We need to add 2 more freedoms to the original four!

Apart from the “four freedoms” described by President Rosevelt, freedom of Expression, freedom of religeon, freedom from fear and freedom from want, it occurs to me that we need to add frredom to experience clean water, and clean air. Mrs Thatcher privatised water companies, and helped the pension funds with their income generation, and if she could have privatised the air we breathe she would have. They have polluted all our rivers, and pose great long term health risks to us and our successors. They will take decades to clean up, and they come “top” (bottom) of my hierarchy of needs as they are physiological .
2022: The Times view on the link between pollution and dementia: Clear the Air – New research shows toxins from traffic are a major contributor to dementia as well as other debilitating or fatal conditions. The next prime minister must toughen up the law

2024: Clean the air: Scientists raise the alarm as air pollution is linked to dementia
Scientific advisers to the government have urged ministers to set tougher limits on air pollution after a landmark report found that it probably contributes to causing dementia.
The Committee on the Medical Effects of Air Pollutants (Comeap), an independent panel of experts, reviewed 70 previous studies and concluded it was “likely that air pollution can contribute to a decline in mental ability and dementia in older people”.
The experts believe that polluted air causes damage to the blood vessels in the brain. In turn this can cause vascular dementia, which is estimated to affect about 150,000 people in Britain. A further 700,000 people have other forms of dementia, such as Alzheimer’s, where links to air pollution are less clear.

Professor Frank Kelly, the Comeap chairman, said the government should “absolutely” adopt stricter targets on the most dangerous type of air pollution, known as PM2.5, based on guidance by the World Heath Organisation (WHO).
PM2.5 is formed of airborne particles with a diameter less than 2.5 micrometres, about a twentieth of the breadth of a human hair. The WHO has called for an average annual exposure not above 5 micrograms per cubic metre, but the government has proposed 10 micrograms per cubic metre for England by 2040. The Environment Act requires a target to be set by the end of October.
Professor Nick Fox, director of the Dementia Research Centre at UCL and one of the authors of the new report, said: “Inaction now will cost people the ability to live independent, healthy lives in years to come . . . The evidence is very strong that exposure to air pollutants is likely to increase your risk of dementia, possibly decades later.”
The Clean Air for All campaign, launched by The Times in 2019, has called for limits based on WHO recommendations. At present, regulations set a limit five times higher, at 25 micrograms.

Sir Andrew Goddard, president of the Royal College of Physicians, said that the type of studies on which the new report is based cannot prove a causative relationship between air pollution and dementia. But he added that they contributed to a growing body of evidence suggesting a link.
He has called for a PM2.5 target of 10 micrograms per cubic metre to be met by 2030, and for 5 micrograms by 2040. “It’s based on the government’s own projection that they could probably get down to 11 by 2030,” Goddard said.
Eight medical royal colleges, including the Royal College of Physicians, said last month that limits proposed by ministers would “fall far short of the level required to improve health and save lives”.
Steps that could reduce PM2.5 would include eliminating fossil-fuel power stations, reducing wood burning in homes, and removing old vehicles. Professor Alastair Lewis, of the University of York, said that meeting WHO targets would be challenging, especially in the southeast of England, which is affected by air pollution from the Continent. He added: “The report adds more evidence on the wide range of effects that air pollution has on public health . . . It’s something that accumulates inside us all over the long term.”

The Department for Environment, Food & Rural Affairs said: “Air pollution at a national level continues to reduce significantly, with nitrogen oxide levels down by 44 per cent and PM2.5 down 18 per cent since 2010, although we recognise we need to go further.”

It has estimated that achieving the targets proposed by ministers would result in up to 214,000 fewer cases of cardiovascular disease, 56,000 fewer strokes, 70,000 fewer cases of asthma and 23,000 fewer cases of lung cancer over 18 years.

The Times manifesto for clean air — revisited

In 2019 The Times launched its Clean Air For All campaign and set out a manifesto of what needed to be done. Here we revisit those demands — and update what has been achieved.
1. A new Clean Air Act to confer a legal right to unpolluted air for everyone in the UK
The first Clean Air Act, introduced in 1956 in response to the Great London Smog, was a world first. Britain has since lost its mantle of world leader in tackling air pollution. A new act should adopt tighter limits based on World Health Organisation guidelines and give local authorities powers and resources to tackle pollution.
2. Pollution monitors in every postcode
When people are given precise and up-to-date information from live local monitors about the level of air pollution near by, they will be empowered to take action and hold politicians to account.
3. Extend temporary traffic bans outside schools
Children at almost 400 schools in London are protected from air pollution by temporary traffic bans. The growth in “school streets”, where cars are banned at drop-off and pick-up times, was a victory for our campaign, but must go further. All vehicles except buses should be banned from roads beside all schools for 45-60 minutes in the morning and afternoon. The ban, which would not apply to main roads, can be enforced by number-plate recognition cameras. More children will walk, reducing both obesity and road accidents.
4. Extend low-emission zones in cities
London and Birmingham led the way with charges on the most polluting cars. Since our manifesto was published, more cities, including Bath and Portsmouth, have introduced levies. Others will follow suit this year, such as Bradford (September) and Bristol (November).
More can be done. Local authorities should introduce measures to disincentivise the use of polluting vehicles in city centres. Those introducing pay zones should ensure they cover all classes of vehicles.
5. Our 2019 manifesto called for a ban on sales of new diesel and petrol cars from 2030
The government acted on this in 2020, putting Britain on course to be the fastest G7 country to decarbonise cars and vans. We applaud this. Grants for electric cars have been scrapped since, however, and should be reintroduced. A push to install chargers is needed if the 2030 deadline is to be achieved.

How badly does air pollution harm health?
It causes 40,000 early deaths a year, according to a 2016 report by the Royal College of Physicians. There is evidence that it causes dementia, heart disease, lung cancer and respiratory conditions including asthma. A government panel has confirmed the link with dementia after a review of 70 studies. A 2018 study in The Lancet said 60,000 of the 209,600 new cases of dementia a year could be due to poor air quality.
Why does air pollution cause dementia?
Tiny particles seep into the bloodstream and damage blood vessels in the brain, reducing the supply of oxygen to brain cells. In rare cases, they may enter the brain directly after being breathed in, causing inflammation linked to dementia.
And other diseases?
Breathing in pollutants can damage the blood vessels by making them narrower and harder, increasing the likelihood of clots, abnormal heart rhythms and heart attacks. Half of those with asthma say toxic air triggers their symptoms, according to Asthma + Lung UK. Air pollution was listed as a cause of death for the first time in the UK after Ella Adoo-Kissi-Debrah suffered a fatal asthma attack in 2013 after being exposed to excessive pollution from vehicle exhausts. The brains of children are particularly susceptible.
What is the government doing?
It has set a target to curb levels of the most harmful pollutant, PM2.5, by 2040, but the limits proposed by the government are not as tough as those recommended by the WHO. Scientists and doctors say the stricter WHO guidelines should be adopted.
What is the role of individual councils?
The government sets pollution limits but local councils enforce them with initiatives such as low-traffic areas, fines for wood burning and speed limits.
How can I mitigate air pollution?
Avoid hotspots such as busy roads or junctions. Travel before rush hour, when pollution levels rise, and walk or cycle on back streets.

Another disillusioned doctor leaves the service.

Doctors are usually intelligent, motivated and driven characters. They could have made a living doing many nother things but they chose medicine. We are losing them. Retiring early, going asbroad, emigrating or into other careers,… if they dont get stress or long covid.
Ikran Dahir reports: NHS doctor quits after going viral on YouTube with skincare advice -Dr Hani Hassan is launching a skincare start-up tailored to help people of colour with hyperpigmentation.
A doctor who graduated during the COVID pandemic became so disillusioned with the pay and conditions that she left full-time work in the NHS to launch her own skincare line.
Dr Hani Hassan finished six years of medical school at King’s College University in the summer of 2020, and immediately found herself among the junior doctors tasked with bearing the brunt of coronavirus, working on the frontline as the virus claimed the lives of 200,000 people in the UK alone.
“The amount of responsibility you have is insane,” she told Yahoo News. “It’s nothing near what your peers would have. To think you’re 25 and going home early means that actually, maybe a patient who might be having a heart attack won’t be seen for a few more hours, and so you just stay late. But essentially, the pay just doesn’t make sense. The amount of responsibility, the amount of work you have to do, the amount of knowledge, and the amount of training.”
Dr Hassan said she loves the NHS and believes in free health care but that the stressful working conditions and low salary meant she was pushed to her limits during the pandemic. “If you don’t have resources, it’s really difficult to sustain yourself, especially in London, on that kind of salary,” she said. “There’s a real culture of things like ‘don’t take your lunch’, ‘do this because people’s lives are on the line’.”

Laura Donelly in the \Telegraph 19th December 2023: Doctors’ strikes will mean NHS fully functions for just four days over next three weeks

The Guardian: Junior doctor strikes ‘will increase risk NHS will be overwhelmed’ this winter

Evening Standard: ‘We cannot go on like this’, say junior doctors as strikes begin

The Chronicle: ‘NHS on a knife edge’: North East junior doctors hit out at ‘joke’ pay offer as they strike days before Christmas

Sky News feb 2023: Record numbers of NHS doctors are resigning. 

BBC News today 20th December: Junior doctor could leave job over pay dispute

Times letters 11th Jan 2024: Doctors’ pay scales

Sir, It is a true but misleading fact that the hourly rate paid to junior doctors is the same as that paid to domestic cleaners (letter, Jan 10). However, 20 years on, cleaners will still be on the same equivalent hourly rate while hospital doctors, now consultants, will be earning far more. The problem is that the pay of junior doctors in their late twenties and early thirties is quite inadequate to meet their expenses, eg mortgage repayments and childcare, at this phase of their careers. The government and BMA should agree that, when pay is next negotiated, consultants should receive a pay increase well below that of inflation. With the money thus saved, junior doctors should receive a pay increase well above inflation. Total career pay would be unaffected. The disgruntlement felt by hospital consultants at this arrangement would be at least partly assuaged by the fact that the morale and eagerness to work of their junior colleagues would be greatly improved by awareness that their value was at last being properly recognised.
Philip Graham
Emeritus professor of child psychiatry, UCL; London NW5

Humanity has long been squeesed out of the mental health services, and now from the general medical service…

Kids are more and more not attending schools. Home learning is becoming more common. Should the state address this with an annual curriculum for each year group and each subject on line? Does out handling of asylum seekers reflect our historic treatment of the mentally ill? Would classes in citizenship help? We allow adverts encouraging gambling, alcohol and vaping – all the vices – on sporting heroes. A retired psychiatrist makes a plea for not introducing FCS (Family and consumer services) into every school, but instead to use resources to facilitate resilience.
On the closure of asylums and letting kids grow up:
My great uncle was superintendent of Derby County Asylum AKA Derbyshire Mental Hospital from 1935 until 1940. My only experience of asylums was working at Macclesfield Asylum in 1994, whilst it was being run down (it is now an executive housing estate as is often the case).
But yes, their closure was not the great liberation promised. The report of the closure of the Friern Hospital in London even managed to spin a positive outcome out of the finding that death rates in the discharged (assessed as well enough to go) were not worse than the death rates of those who remained (assessed as too unwell to survive in the community).
As a psychiatrist I spent 29 years battling the political decimation of mental health care, mainly in Manchester. Part of that was militant nursing colleagues who were antipsychiatry, and antidoctor. They led the “New Ways of Working” debacle of the 2000s, and its resurgence in the last 10 years. In the end I had enough. That the same deprofessionalism of mental health care is now extending to general medicine has finally woken my colleagues up.
It should be said that the asylum building project of the mid-1800s was not an upsurge of altruism on the part of the establishment. Edward Oxford attempted to assassinate Queen Victoria in 1840. John William Bean attempted to assassinate Victoria in 1842. Daniel M’Naghten attempted to assassinate the Prime minister in 1843. They were all found to be insane. The County Asylums Act 1845 was to remedy the failure to lock up their ilk. Why do the rich have to feel threatened before they do something, I wonder?
The principles are clear, and rooted in humanity. Unfortunately a lot of humanity has been squeezed out of mental health services, and as a knock on effect, from the community. We need a mental health grouping to advise, but unfortunately in Wales it is too dominated by professional interests. A psychologist in every school FCS (Family and consumer services) ? Last thing we need. How not to instil resilience in kids.

Public health director attests the long term degeneration of the 4 health services.

Our excess deaths are no more or less than other countries, but there does seem to be a deferred excess death rate. Perhpas due to “long covid” but perhaps also due to the long term effects on the cardiovascular system as well as the unhealthy lifestyles many people got used to during the lockdown. We were unprepared.
Yvonne Doyle reports in the Times 14th December 2023: Public Health England director: Covid inquiry should focus on avoidable deaths : An unhealthy society is more vulnerable to new pandemics
More people are dying since 2020. The prime driver of this has not been Covid-19, despite its heavy death toll. Even in the pandemic other causes of death were more common. The World Health Organisation has confirmed 6.99 million deaths from Covid to this month while global excess deaths over the same period are estimated to be over 27 million. The UK follows this pattern: annual deaths are over 20,000 higher than would be expected from the previous five-year average, according to the Office for National Statistics.
These deaths represent an underlying pandemic of ill health. They are driven by highly preventable conditions such as heart disease, diabetes and cirrhosis caused by lifestyle choices. They mainly occur at home now. Unless access to preventive and early treatment improves, these causes of death will continue, and be joined by cancer.
In this struggle against ill health the UK is faring worse than many similar economies. This is an important finding masked by Covid. Unfortunately, what has been said at the Covid inquiry about preventing the next pandemic focuses solely on tactical decision-making by political leaders.
This misses the point. Infections move along easy lines of transmission: an unhealthy society is more vulnerable to future pandemics. A disproportionate number of those who died from Covid were obese, diabetic, or lived in poverty with poor access to social care. People in these categories will be at most risk in any future pandemic and this is where the UK needs to focus its public heath attention.
There is also a large economic impact to these health trends. Avoidable ill health costs the UK hundreds of billions of pounds every year. Unhealthy lifestyle is strongly associated with early avoidable disability, inability to work, demand on the NHS and dependence on social support.
Inaction and funding cuts in preventive services relating to obesity, alcohol consumption and substance misuse make choosing a healthy lifestyle difficult for many and have added to these longer-term costs.
However, attention to people’s lifestyle, encouraged by government support, will address many of these issues. Scientific evidence shows that brisk daily exercise, avoiding unhealthy food, smoking and excess alcohol consumption are simple ways of ensuring good health.
The pandemic has demonstrated that a population with resilient underlying health and good social care is not just “nice to have” any more. Helping to prevent these deaths will also help us to be more prepared for future health shocks.

The Economist: The National Health Service faces a terrible winter

Britain’s NHS will continue to be a political hot potato in 2024 – Perhaps hotter than usual – listen

Covid origins don’t really matter, because new pathogens are always a risk, and government reductions in Public Health expenditure mean they were unprepared.

An “Unprepared government” is a result of our political system. Hospitals are unfit to fight a modern war.

NHSreality on public health

Technology has failed in the health service – apart from Primary Care

The Time s letters 7th November 2023: ADOPTING NHS TECH
Sir, Regarding Emma Duncan’s piece (“Tech can transform the NHS — if doctors will let it”, Nov 3; letters, Nov 6), when I was appointed as a consultant orthopaedic surgeon in 1986 I requested that my secretary be issued with a computer rather than a typewriter to save time and eliminate carbon paper and Tippex for corrections etc. I was told this was not possible as only the managers had these. Later that decade our region invested in RISP, a computerised system to link hospitals, which we all welcomed but which failed, resulting in no money for investment in any regional capital project for two years. Then towards the end of my career I was involved in final testing of the latest software for operating theatres nationally after significant NHS investment. It was not fit for purpose and was scrapped at a huge financial loss. I have never met a doctor who did not embrace new technology but we have been badly let down over a long period and do not wish to see good money thrown after bad. Any system should be fully tested before implementation with no NHS money committed irrevocably beforehand.
Neil Thomas
Emeritus consultant orthopaedic surgeon, Itchen Stoke, Hants Sir, I fear that Emma Duncan’s view of “recalcitrant doctors” maligns the wrong group. Over my long NHS career, every innovative surgical and IT system introduced to improve clinical efficiency, patient care and safety (eg, keyhole surgery and surgical electronic databases) was driven and introduced by doctors. Initially, at every potentially transforming turn, the innovative and technologically savvy doctors were obstructed, frustrated or simply ignored by a wall of obfuscation from recalcitrant managers, purchasers and fundholders.
Dr David Farnworth
Rowlands Castle, Hants

Letters 6th November 2024: Use of tech in the NHS

Sir, Emma Duncan is right that the NHS needs more computer systems that are up to scratch and doctors who are more open to change (“Tech can transform the NHS if doctors let it”, Nov 3). I research digital inclusion, adoption and the use of innovative technologies, and we have found that users need to adopt these novel technologies to make an impact. If they are not widely adopted they will not be used and any investment or updates made will not have any impact. Instead the technology will become obsolete, with no returns on investment. This was what we learnt when researching broadband, electronic government, enterprise social systems and now AI-related technologies. When we conducted research about the use of chatbots for the management of early-stage dementia, we found that when the patients understood the potential of the technologies, they readily accepted it — leading to some small but significant delays in dementia.
Jyoti Choudrie
Professor of information systems, University of Hertfordshire

Sir, Emma Duncan claims that “recalcitrant doctors” (specifically GPs) stand in the way of technological progress in the NHS. In fact GPs are often at the forefront of innovation compared with the wider NHS beleaguered by bureaucracy and outdated IT systems. She is further mistaken about patients’ GP record access via the NHS app. Patients who want to do this are already able to upon request. The BMA’s concerns are targeted at the lack of safeguards in place with a mass switch-on, to protect our vulnerable patients from unintended consequences, a concern that is openly shared by anti-domestic violence campaigners. On UK Biobank, we support data sharing when it is done well, as evidenced by our endorsement of OpenSAFELY for research and planning purposes, and when requested through appropriate channels (the BMA and RCGP joint IT committee). Health data is an invaluable resource with the potential to help patients and improve health outcomes, but any sharing must be done safely, securely and not put patients or doctors at risk.
Dr Katie Bramall-Stainer
GP and chair, BMA England GP committee

NHSreality on technology in the 4 dispensations

The future is not hanging by a thread – the thread has broken, and the staff are broken. The Guardian writers are living in the past.

The medical professions have known all this for 20 years. Its the media led society and short term political horizons that has managed to ignore and deny an existential problem. Long term planning would have ensured enough staff, enough plant and equipment, and a sustainable single health service. Instead we have the opposite, in multiple systems, all of which encourages the health divide, private health care, and lower life expectancies for the poorest people in our society, such as the ex-mining community of Tredegar. The political class is out of touch with reality, as is evident from the evidence presented to the covid enquiry. Lets hope the conclusions are not about blaming people, but about improving systems and sustainability – before the next pandemic. Where NHSreality differs from the Guardian is that the future is not hanging by a thread – the thread has broken, and the staff are broken. We need NEW!
Inside the NHS as staff say future hangs in the balance – video – in the guardian 4th July 2023 Andrew Gregory and his associates report by video:
The NHS was launched in 1948 by the Labour MP Aneurin Bevan, inspired in part by the Tredegar Medical Aid Society in his constituency. It has since saved the lives of millions and inspired health systems around the world. Seventy-five years on, the Guardian video team was given access to NHS services in the south Wales town, and found residents, patients and staff still proud of Bevan’s legacy, but anxious about the future.

Kat Lay in the Times 6th November 2023: Patients ‘forced to go private’ as NHS braces for winter pressures……..Rachel Power, chief executive of the Patients Association, said she feared that in the coming months the health service would see a repeat of last winter’s problems, urging more focus on basic communication with people under the care of the NHS…….
She said: “If you are in a hospital bed you just don’t have agency and don’t have that power. So you really need the healthcare professional to have the confidence to say, ‘What’s important to you today? What’s up today? What are you feeling today? What can we do together?’ And I think they’re very basic questions.”
The Patients Association was established 60 years ago to fight for patients amid the thalidomide scandal. It now campaigns for improvements in health and social care for patients 

A cruel law on assisted dying is regressive and unfair

KEN MACDONALD KC opines in the Times: The law on assisted dying is cruel — reform is needed – With strict safeguards in place, people in terminal distress should have agency over their own demise in the UK, and families should not fear prosecution.
Scores of cases of assisted suicide came across my desk when I was director of public prosecutions for five years until 2008. Always distressing, they usually involved a journey to Dignitas in Zurich and an administered end of life. The victims earnestly wished to die, and our suspects were husbands, wives, parents and children. Sometimes the bodies were cremated in Switzerland, with no cause of death available. But often the remains were returned to the UK and post-mortems showed the truth, usually massive barbiturate poisoning. Evidence of crime seemed overwhelming.But we did not prosecute because a criminal charge requires two things: sufficiency of evidence and a finding that a prosecution would be in the public interest. Invariably we felt the circumstances failed this second test.
We felt that a parent, faced with the option to accompany their child to Dignitas or to have someone go in their place, had no choice that the public would regard as real. We felt that a husband, required by law to let his wife travel to Switzerland without him, would not, if he nevertheless went with her, face a charge that the public could understand. Who would not need to hold hands at the end? In this sense, we prosecutors made law — and were even obliged by the Supreme Court to publish the factors we considered, so that people might better know how to assist a suicide without facing prosecution. This was in the face of parliament steadfastly refusing to change the law. For many years, despite the uncomfortable constitutional implications of taking the law into our hands in this way, I felt this was a good compromise. A general prohibition on assisting suicide would protect the vulnerable from exploitation, while a merciful exercise of prosecutorial discretion could shield loved ones acting in good faith. Surveys seemed to show that the public approved of our stance.
But I no longer think that this unspoken bargain is sufficient. If you believe, as I have come to, that men and women in terminal distress are owed some agency over the time and manner of their demise, relying on foreign law and a British blind eye is a coward’s compact. It ignores the impossibility of travel for many, through sickness or poverty, and it is exclusionary and unfair, leaving most who wish to die to suffer in Britain instead. It fails the courage of its own convictions by putting widows and bereaved parents through the compounded torment of a criminal investigation, even if no prosecution results. It is cruel.
Beware the slippery slope, we are warned. Beware the creation of a burden of expectation weighing on elderly shoulders. These are valid concerns, which I share. But British proposals repeatedly before MPs contain tightly drawn rules: safe medical evidence of suffering and the prospect of an imminent bad death, a settled will to die, and, crucially, the prior approval of a high court judge. Against real end-of-life distress, these are compelling safeguards which ought to satisfy our parliament as they clearly satisfy the British public. In the end, as I cast my mind back to the many cases I saw as a prosecutor, I cannot avoid a conclusion that has led me to support reform of the law: those people whose statements I read had done nothing wrong.

Lord Macdonald KC is a former director of public prosecutions

NHSreality posts on assisted dying

Letters 20th October: DIGNITY IN DYING
Sir, Those involved in all levels of the criminal justice system have lost faith in our laws on assisted dying (“The law on assisted dying is cruel”, Law, Oct 19). Until recently I was a police officer and control room supervisor. In 2019 my professional and personal lives collided when my terminally ill mother decided to travel to Dignitas in Switzerland, the only way she felt she could guarantee a peaceful end. I was faced with breaking the law or knowing she’d die alone.
While it was perfectly legal for my mum to do so, it would be illegal for me to help her in any way. She knew I’d be under even greater scrutiny given my job. As I had a young family to look after, she made me promise not to go with her, terrified I could lose my livelihood. It was the hardest decision I’ve ever had to make. The memory of saying goodbye, fighting the urge to run after her, will always haunt me. I needed to hold her hand at the end. But I couldn’t.
I’ve seen first-hand that the law on assisted dying does not fulfil its duty to protect. It causes suffering. It forces dying people abroad. It rips families apart. It wastes police time. The only sensible response is to make assisted dying a safe, legal option in the UK. Former colleagues, senior figures in the police, MPs, peers and candidates standing in the next election have agreed with me. I urge parliament to do the right thing and change the law.
James Johnson
North Baddesley, Hants

Update 21st October: Times letter Assisted dying law

Sir, Suicide is not a benefit, and it is not “exclusionary and unfair” that physical or financial constraints prevent people travelling abroad for assistance in suicide (“The law on assisted dying is cruel”, Law, Oct 19, and letter, Oct 20). It is important to recognise that taking lethal drugs does not always lead to a quick and easy death. In the Netherlands last year 219 people were legally assisted with suicide but of these 33 had deaths that were so lingering or distressing that the doctor felt it necessary to administer a lethal injection as the coup de grâce. In Switzerland, such direct action by a doctor would be illegal and typically a doctor is not even present when death is occurring. We have little medical evidence of rates of complications of the cocktail of drugs used for assisted suicide in Switzerland. In England and Wales, what is needed urgently is to expand provision of care at the end of life and to develop suicide prevention strategies to support people who are elderly, sick or disabled. What we do not need is a romanticised picture of death in Switzerland.
Professor David Albert Jones
Director, Anscombe Bioethics Centre, Oxford, and professor of bioethics, St Mary’s University, Twickenham

Letters 23rd October 2023: Dignity in death

Sir, Professor David Albert Jones (letter, Oct 21) is right; we urgently need expanded provision of end-of-life care but we also need individual freedom.

My sister had aggressive cancer diagnosed in April, bedridden by June and, despite excellent treatment, experienced excruciating and all too frequent pain. Fortunately she lived in New Zealand and last week, with the help of her GP, community nurse and an anaesthetist from the local hospital, she died a peaceful death eight days after her 70th birthday. She was fortunate in being able to prepare for this moment, to say goodbye to family and friends and to feel that she had some control over her inevitable end.

As Rabbi Jonathan Romain has said, assisted dying shortens death, not life. There was nothing romantic about my sister’s suffering.
Jill Beck
Kingston-upon-Thames, London

Sir, Professor Jones has a strange idea of romance. Suffering indignity, pain and fear. Dealing with complicated paperwork and the cost. Summoning great courage to travel abroad and dying in a flat helped by strangers. Romantic, I don’t think so.
Mary McMillan
Haddington, East Lothian

Sir, The letter from Professor Jones contains errors of fact. All three assisted dying institutions in Switzerland use a single drug and not a “cocktail of drugs” and there are no recorded cases of patients not succumbing peacefully with death soon after.

Perhaps the professor could also have mentioned that the offices he holds are with Roman Catholic organisations whose stated aim is to influence not only the dying of their flock but the suffering in terminal illness of the whole of society.
David Cunningham Green
London N19

Sir, Professor Jones states that some assisted dying deaths are “lingering or distressing”. I always believed I earned my money as an anaesthetist not for putting people gently to sleep but for ensuring that they woke up. Providing a peaceful and pain-free death is not technically difficult.

There is a legitimate debate to be made about the wisdom of voluntary euthanasia. It should not be distracted by discussion about the effectiveness of methods for bringing this about.
David Goldhill
Retired consultant anaesthetist, Whitstable, Kent

Live a shorter life: access care is slower, choice is absent, and wait is longer – in Wales… Aneurin Bevan’s dream that the miners of Tredegar would have the same life chances as the bankers of London has become a nightmare.

As a resident and citizen in Wales I am aware that none of the news bulletins in the media under the headline “NHS” apply to me or to the people who live in my town. Published figures are deliberately generated differently, and therefore we are comparing “apples with pears” when it comes to performance with the other 3 dispensations. Now we hear that the figures we have been given are inaccurate anyway. NHSreality has no faith in the Welsh Governement (Synedd) and opines that devolution has failed. Kat Lay for The Times reports that “Long waits in A&E left out of Welsh data” (not on lione at time of posting) , but then our A&E was rebranded an “Urgent Care” centre some 3 years ago and the desperate figures from this would not be included anyway! Aneurin Bevan’s dream that the miners of Tredegar would have the same life chances as the bankers of London has become a nightmare. In the general article by Lay the graph below shows the different boards’ figures:

Jenny Rees for BBC News Wales 17th October 2023 reports: NHS Wales: Thousands of hours missing from A&E figures – doctors – The true picture of A&E waiting times in Wales has been seriously under-reported for a decade, senior doctors have told the BBC. …. Wales’ health minister has repeatedly claimed A&E waiting times in Wales have “bettered English performance”. But once the missing data is taken into account, it suggests the performance in Wales is worse…..

January 2022: NHS Wales: Record waiting times for 19th successive month and Alex Massie: We can fix the NHS only with honest leadership

2021: Comparing apples and pears will not make it easier for the devolved citizens to know how their system compares. If devolution has failed, equity has failed even more.

2019: Poor state of Welsh health. The experiment with devolution has failed…. and Wales is bust, and cannot pay for its citizens care. Devolution has failed. This is the thin end of a very large wedge..

2021: If we cannot agree to reverse the devolution at least we could unify public health.

Update 21st October 2023: Live longer, in poverty
Successive governments and businesses are failing to plan for demographic change. We are not prepared for the aged to live to 100, let alone 120 (Technology Quarterly, September 30th). Short-term reactive policymaking has contributed to workforce shortages, economic stagnation and a health and care system failing to meet our changing needs.
Future generations may not only be bored—not least if they continue to be pushed out of the employment market soon after they hit 50—they are also likely to spend longer living in poverty and with ill health. Innovations in biotech are one thing, but finding solutions to the financial, health, housing, transport and leisure needs of our ageing society is the challenge we must address first.
david sinclair
Chief executive
International Longevity Centre
London

People need to move to improve their lives. Living in cities reduces birth rates… But they are hotter..

As the city life becomes more attractive, and work opportunities are greater, government needs to consider helping people move. The evidence is, that in Africa particularly, moving to cities means better health, more money, and choosing to have fewer children. However it means living in a hotter world… Where rich countries have air conditioning, poorer ones need to use other means to make life pleasant. Before the advent of electric air conditioning, persians used tall wind towers called badgirs and cool air from qanats (underground aquaducts) to remove some of the hot air from living spaces¹². The ice house, known in Persian as yakhchal, was used to store ice in alternating layers of ice and insulating straw³. Wind catchers are an ancient Persian technology that could produce refrigeration temperatures⁴.

In the poorest parts of the UK (NE and Welsh Valleys) people could move to new places where there is plenty of work: moving from Wales to England increases life expectancy by up to 10 years, and “Healthy life expectancy” (HLE) by 5 years. The correlation with house growth is evident.

Tom Calver – Data editor Sunday Times reports 30th July 2023: Inside Newbuild City: We love our homes but we’re crying out for schools and GPs

Where people want to live: new homes built in the last decade

Richer societies mean fewer babies Economist 2022

The Guardin Want to fight climate change? Have fewer children 2017

Vegard Skirbekk on why we should embrace low fertility rates 2022 in The Economist and 2013: Family size: why are we having fewer children?

2023: Americans are moving to places besieged by extreme heat -To stay liveable, hot cities are experimenting with ways to keep cool

June 2016: Why rural Britain is struggling

The doctor juggler – some patients will inevitably fall…

I have the privilege of knowing many doctors and GPs in particular. The GPs all start work early, and are given a ball to catch, followed by another and another. By the time they have answered their e-mails and read their mail (100 of each ) taking actions when necessary, they have many balls in the air. Juggling GPs are proliferating, and dropping a ball is becoming more commonplace. Many are detail people who hate compromising their standards, and so they feel disappointed with themselves as well as the system that has cranked up the abuse and the pressure of multiple balls over the years of neglect. Imposter doctors will mean more balls fall…

Rob Hastings reports 31st July 2023: Diary of an NHS GP: 12-hour plus shifts, ‘nonsense’ admin, vandalism and tears at the end of the day (msn.com)

If you ask John whether he loves his job as a GP, he feels conflicted. 
Helping children with fevers, elderly cancer sufferers and people stifled by depression still feels as rewarding to him as ever. Along the way, he’s prepared to start early, stay late, spend his Sunday afternoons doing admin and sometimes even unblock his building’s toilets. It’s all part of the job. 
But his team’s increasing workload, the feeling that things will only get worse in GP practices in the coming years, plus the troubling state of the wider NHS his patients rely on, often leaves him feeling desperate. 
Like many family doctors, John – whose name has been changed – is fearful about risks to the public as GPs come under pressure to cram in more and more appointments. He’s frustrated at how different parts of the healthcare system end up making things worse for each other because they are all overwhelmed. He’s angry at how GPs have been portrayed as lazy and overpaid while struggling to cope with the post-pandemic surge in demand. He feels weighed down by pointless bureaucracy. “The way that it’s run at the moment, I feel the NHS is beyond repair,” he says. “All the politicians are being really disingenuous about how bad things are and how dysfunctional it is. It’s totally propped up by the goodwill of the people working for it. You can see with the junior doctors, the nurses and everyone else who’s been striking that they’ve had enough.” He adds: “I think it was potentially remediable a few years ago but the pandemic was potentially the final nail in the coffin. My gut feeling is we’re just kidding ourselves that it can continue in its current guise for much longer. I fear it can’t.” John, who is based in the West Midlands and has been a GP partner for over a decade, recently spoke to i each evening for several days for a detailed account of what a family doctor’s work really involves. You can read his diary below.
He isn’t speaking out just to try and increase pressure on the Government to offer GP partners a pay rise. He is no union militant. Asked if he would support a strike ballot being called by GPs and whether he would vote in favour of industrial action, his answer comes quickly. “No and no,” he says. “GPs handle 90 per cent of NHS contacts with patients (with 10 per cent of the budget), so the potential for harm is too great.” He simply feels that patients’ health is already being put at risk by the overloaded system and can’t contemplate worsening that by shutting his surgery’s doors. 
He was deeply troubled to read about the case of law student David Nash, who died in 2020 after four remote GP appointments about an ear infection which caused an abscess on his brain. In January a coroner ruled that Nash was likely to have lived if he’d been seen face-to-face. John feels this is an example of how patients’ lives can be endangered if GPs become overwhelmed. 
In common with plenty of colleagues these days, he deals with far more daily cases than the 25 deemed safe by the British Medical Association. “I see 30 to 40 patients a day,” he says. That’s on top of helping to run his practice, which is a semi-independent business like all GP surgeries in the UK. He is one of a handful of partners at his surgery, which also employs several other GPs and is training a few more. As desolate as John feels sometimes, even he finds reasons for hope, which is evident in his diary. Practical changes like IT improvements for better appointment-booking systems might sound minor or mundane but they can improve experiences for the public and medics hugely. But that doesn’t get away from how badly the country needs more GPs, at a time when their numbers are actually falling, John says.

Friday: Our mystery vandal 
Today ended with a job I’ve never had to do before: I sat down and watched our CCTV because we’ve had some vandalism at the surgery. Believe it or not, someone poured concrete down one of the patient toilets. I wasn’t in when it happened. The next day people were joking about the toilet being blocked, and someone had to deal with it, so I stuck a mask on and found a stick. I was expecting just to be faced with a massive poo, but I walked in and it was literally concrete. I think it’s the stuff you use to set fence posts. 
It was rock hard. We had to get a plumber in for a whole new toilet and pipework. It probably cost about £1,000 to fix. Obviously it was a deliberate act. Anyway, we have a new CCTV system so I went through a whole day’s recordings and found the little git. He walked in, tried to cover his face from the cameras, went to the toilet with a backpack on, walked out, wiped the door handles with his sleeve – presumably to remove fingerprints – and then walked out of the building. 
We don’t recognise him which is a bit weird, because we’re assuming it’s someone with a grudge against us, but we’re sending screenshots to the police and we’ll put signs up in reception.  …….

Virtual hospitals, medical triage and imposter doctors mean more litigation and complaints, and is short termism appropriate to the disastrous times ahead..

NHSreality on no fault compensation and litigation

Rob Hastings for INews: ‘I’m seeing 60 patients a day’: NHS GPs warn that patient safety fears are increasing risk of strike ballot – GPs warn they are sometimes seeing twice as many patients in a day as recommended under union safety guidelines