Choice GP

Places to die and sleep, and "the forces of conservatism"

Where to die, where to sleep? Tentative answers to these paraShakespearean questions are offered in this week's journal. Most people in Britain want to die at home, and carers are more likely to say that the place of death was right if the patient dies at home. Yet only about a quarter of people die at home. That is why "hospital at home" schemes have been developedto try to help more people to die at home. But do they work? Gunn Grande and others have tried to do a randomised controlled trial to answer that question (p 1472). As is so often the case with palliative care, the trial was not entirely successfulbut it did not show that patients receiving hospital at home care were more likely to die at home. Duncan Keeley questions in an editorial (p 1447) "how much evidence do we need that skilled home nursing available round the clock would be a good idea?" One answer might be that medical and social care are littered with examples of schemes based on the best of intentions not achieving their aims.

The question of where to sleep relates to babies. There is now irrefutable evidence that putting babies to sleep on their backs reduces cot death, but there has been conflicting evidence on whether it is dangerous for babies to sleep in their parents' beds. Today we publish the first big case control study (325 babies who died, 1300 control infants) to be conducted since putting babies on their backs to sleep has become common (p 1457). The main finding is that sleeping with the baby does seem to increase the risk of cot death if the mother smokesbut not if she doesn't. Another finding was that the increased risk was very high if parent and baby slept on a sofa. Ed Mitchell summarises the story on cot deaths so far (p 1461).

Tony Blair, Britain's prime minister, caused a stir in the summer by attacking "the forces of conservatism" and choosing doctors as his example. The government linerepeated by Alan Milburn, secretary of state, last week (p 1505)is that the pace of change must accelerate in the NHS, ensuring that it is responsive to the needs of patients rather than the needs of professionals. Chris Ham unpicks government thinking on how to get the best from the NHS and argues that the government might be about to make a serious mistake (p 1490). It is tending to see staff in the NHS as part of the problem rather than as part of the solution and may not be recognising that "staff are fundamentally well motivated to deliver service improvements and simply need training, development, and support to enable them to realise their potential."

Footnotes

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