Our vulnerable world of vanishing safety nets

How vulnerable do you feel as 2022 draws to a close? How worried are you for family and friends? How much more vulnerable are your patients in a world of vanishing safety nets?

Perhaps the most tragic statistic is that 10.5 million of the world’s children are now orphaned by covid-19 (doi:10.1136/bmj.o2838).1 The impact is greatest, as ever, in the poorest countries and among the most disadvantaged populations. Thus far, solutions are few and specific initiatives rare, even in rich countries. Here is a clearly identified group of people who need support—and society, the safety net, is failing them.

A rise in hospital admissions for respiratory illnesses and cases of fatal invasive group A streptococcal infections are rightly receiving attention (doi:10.1136/bmj.o2941).2 But some discussion around these cases is missing. Helen Salisbury argues that safety netting—“come back if she doesn’t get better”—works only if patients and carers have easy access to primary care doctors (doi:10.1136/bmj.o2936).3

When workforce shortages make out-of-hours appointments, and home and return visits, harder, what sense is there in the media vilifying doctors for providing virtual consultations and a virtual safety net (doi:10.1136/bmj.o2934)?4 Innovation, a popular solution to health service crises, isn’t so welcome when it can be used as an excuse to advance an agenda against health professionals.

An end to attacks on doctors in the media would help retention, as would a solution to the UK’s pensions dispute. Losing GPs and hospital consultants in their prime because they pay more on their pension’s tax bill than they earn seems the height of negligence, and the solutions being proposed are clearly inadequate (doi:10.1136/bmj.o2945).5

When safety nets fail, workarounds become solutions. A rise in food banks, for example, is no substitute for increasing low pay and meaningfully tackling the cost of living crisis (doi:10.1136/bmj.o2019).6 Putting asylum seekers in overcrowded detention centres isn’t justifiable when our obligation under international humanitarian and human rights law is to develop a “fair, humane, and effective refugee system” (doi:10.1136/bmj.o2709).7

When safety nets fail, women are at risk. For the first time, a coroner has cited domestic abuse as causal in the death by suicide of a 34 year old woman. Roxanne Keynejad and colleagues argue for prioritisation of domestic abuse, mental health, and specialist third sector services (doi:10.1136/bmj.o2890).8

Women have questioned the clinical safety net for pain and other complications of endometriosis, a condition that affects 190 million women worldwide but one that only 20% of the UK’s general public have heard of. Management strategies have been established (doi:10.1136/bmj-2022-070750), although endometriosis is easily missed (doi:10.1136/bmj-2021-068950) and remains a complex and disabling illness whose symptoms are hard to relieve.910

Investing in women was a reason for Sri Lanka’s favourable health outcomes and prosperity relative to other south Asian countries, but an economic collapse has triggered a health crisis and reminds us of the importance of strengthening health systems and access to essential drugs (doi:10.1136/bmj-2022-073475).11

Those were two of the factors that Adrian Hill and Sarah Gilbert sought to overcome with their approach to the manufacture and distribution of a covid vaccine (doi:10.1136/bmj.o2592).12 Their institution’s partnership with AstraZeneca and vaccine breakthrough ended up being a first mover disadvantage, despite its aspirations for global equity. Manufacture of AstraZeneca’s vaccine has all but halted, with Pfizer and Moderna winning the vaccine wars. In a ruthless commercial landscape, publicly minded innovators need safety nets too.

One safety net that has survived the assault on safety nets is awake prone positioning of patients with covid-19 related hypoxaemic respiratory failure. A new systematic review and meta-analysis finds that prone positioning reduces the need for intubation (doi:10.1136/bmj-2022-071966).13 It is also unlikely to worsen mortality, although this finding is inconclusive. Questions remain unanswered, but an intervention with potential to benefit patients with hypoxaemia merits further evaluation (doi:10.1136/bmj.o2888).14

Rigorous evidence gathering and sound evaluation build confidence in interventions. These were hallmarks of the UK National Institute for Health and Care Excellence as it established an international reputation for setting standards in health technology assessment. A new approach to NICE’s methods that prioritises access to innovation will benefit some patients and certainly manufacturers but may mean that another safety net is slipping away for many other patients (doi:10.1136/bmj-2022-071974).15