BMJ - British Medical Journal

The government has released preliminary details of what it wants to include in the new contract for GPs in England, including adding an extra £889m to the existing budget for general practice.Discussions on the new GP contract 2025-26 will also focus on reducing the number of targets in the Quality and Outcomes Framework (QoF) from 76 to 44 to cut bureaucracy, the Department of Health and Social Care said.The government said it would consult the BMA’s General Practitioners Committee for England (GPC England) on the details of its proposals over the coming weeks, before unveiling the new contract in spring 2025.The health and social care secretary, Wes Streeting, said, “General practice is buckling under the burden of bureaucracy, with GPs filling out forms instead of treating patients. It is clear the system is broken, which is why we are slashing red tape, binning outdated performance targets, and instead freeing doctors...

Flu hit early this year, and NHS hospitals are being inundated with respiratory illness.1 Beds are full, and surveillance across primary and secondary care suggests that the rate is increasing steeply.Yet when winter respiratory viruses are circulating it is not just the patients who are affected. Data for the week to 15 December showed that 54 165 staff were off sick, around 4476 more than in the same week in 2023.2 The numbers exemplify why the NHS made an operational decision to offer influenza and covid vaccines to frontline workers (involved in direct care).But there has been a noticeable decline in vaccine uptake among staff in recent years. In England in 2023-24 less than half (42.8%) of staff in NHS trusts involved in direct care of patients had had a flu vaccine—a seven percentage point drop from the previous year.3 This was the third year in a row that the...

Announcing investments in a five year trial ­­­­­­of tirzepatide (a glucagon-like peptide-1 analogue weight loss drug), health secretary Wes Streeting showed support for prioritising patients able to return to work, saying that obesity was not only a health issue but also “holding back our economy.”12 Incorporating the economic benefits of returning people to work sooner echoes concerns raised in the Darzi report, commissioned by Streeting.3 This might sound like low hanging fruit for improving the nation’s health, but there’s a catch.The National Institute for Health and Care Excellence (NICE) currently uses a costing perspective that only counts benefits accrued in the healthcare sector and excludes productivity gains; accounting for the benefit of returning to work extends towards a societal costing perspective.45 After the tirzepatide trial, reimbursement will be decided by NICE, which has previously concluded against switching to a societal costing perspective given the substantial ethical, practical, and methodological challenges...

GPs in Wales have delivered a resounding rejection of the proposed General Medical Services (GMS) contract from the Welsh government.In a BMA ballot of its members in Wales, almost all (98.7% or 1079) doctors rejected the proposed contract for 2024-25, with just 14 doctors voting for it. The ballot had a 68% turnout.The offer included a 6% pay uplift to GP pay, extended to all practice staff, £1.8m for other practice expenses, and an extension of the additional capacity fund for 2025-26, meaning an additional £4m investment next year.1The BMA’s Welsh General Practitioners Committee (GPC Wales) had asked the Welsh government to invest £10.8m into contractor GP pay, £8.9m to allow practices to cover “unavoidable” practice costs, and an overall investment of £27.2m for staff pay.2But although the 6% offer matched the recommended pay uplift intended for GPs from the Review Body on Doctors’ and Dentists’ Remuneration (DDRB), GPC Wales...

The US has reported its first severe case of H5N1 avian influenza in a patient who has been admitted to hospital in Louisiana, bringing the total number of human cases of H5 bird flu in the country to 61 since April 2024.In a statement issued on 18 December the US Centers for Disease Control and Prevention (CDC) said that genome data indicated that the virus that infected the patient in Louisiana “belongs to the D1.1 genotype,”1 which is related to other D1.1 viruses recently detected in wild birds and poultry in the US and in the recent severe case in a Canadian teenager.2 This is different from the genotype (B3.13) of the virus detected in dairy cows.The CDC said that although the investigation into the source of infection was still ongoing, the patient had been exposed to “sick and dead birds in backyard flocks.” It added that a “sporadic case...

AbstractObjectivesTo compare the manual dexterity and composure under pressure of people in different hospital staff roles using a buzz wire game. DesignProspective, observational, comparative study (Tremor study).SettingLeeds Teaching Hospitals NHS Trust, Leeds, UK, during a three week period in 2024.Participants254 hospital staff members comprising of 60 physicians, 64 surgeons, 69 nurses, and 61 non-clinical staff.Main outcome measuresSuccessful completion of the buzz wire game within five minutes and occurrence of swearing and audible noises of frustration.ResultsOf the 254 hospital staff that participated, surgeons had significantly higher success rates in completing the buzz wire game within five minutes (84%, n=54) compared with physicians (57%, n=34), nurses (54%, n=37), and non-clinical staff (51%, n=31) (P<0.001). Time-to-event analysis showed that surgeons were quicker to successfully complete the game, independent of age and gender. Surgeons exhibited the highest rate of swearing during the game (50%, n=32), followed by nurses (30%, n=21), physicians (25%, n=60), and non-clinical staff (23%, n=14) (P=0.004). Non-clinical staff showed the highest use of frustration noises (75%), followed by nurses (68%), surgeons (58%), and physicians (52%) (P=0.03).ConclusionsSurgeons showed greater dexterity, but higher levels of swearing compared with other hospital staff roles, while nurses and non-clinical staff showed the highest rates of audible noises of frustration. The study highlights the diverse skill sets across hospital staff roles. Implementation of a surgical swear jar initiative should be considered for future fundraising events.

AbstractObjectiveTo evaluate the cognitive abilities of the leading large language models and identify their susceptibility to cognitive impairment, using the Montreal Cognitive Assessment (MoCA) and additional tests.DesignCross sectional analysis.SettingOnline interaction with large language models via text based prompts.ParticipantsPublicly available large language models, or “chatbots”: ChatGPT versions 4 and 4o (developed by OpenAI), Claude 3.5 “Sonnet” (developed by Anthropic), and Gemini versions 1 and 1.5 (developed by Alphabet).AssessmentsThe MoCA test (version 8.1) was administered to the leading large language models with instructions identical to those given to human patients. Scoring followed official guidelines and was evaluated by a practising neurologist. Additional assessments included the Navon figure, cookie theft picture, Poppelreuter figure, and Stroop test.Main outcome measuresMoCA scores, performance in visuospatial/executive tasks, and Stroop test results.ResultsChatGPT 4o achieved the highest score on the MoCA test (26/30), followed by ChatGPT 4 and Claude (25/30), with Gemini 1.0 scoring lowest (16/30). All large language models showed poor performance in visuospatial/executive tasks. Gemini models failed at the delayed recall task. Only ChatGPT 4o succeeded in the incongruent stage of the Stroop test.ConclusionsWith the exception of ChatGPT 4o, almost all large language models subjected to the MoCA test showed signs of mild cognitive impairment. Moreover, as in humans, age is a key determinant of cognitive decline: “older” chatbots, like older patients, tend to perform worse on the MoCA test. These findings challenge the assumption that artificial intelligence will soon replace human doctors, as the cognitive impairment evident in leading chatbots may affect their reliability in medical diagnostics and undermine patients’ confidence.

Mathew is correct that patients need to understand what is causing musculoskeletal symptoms; she is wrong that the diagnosis lies in expensive magnetic resonance imaging (MRI).1 The advanced nurse practitioners, extended scope physiotherapists, and musculoskeletal physicians in specialty clinics usually do have the understanding of musculoskeletal symptoms and management. What they might need to develop is a way of communicating and explaining to patients how their symptoms are generated and how to treat them and of dealing with patients’ expectations of imaging. Research has shown that patients set a high value on imaging but that clear explanation preceded by a detailed examination usually circumvents unnecessary imaging. Patients need to be informed that MRI, ultrasonography, and radiography should only be used when needed to direct treatment. A patient over 50 years old with a soft tissue knee injury does not need to undergo MRI unless their knee is locking or giving...

What price experience? I have been working across several safety critical industries for years and in terms of the approaches that these industries take to workforce issues there are some stark differences between safety critical industries and healthcare. One of the most striking differences is the failure to value a risk facing, proficient workforce where safety and productivity are two sides of the same coin rather than competing.1 When we think of safety critical industries, there is often a focus on the retention of expertise and experienced workers as they improve the bottom line in terms of productivity and safety, whereas in healthcare the focus is fundamentally one of more hands for least money and a focus on activity rather than outcome.23In their seminal work Dreyfus and Dreyfus describe the novice to expert continuum, through novice, advanced beginner, competency, proficiency, and expertise.4 While expertise is needed, it’s a proficient workforce...

The selective noradrenaline reuptake inhibitor atomoxetine and stimulants (amphetamines and methylphenidate) are the “most effective treatments” for managing the symptoms of attention deficit/hyperactivity disorder (ADHD) in adults, researchers have said.In a meta-analysis published in Lancet Psychiatry researchers looked at 113 randomised controlled trials involving nearly 15 000 adults with ADHD to assess the efficacy of treatments in reducing core symptoms and their safety and acceptability.1Treatments included stimulants (amphetamines such as lisdexamfetamine and methylphenidate), atomoxetine, bupropion, clonidine, guanfacine extended release, modafinil, viloxazine, and non-pharmacological strategies such as cognitive behavioural therapy (CBT). The research team noted that few studies had assessed the effects of these treatments beyond 12 weeks.Using these short term data, the researchers found that at 12 weeks atomoxetine and stimulants were most effective at reducing core ADHD symptoms (inattention, hyperactivity, and impulsivity) when compared with placebo. This was true for both the self-reported (standardised mean difference for atomoxetine –0.38...

War and disease are old friends. In the Napoleonic wars and the American Civil War, more soldiers died from disease than in battle. It was no coincidence that the 1918 influenza pandemic erupted during the first world war or that the final frontier for eradicating polio is in the most insecure regions of Afghanistan and Pakistan. In the Democratic Republic of the Congo, the Ebola outbreak in the relatively stable Équateur province in 2018 took just two months to control, whereas the outbreak in the insecure provinces of North Kivu and Ituri in 2020 took two years.Israel’s wars with Hamas and Hezbollah have had devastating consequences for the health of the people of both Gaza and Lebanon. At the time of writing, more than 43 000 people have been killed in Gaza, more than 10 000 are missing, and more than 102 000 are injured, at least one quarter of...

General practitioner (GP) Victoria Wilson presents a weekly live show on Hospital Radio Exeter after she visits the wards to take music requests and dedications. “It’s a nice way to interact with patients. Some patients want to chat but then don’t request a song,” she tells The BMJ. “But if they've enjoyed the conversation then that's equally as worthwhile.”Wilson explains: “Patients often have magazines and books, but when they’re feeling poorly, listening to something in bed, eyes closed, might take less energy yet it's still entertaining or distracting.”The Hospital Broadcasting Association supports 170 such UK stations, mostly charities, and several thousand volunteers like Wilson with the aim “to aid patient recovery and promote health and wellbeing to all listeners.”Many patients still access the radio through hospital bedside units: on average 1231 a day for 6.2 hours each across the UK in November 2024. But broken bedside units are often not...

The Scandinavian social democracies are widely admired for their world class public services, which are supported by high levels of taxation, productivity, and education, and equality of income and opportunity. In 2021, for example, Norway had a tax-to-GDP (gross domestic product) ratio of 42.2% compared with 33.5% in the UK and 24.5% in the US.12 Conversely, income inequality is notably low in Norway, which has a Gini coefficient—a measure of income distribution within a population—of just 22.7 compared with 32.6 in the UK and 39.8 in the US, where inequality approaches that in many Latin American and African countries.3But is this egalitarianism translatable to other settings? Can other nations longing for better public services learn from this? In the Scandinavian virtuous cycle of welfare, equality, happiness, and trusted governments and institutions, it is hard to distinguish cause from effect. The fact that Scandinavians expect, and get, high quality public services...

Our oldest stories begin in the soil or by the sea, myth being the original ecological narrative. The Mandé and Sumerians tell of people growing from seeds or moulded from earth; Rigveda, the ancient Hindu sacred text, and the Kojiki, the earliest written Japanese chronicle, speak of births from primordial oceans; and Abrahamic traditions place us in Eden’s lushness. With industrialisation came a new imperative: writers began exploring not just our connection to nature but also our power to destroy it.Climate fiction is a recent literary genre confronting environmental and societal breakdown. But literature has grappled with the interplay of people and environment long before “cli-fi” exploded in the 2010s. These works offer more than historical perspective. They reveal how story and imagination might help us grasp what climate data alone cannot—the full scope of our crisis—while helping us to envision paths beyond catastrophe.Last Man by Mary Shelley (1826)Lionel Verney...

Six hundred miles north of mainland Norway, deep in the Arctic Circle, the Svalbard archipelago spans over 60 000 km2, with a population of just 2596. Longyearbyen, the “capital city,” has a small hospital to provide primary and emergency care. The hospital has 24 staff,1 including three doctors and at least one surgeon. Longyearbyen also has a fire department that has one ambulance with a stretcher.With few roads and rugged terrain, Svalbard has two search and rescue helicopters that also provide helicopter emergency medical service (HEMS)—and unusual transfer missions.2 Each helicopter crew includes a medical rescue technician, and one has an anaesthetist. The helicopters carry the same equipment as mainland HEMS bases, including a handheld ultrasound machine and blood products.2 Annually the crews conduct over 80 missions, mostly search and rescue or as primary responders to medical emergencies. Authorities have recorded fewer than five cardiac arrests that occurred outside of...

bmj;387/dec18_4/q2802/FAF1faLeslie was born in Southampton in 1928 but when he was 8 his family returned to Aberdeen, which remained his spiritual home. He qualified from Aberdeen University in 1951 and his first house job was, unusually, in a mental hospital in Scotland. In 2017 he published a vivid account of his time there, noting the seismic change in psychiatric practice during his long career.After house jobs he undertook national service, treating soldiers during the Korean War. As the only qualified doctor in his unit, and with no senior support, he relied on his resilience and intuition to make clinical judgements. He reported that he gained more valuable experience in one year in Korea than in 10 years in the NHS.After this Leslie returned to Scotland to work in mental health departments, followed by a senior registrar post in Hertfordshire, before being appointed as a consultant child psychiatrist for Hampshire.Leslie was...

Women aged 30 to 65 should be screened for cervical cancer every five years with a test for human papillomavirus, the US Preventive Services Task Force has recommended in draft recommendations.1For the first time, new draft guidelines include self-collected HPV tests, where women can use a swab to collect their own samples, alongside the other options. The task force said that this choice was just as effective as when a clinician collects the sample to be tested for HPV, and it increases testing in groups in whom screening is traditionally lacking.For women aged 21 to 29 the task force continues to recommend screening every three years with a cervical smear test, called a Pap test in the US.In a change from previous guidelines, the task force recommended that women aged 30 to 65 be screened every five years with an HPV test. Alternatively, women in this age group could be...

Almost one in eight phone calls made to NHS hospitals under the Martha’s rule programme have led to a potentially lifesaving change in a person’s treatment, NHS England has said.Early data from hospital pilot sites show that patients have been urgently transferred to intensive care, received antibiotics, or been given oxygen as a result of hospitals adopting the scheme.Martha’s rule allows patients and families to seek an urgent review if their or their family member’s condition deteriorates and they feel that their concerns are not being responded to. The programme is named after Martha Mills, who died in 2021 from sepsis after her family’s concerns about her deterioration were not dealt with.1 An inquest concluded that Martha would probably have survived if she had been moved to intensive care earlier.2The scheme is currently being trialled at 143 hospital sites in England. Data from 136 of these sites show that in...

AbstractObjectiveTo assess the effect of electrically heated mittens on physical hand function in people with osteoarthritis of the hands compared with control mittens.DesignRandomised controlled trial.SettingOsteoarthritis outpatient clinic, Copenhagen, Denmark.Participants200 people with hand osteoarthritis aged 42-90 years. 100 participants were assigned to the intervention group and 100 to the control group.InterventionsElectrically heated mittens or control mittens (heating elements disconnected) worn for at least 15 minutes daily for six weeks.Main outcome measuresThe primary outcome was change in hand function measured on the function subscale of the Australian/Canadian hand osteoarthritis index (AUSCAN; score 0-100 points) at six weeks. Key secondary outcomes included changes in the AUSCAN hand pain subscale (score 0-100 points), global rating of hand osteoarthritis related problems (0-100 visual analogue scale), and grip strength (newtons) at six weeks. Analysis of secondary outcomes was performed using a hierarchical gatekeeping approach.Results91 participants in the intervention group and 95 in the control group completed the trial. The mean age of participants was 71 years, 87% (n=173) were women, and mean body mass index was 24.9 (SD 4.4). Median disease duration was 10 years (interquartile range 5-15 years). The between group difference for change in AUSCAN function at week 6 was 3.0 points (95% confidence interval (CI) −0.4 to 6.3; P=0.09) in favour of heated mittens. For the key secondary outcome, change in AUSCAN hand pain score from baseline, a group difference was observed of 5.9 points (95% CI 2.2 to 9.5) in favour of heated mittens. Changes in global rating of hand osteoarthritis related problems and grip strength did not differ between the groups with an observed difference between groups of 2.8 points (95% CI −3.7 to 9.2) and 2.3 newtons (95% CI −16.3 to 21.0) in favour of heated mittens, respectively.ConclusionUse of electrically heated mittens for six weeks was not related to a positive change in physical hand function compared with control mittens. Heated mittens provided no additional benefits on global rating of hand osteoarthritis related problems and grip strength. A small benefit was detected for hand pain, but this could have been overestimated.Trial registrationClinicalTrials.gov NCT04576403.

Mathew discusses GP access to magnetic resonance imaging (MRI).1Multiple studies have been published in which patients without symptoms underwent MRI of the knee and were found to have abnormalities.23 It follows that the more scanning we perform, the more of these “incidentalomas” will be found, most of which are irrelevant to a patient’s symptoms. The resulting radiology reports then recommend an “orthopaedic opinion” to discuss a harmless finding, for which no intervention is indicated.Often, the most helpful imaging when considering joint replacement surgery is a weight bearing radiograph,45 and it’s frustrating when the patient’s time and taxpayers’ money is wasted on MRI which turns out to be unhelpful. MRI should be approached with the same caution as screening—too many incidental findings lead to health anxiety and over-investigation.Managing patients with chronic pain is challenging, but additional imaging often amplifies anxiety. An incidental finding that appears to be serious enough that a...