Fat Kids, Fat Profits

In 1946, poor children in the UK were on average 2kg lighter than rich children at the age of 11. Today, they are 2 kg heavier, according to an analysis in The Lancet Public Health. Then and now, poorer people struggle to eat sufficient nutritious food. But now they eat an excess of cheap, sugary, salty highly-processed crap, triggering an obesity epidemic that has become the commonest cause of preventable disease and premature death, and is bringing every health service to its knees. Nearly a third of UK children aged two to 15 are overweight or obese and younger generations are becoming obese at earlier ages and staying obese for longer. So who’s to blame?

The strategy for the last 40 years has been ‘to encourage individuals to make healthy choices’ whilst giving them the wrong information and allowing the food industry to run riot. But simply blaming the food industry is too simplistic. Egged on by the pharmaceutical industry, doctors have for decades focused on the aggressive lowering of low-density lipoprotein cholesterol to reduce heart disease risk by cutting out saturated fats in the diet and prescribing statins. This in turn encouraged the food industry to aggressively market zero or low fat foods that claimed to be ‘heart healthy’ but were anything but, being crammed with sugar. This slavish mantra of low fat, low cholesterol and ‘statins for all’ has made billions for food and pharma firms but has helped trigger the massive rise in obesity and type 2 diabetes, where the main culprit is the sugar spikes from processed foods causing insulin resistance. And the solution is not new and better drugs, but better food.

The trouble is, it’s hard living the Mediterranean dream in, say, Gateshead. A wide variety of seasonal fruit, vegetables, legumes, nuts, seeds, extra-virgin olive oil, sustainable fish and organic meat may not always be easy to source. Preparing the meals from these raw ingredients takes time and skill. Wastage is higher because fresh food spoils more quickly. And the ingredients cost far more than, say, multi-buy frozen nuggets, burgers, chips and pizza. Even if you could persuade your children to fill in a rainbow chart on the fridge to ensure they’ve eaten their daily seven different coloured fruits and vegetables, rich in antioxidant polyphenols, the chances are they’d be social outcasts at school.

According to an excellent report on the social determinants of health by the Health Foundation, it is three times more expensive to get the energy we need from healthy food than unhealthy food. It is not only harder to buy healthy foods in deprived areas, but there is also a higher density of fast food outlets. Just 1.2% of advertising spend each year goes on vegetables, compared with the 22% spent on confectionary, cakes, biscuits and ice cream. While ministers ‘consider’ curbs on advertising, pack sizes, ingredients and two-for-one deals on unhealthy food, poorer children are eating themselves to ill health and premature death. A baby girl born in Richmond upon Thames is expected to live 17.8 more years in good health than a baby girl born in Manchester, and to live almost a decade longer. And much of that is down to diet.

Gateshead Council is at least doing its bit. It has used local planning policy to ensure that any application for a hot food takeaway will be declined if it is in an area where more than 10% of children in year 6 are obese; if it is within 400m of secondary schools and other community amenities, or if the number of hot food takeaways in the area is equal to?or greater than the UK national average. Schools and hospitals should also ban highly processed food and sugar drinks from their sites. Too many hospitals are tarts to the processed food industry, and some have even had fast food outlets on site. It is still not uncommon in the NHS for someone to have a lifesaving stent inserted into a blocked coronary artery only to be served a burger and chips afterwards.

But the overriding message of the global obesity epidemic is that ‘encouraging healthier choices’ hasn’t worked. Politicians have to get their shit together and legislate for healthier food, particularly in areas where it may not be top priority. If you have no job, no house, no self-esteem and no future, you’re unlikely to pop down to Waitrose for some oily fish and a punnet of seasonal berries. The government’s childhood obesity plan has at least committed to the reformulation of nine categories of popular, mass market foods, to reduce their sugar content. If you can’t change the people, you have to change the food. Time for the Nanny state to act, and the food industry to pay. Enjoy those Easter eggs, while you still can. (PS 100% dark chocolate is best, being rich in anti-oxidant polyphenols).

Safety First?

The 2018 World Patient Safety, Science and Technology Summit at the ‘stunning’ 8 Northumberland Avenue in London ‘was organized with the support of the Secretary of State for Health and Social Care, the Rt. Hon. Jeremy Hunt MP’. Prices were $1000 for hospitals, healthcare organizations and committed partners that have made a formal pledge of allegiance to the Patient Safety Movement Foundation (PSMF). For ‘first time’ attendees who were ready to commit it was also $1000. For medical technology, medical product and pharmaceutical companies that have not formally affiliated with the PSMF, the price rose to $5000. The highlight of the conference is the PSMF Humanitarian Award which each year goes to the ‘patient safety leader who has made significant progress in eliminating preventable patient deaths so that we can reach our shared goal of zero by 2020.’ Step forward Jeremy Hunt, without whose support the conference would not have been possible.

Given the large number of preventable patient deaths and widespread avoidable suffering in the NHS due to insufficient capacity, unsafe staffing levels and widespread cancellations of routine care, this would seem a bold choice. True, MD would far rather have a health secretary who is interested in patient safety than one that isn’t, and Hunt has certainly listened selectively to the stories of some people whose relatives have been seriously harmed by healthcare, whilst ignoring the tales of others, particularly NHS whistle-blowers, whose stories are politically inconvenient. His latest campaigns are to try to reduce medication related fatalities (a good thing) and to encourage staff to call consultants by their first name to try to make it easier for anyone to speak up if they spot and error. Hunt cited, as he often does, the preventable death of Elaine Bromiley as an example of a nurse knowing what to do (an emergency tracheotomy after a failed anaesthetic intubation) but not being able to override the consultants. Whether calling them by their first names would have made a difference is debatable.

Elaine Bromiley died in 2005, and MD wrote about it long before Hunt became health secretary (Eye May 2008). She was operated on privately by a very experienced team – her consultant anaesthetist had sixteen years of experience, the ENT surgeon had 30 years under his belt and three of the four nurses in the theatre were also very experienced. There was no short staffing or competing interests of emergency cover and the theatre was fully equipped. It was a ‘dream scenario’ for patient safety, rarely found in the NHS. And yet they made a catastrophic error when the intubation turned out to be unexpectedly difficult. No-one was found guilty of gross negligence manslaughter or struck off.

Contrast this to the preventable death of Jack Adcock in 2011, in NHS circumstances so unsafe that no amount of consultant first-name calling would have made a jot of difference (Eye recent). Indeed, Dr Hadiza Gawa-Barba had no consultant cover on site when she made errors in Jack’s care in an otherwise unblemished career. She missed a diagnosis of sepsis, as thousands have before and since, and yet was singled out for gross negligence manslaughter and aggressively pursued and struck off by the GMC. In 2005, Professor Graeme Catto admitted to missing a diagnosis of septicaemia in a man in his twenties admitted as an emergency, who subsequently died. Catto was not found guilty of manslaughter or struck off, but he had been president of the GMC for 4 years when he made his public admission.

The GMC has variously been described as racist and vindictive in pursuing a BME junior doctor when so many senior white men who make similar human errors face no sanctions. Hunt has at least spoken up about the folly of permanently erasing an otherwise competent doctor who openly admitted to her errors and should never have been put in such an unsafe situation, but he has overseen the 100,000 vacancies and widespread bed shortages in the NHS workforce that make it such an unsafe place to work and be sick in. As he was collecting his award, Dr Chris Day tweeted ‘Had a man with bowel obstruction with lactate of 4 (seriously ill). Patient had to have fluids in corridor and his wife had to act as a drip stand as one could not be found. Whilst all the patient safety champions are off at conferences congratulating themselves, NHS staff deal with reality.’ Dr Day is a true patient safety champion who blew the whistle on unsafe staffing levels in intensive care in Woolwich, was removed from his training program and discovered that 55,000 junior doctors have no whistleblowing protection. (Eye). The NHS has spent £100,000 trying to block his case getting to court and Jeremy Hunt, global humanitarian patient safety leader, refuses to meet him. Perhaps Dr Day should organise a global patient safety conference and give Mr Hunt another gong.

Shoot the Junior Doctor

The government’s 2015 manifesto commitment that the NHS ‘will offer you the safest and most compassionate care in the world’ has looked terminal since the winter crisis (Eyes passim) but may now have been killed off forever after the striking off by the GMC of Dr Hadiza Bawa-Garba. Health secretary Jeremy Hunt has questioned the GMC over the decision, but he too must act urgently to legislate for mandatory safe staffing and skill mix, time-limited shifts and compulsory breaks for acute and emergency NHS care – even if routine care has to be postponed as a result. A plane would be grounded without the right staff to fly it and a safe number of passengers on board. But every day in the NHS patients die because of staffing gaps and a lack of beds to cope with the demand.

Hunt talks a lot about ‘zero avoidable harm’ in the NHS and – just last week – ‘zero in-patient suicides’ but his track record on the essential safe staffing to support this is poor. The NHS provides widespread exceptional care but its recurrent weakness is that it has had, for decades, far fewer staff and beds per head of the population than other comparable countries (Eyes passim ad nauseum). If the government was serious about safety, it would have invested in increasing staff numbers far sooner, and expanded bed numbers so that hospitals are not dangerously full every winter with patients dying because they can’t access prompt emergency care. A brave Hunt would have supported legally enforceable safe staffing and skill mix rotas long ago. Instead, the safe staffing work of NICE was side-lined as too costly, and Hunt blundered into a highly damaging war with junior doctors to try to stretch them across more weekend shifts when they argued there were already far too many dangerous gaps in the rotas on weekdays and more staff (and beds) were urgently needed. The winter crisis shows how right they were to speak up, but the striking off of Dr Bawa-Garba by the GMC may drive them back to secrecy and cover up, fearful that telling the truth will leave them hung out to dry.

Dr Bawa-Garba admits and deeply regrets making serious errors in the care of Jack Adcock, a seriously ill 6-year-old boy who died in Leicester Royal Infirmary (LRI) on 18 February 2011
But MD – and many other doctors – would have made similar errors if forced to work in such an unsafe, unregulated environment. Bawa-Garba, a highly regarded junior doctor with an unblemished career before and since Jack’s death, had no consultant cover for her emergency paediatric shift (he was delivering a guest lecture outside the hospital) and the registrar on the children’s assessment unit was also absent. If the NHS had mandatory safe staffing and skill mix levels, managers at LRI would be obliged to transfer other staff to emergency care even if routine procedures were cancelled. Instead Dr Bawa-Garba was cut adrift and expected to cope in impossible circumstances.

Bawa-Garba had just returned from 13 months’ maternity leave and had little experience of working on the child assessment unit. Her crucial induction training was cancelled due to lack of staff. She had to cover six hospital wards across four floors, responsible for dozens of critically ill children during an inhuman 13 hour shift, with no time from food, drink or rest. The IT system crashed and the results alerting system never came back online. An emergency prevented her from attending the vital morning handover. Despite this absurdly dangerous environment, she helped save a child after cardiac arrest, performed a lumbar puncture, stabilised a child having epileptic seizures and provided compassionate, competent and highly complex care. Amidst dozens of high pressure decisions, she made three diagnosis and treatment errors, all in Jack Adcock’s care. But in a safely staffed team, they would either not have happened or would likely have been checked and corrected.

A jury decided Dr Bawa-Garba was guilty of gross negligence manslaughter and the GMC argued this should automatically mean she should be struck off, rather than supported to return to work. The judges ruled that ‘each case would turn on its own facts’ which in this instance were sufficient to merit her erasure. The facts included her own feedback to her consultant that she could have done better, and her honest self-reflection notes she voluntarily submitted to the trial. A vast sum of money has been raised for her appeal, largely donated by those who know they would have made similar errors in such dangerous circumstances. Hunt must now push for safe staffing legislation in the most dangerous specialties, many of which have daily staffing gaps. And the GMC must admit that in pursuing, blaming and erasing Dr Bawa-Garba it has made a serious error that is likely to make NHS cover-ups even worse, and even more young doctors walk away from the highest-pressure jobs.