cambridge University Hospitals NHS Foundation Trust, which runs Addenbrooke’s, has also commissioned an independent investigation by the specialist company Verita into “whether there were any missed opportunities to have identified concerns and acted earlier,” given that concerns were raised as early as 2015 and were the subject of an external review in 2016.Verita has been asked to look into whether...

The timeline for the proposed introduction of assisted dying in England and Wales could be pushed back to four years, raising fears among supporters that its introduction may be abandoned altogether.An amendment approved by the Commons committee scrutinising the bill came as the Isle of Man took its final step to legalise assisted dying, the first area of the British Isles to do so. The Isle of Man Assisted Dying Bill 2023 will now be sent for royal assent before an implementation period begins, with assisted dying potentially available to terminally ill residents from 2027.The deferral in England and Wales was proposed by Kim Leadbeater, the Labour MP behind the private member’s bill. She proposed the amendment to change the maximum implementation period from two to four years after consulting with civil servants, who advised that more time would be needed to set up training and systems for the new...

The NHS is relying too much on recruiting doctors and nurses from countries that have their own significant healthcare workforce shortages instead of training and retaining enough domestic staff, a damning report has concluded.By November 2024 around one in eleven NHS doctors in England (9%) held a nationality from a “red list” country—those listed by the World Health Organization (WHO) as having such a shortage of staff that other countries should not actively recruit from them—found the report from the Nuffield Trust think tank and academics from the University of Sheffield, Queen’s University Belfast, and the University of Michigan.1The report, funded by the Health Foundation, found that since Brexit all UK countries had relied heavily on very high migration of healthcare staff from outside the EU.Mark Dayan, Nuffield Trust policy analyst and Brexit programme lead, told The BMJ, “Yet again, British failure to train enough healthcare staff has been bailed...

As paediatricians working in the US, we view the changes being made to our healthcare and education systems, research enterprise, and regulatory agencies1 as truly dystopian.The damage is clear to us. The breakdown of information from the Centers for Disease Control and Prevention; unjustified firing of workers from the National Science Foundation, US Department of Agriculture, Food and Drug Administration, and Environmental Protection Agency; decreasing the funding of university research through the National Institutes of Health; dismantling the US Agency for International Development; and withdrawal from the World Health Organization and the Paris Climate Agreement have disproportionately adverse effects on children. Children will suffer from diseases and disabilities that otherwise could be prevented and treated, a dire consequence of policies adopted by the very federal government entrusted with promoting and protecting their health, development, and functioning.Dictators have historically used health as a target to destroy the core strength of their...

In this episode of Sharp Scratch, the panel got together to discuss the importance of properly listening to patients.The panel was joined by guest Rageshri Dhairyawan to explore how medical students and doctors can work to improve their listening by increasing their awareness of biases that may lead to some groups of patients being dismissed. The episode highlighted the broader implications of not properly hearing patients, including the impact on health equity. The discussion also covered the challenges of dealing with uncertainty and acknowledging the social factors that can affect healthcare outcomes. The episode emphasised the ways in which becoming a better listener as a medical professional can help us to provide more compassionate and holistic care.Rageshri Dhairyawan is a consultant in sexual health and HIV medicine at Barts Health NHS Trust and deputy director of the SHARE Collaborative for Health Equity, Queen Mary University of London. She is author...

Rising cases of tuberculosis (TB) and measles and an intense influenza and respiratory syncytial virus (RSV) season were seen in England in 2024-25, reiterating the fact that “we cannot be complacent,” the outgoing head of the UK Health Security Agency (UKHSA) has said.The agency’s first report on infectious diseases looks at data from 2023 to early 2025 and acknowledges that social mixing, international travel, migration, and vaccine hesitancy following the covid-19 pandemic have contributed to these patterns of infection.1Provisional data for 2024 show that there were 600 new cases of TB in England in 2024, 13% more than in 2023. This followed an 11% increase in cases in 2023, with 4855 notifications of the disease compared with 4380 in 2022.If cases of TB continue to increase on their current trajectory the UK would lose its World Health Organisation low incidence status, warned Jenny Harries, chief executive of the UKHSA, at...

Decades of progress in improving childhood survival are being put at risk because of major cuts to aid funding, the United Nations has warned.In a report1 published on 25 March the UN found that the number of children dying globally before their 5th birthday has more than halved from 10.1m in 2000 to 4.8m in 2023. Stillbirths have declined modestly, from 2.9m in 2000 to 1.9m in 2021.2But it warned that these gains are now under threat as major aid donors such as the US have announced funding cuts. Earlier this month the Trump administration permanently cancelled funding for nearly 10 000 projects supporting global health and development, equating to a cut of nearly $60bn in aid spending.3 US cuts to foreign aid have already closed vital child malnutrition services in war torn Sudan.4World Health Organization director general Tedros Adhanom Ghebreyesus said, “In the face of global funding cuts, there...