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All rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on 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: The hackers holding hospitals to ransom Krishna Chinthapalli. 357:doi 10.1136/bmj.j2214

Whilst many practices who experienced the impact of the cyber attack struggled to signpost patients to services or update them on the impact on practice IT systems, across North Staffordshire practices have developed a clever work around.

Of the 82 practices across Stoke-on-Trent and North Staffordshire, 62 regularly use social media to engage with patients. This infrastructure came into its own on the afternoon of the attack. Not only were they able to send out valuable information to their patient populations, they were also able to alert patients to the problems being experienced at Royal Stoke Hospital. Insight data shows engagement levels were significant and patient reach for the average practice was over 2,500 people. On the same weekend, practices were also able to use heightened interest in their social media Facebook pages to promote other services - a drop in heart screening session for instance reached over 40,000 people over the weekend with sessions booked up immediately.

The impact of the cyber attack clearly showed those practices that have embedded social media into their communication mix now have a valuable tool sitting outside of the network to get information out to their patients quickly and effectively.

Competing interests: No competing interests

23 May 2017
Marc J Schmid
North Staffs CCG
Stoke on Trent
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Re: Frequent personalised emails match effective medicine for smoking cessation, study finds Susan Mayor. 357:doi 10.1136/bmj.j2459

The Journal has always been concerned by adequate resources for the NHS.(1) Sadly, despite the Journal’s efforts, less and less is available and more and more achievements are required.(2)

In this context Mayor’s unbalanced comment commending a randomized trial investigating personalised emails for smoking cessation seems an alarming position.(3,4)

Indeed, 27 tailored cessation emails (the “deluxe email group”) only increased by 3% the smoking cessation rate (declarative basis) vs an intervention with 3-4 emails (“basic email group”): 34% vs 30.8%; respectively.(4)

Brief smoking-cessation interventions in primary care, minimum care, has been the motto for a long time. Will the NHS now consider like Westmaas et al that brief face to face intervention could be a too costly intervention for a condition killing prematurely one out of two among those affected? Nevertheless, as a skeptic I would like to be sure that Westmaas et al’s findings are not biased. Indeed, could it be possible that smokers submerged by emails might declare they quit smoking in order to get rid of email harassment? However, I must confess that “deluxe email medicine” is a new paradigm offering incredible possibilities: obesity and nutrition, life-style intervention …

1 [No authors listed] Inadequate NHS resources. BMJ 1978;1:189-90.

2 Gulland A. Protesters march to stop NHS from being "hung out to dry". BMJ 2017;356:j1204.

3 Mayor S. Frequent personalised emails match effective medicine for smoking cessation, study finds. BMJ 2017;357:j2459.

4 Westmaas JL, Bontemps-Jones J, Hendricks PS, et al. Randomised controlled trial of stand-alone tailored emails for smoking cessation. Tob Control 2017. doi:10.1136/tobaccocontrol-2016-053056.

Competing interests: No competing interests

23 May 2017
alain braillon
senior consultant
University Hospital. 80000 Amiens. France
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Re: Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder Paul A Boelen, Geert E Smid. 357:doi 10.1136/bmj.j2016

Dear Sir/ Madam

I read with great interest your article on prolonged grief disorder.

I was however greatly surprised that no mention was made of religious beliefs in the management of grief and loss.

I have found that as a GP relatives and patients frequently present to me greatly distressed by a loss.

I most often enquire in a sensitive manner as to whether they have any religious beliefs.

If they do I signpost them to a priest, vicar , rabbi or imam and/or to reading sacred texts. So often the patient seems uplifted by my response.

I would urge discreet and sensitive enquiry into religious beliefs when dealing with a patient who has suffered a great loss.

Walsh et al published an interesting article in the BMJ in 2002 showing that spiritual beliefs could affect bereavement.

I would argue that patients suffering loss or grief should be offered spiritual as well as psychological support.

BMJ. 2002 Jun 29; 324(7353): 1551.
PMCID: PMC116607
Spiritual beliefs may affect outcome of bereavement: prospective study
Kiri Walsh, research fellow,a Michael King, professor,a Louise Jones, research physician in specialist palliative care,b Adrian Tookman, consultant physician in specialist palliative care,b and Robert Blizard, medical statisticiana

Competing interests: No competing interests

23 May 2017
Anne Pauleau
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Re: GP leader urges politicians to end “callous disregard” for NHS Gareth Iacobucci. 357:doi 10.1136/bmj.j2424

The announcement last week by GPC Chair Dr Chaand Nagpaul of the crisis in general practice is only the latest in a long string of warnings. The government's response to this was to announce the number of 'new' doctors and nurses injected into the NHS. This response is nothing if not misleading in nature since most of these 'new' staff have been absorbed into the secondary care sector.

Dr Nagpaul's description of the problem as 'spiralling pressures' is an exact description of the problem. At the core of the problem is the changing nature of the care provided in a GP Surgery. Originally, the GP was described as a 'gatekeeper' who controlled access to further care in the NHS. If long term management of a patient was required they went into the outpatient clinics. Moving forward in time this was followed by a prevention/health promotion agenda which was highly successful as evidenced by increasing life expectancy and an increasing number of patients living with many long-term health conditions. The spiralling feedback loop of lengthened life, extending the length of time a patient lives with a health condition and the transfer of chronic disease management into primary care has produced a steadily increasing workload in the Surgery.

But, as is true with all things in life, it is not that simple. GP contracts, the monitoring and surveillance data collected, and the structure of primary care need to change. Policy makers need to see the whole picture rather than just the fragment that is under their purview. The constant reference to GPs managing chronic conditions when most of that work is done by Practice Nurses would be a good place to start reframing the discussion. Policy-makers also need to recognise that the new 'gig' economy means that people lose pay to attend working-hours appointments.

A co-ordinated rethink of the approach to staff training in general practice is also needed. For example, GP surgeries are independent businesses but medical schools don't teach doctors how to run a business. There is currently no UK recognised professional qualification for healthcare managers and an MBA is not fit for purpose as evidenced by the presence of such a qualification in most other developed countries. The fragmented nature of the current GP contracts make a co-ordinated approach more difficult but this is what is clearly required for change to be successful

Competing interests: No competing interests

23 May 2017
Shona J Kelly
Dr Robin Lewis
Sheffield Hallam University
Collegiate Crescent Campus, Sheffield S10 2BP
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Re: Effective cybersecurity is fundamental to patient safety Guy Martin, James Kinross, Chris Hankin. 357:doi 10.1136/bmj.j2375

There will be much written about the sociotechnical reasons for breaches in security generally and the "Wannacry" problem specifically.

I will only highlight a fundamental problem that predisposes to exposure to cyber attacks - the lack of timely maintenance and updating of systems and operating platforms in organisations. This is increasingly becoming the norm in hospital networks and information systems. Financial constraints leading to limited and delayed technical support means that a significant proportion of workstations in large and fiscally compromised health organisations are vulnerable to cyber attacks.

Digital innovations are double-edged swords!

Planners and legislators must recognise that inadequate allocation of resources to establish and maintain information systems over the long term not only limit the ability to achieve the desired deliverables but can also lead to harm to the organisation. This is particularly relevant in lesser developed countries with limited resources. This inequity further compromises the global network (digital village) with its multi-directional connectivity. The approach to cybersecurity must be a global one and requires bridging the global digital divide.

Competing interests: No competing interests

23 May 2017
Siaw-Teng Liaw
Clinical academic
UNSW Medicine Australia
1 Campbell Street
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Re: Italy recognises patient safety as a fundamental right Tommaso Bellandi, Riccardo Tartaglia, Aziz Sheikh, Liam Donaldson. 357:doi 10.1136/bmj.j2277

May I take this opportunity to congratulate Dr. Tommaso Bellandi and his colleagues on this very timely reminder to national medical establishments of their responsibility to ensure patient safety. Primarily this can be achieved by a safety plan that treats reporting of unsafe practices (currently treated as unacceptable whistle blowing) as an acceptable and responsible practice. This could be developed on the basis of no names, no pack drill; thus avoiding the issue of "status". Of course serious events would have to resolved differently, but I suspect that most events would not be of this importance.

The results of an inadequate safety policy are clearly outlined by the authors in the costs involved in reparations and legal defense; money that would be far better spent on proper safe health care than on providing large sums of money on reparation and legal fees.

Will the medical establishment and the NHS do anything to rectify the current inadequate/negligible safety? I doubt it unless considerable political and patient pressure is exerted on them.

Competing interests: No competing interests

23 May 2017
Michael J. Hope Cawdery
Retired veterinary researcher
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Re: Seven days in medicine: 10-16 May 2017 . 357:doi 10.1136/bmj.j2363

Please don't remove chocolate from the vending machine in theatre. It may be bad for patients when they eat it themselves, but it's probably very beneficial when eaten by their anaesthetist (and surgeon) at 4 o'clock in the morning - after 8 hours without a break.

Competing interests: No competing interests

23 May 2017
Thomas R Miller
ST4 anaesthesia
Mark W Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

I often have thoughts similar to David Oliver's:

'Not only is the study subject to multiple confounders but its external validity in other very different health systems is doubtful.'

when I read papers about healthcare 'behaviour'.

Competing interests: No competing interests

23 May 2017
Michael H Stone
Retired Non Clinical
Coventry CV2 4HN
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Re: Cannabis as medicine Giles Newton-Howes. 357:doi 10.1136/bmj.j2130

Clinicians should be made aware at the outset that all forms of cannabis are not equal and the medicinal benefits and risks vary accordingly.

A study published by the WHO in 2015 clearly states that butane hash oil, because of the much higher THC content, has the potential to cause psychosis and addiction equal to that of cocaine.

Under normal circumstances, and because of the strains being grown, the THC content of many plants is now around 12-16%, which some consider to be of concern in itself as this is much greater than the amounts contained in plants found in nature.
However, butane hash has a THC content of around 80% (1)
This product is largely being sold unregulated and also marketed as being of medicinal value to patients looking to mitigate symptoms of various illnesses. It would though appear, that the potential side-effects are not being pointed out.

I contacted several national drug and health authorities throughout Europe and none appeared to be aware of the significance of the issue.
Unfortunately THC is the compound contained within cannabis which, few would argue, provides the medicinal benefits. But, conversely, it is also the compound which causes side-effects. Therefore the greater the medicinal benefit, the greater the risk of addiction and psychosis.
Clearly, patients and professionals alike, must be made aware that all forms of cannabis are not equal and some carry much higher risks than others. This will allow them to make an informed judgement irrespective of whether national health authorities have yet to update their own knowledge and guidelines.

(1) Update of Cannabis and its Medicinal Use. Bertha K Madras. 37th ECDD (2015)

Competing interests: No competing interests

23 May 2017
Karen L Thompson
Freelance Researcher/Writer
S. Paio, Gouveia, Portugal
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Re: Implementing shared decision making in the NHS: lessons from the MAGIC programme David Tomson, Sheila Macphail, Carole Dodd, Kate Brain, et al. 357:doi 10.1136/bmj.j1744

I am a GP with an interest in SDM.
I listened to the sound cloud audio on BMJ yesterday and reflected that the elephant in my consulting room is made up of time, mental bandwidth to handle another agenda in addition to the 3+ problems that the patient has already brought and easy access to PDAs. Then the follow up appointment ( as a phone call or FTF) has an impact on our access targets.
For my colleagues, understanding and practising the consultation model, when this has not featured in mainstream education agendas would be a challenge. Then, no one is “telling “ us to do this, or with any recognition of resources needed. All within a 10 minute consultation model.
I believe that the model does overall save time and can improve patient experience - it is just that the immediate cost of time to undertake it is paid now, by stretched GPs.
I'd be only too happy to consider ways that could help SDM work in a practical context for us and our patients. Any ideas?

Competing interests: No competing interests

23 May 2017
Pawan Randev
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