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Press releases Saturday 26 August 2006

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(1) MENTAL HEALTH UNITS SHOULD NOT BE EXEMPT FROM SMOKING BAN

(2) CERTIFICATION OF UK DOCTORS WOULD IMPROVE QUALITY OF CARE

(3) WHY ARE SO MANY PEOPLE DYING ON EVEREST?

(1) MENTAL HEALTH UNITS SHOULD NOT BE EXEMPT FROM SMOKING BAN

(Editorial: Exempting mental health units from smoke-free laws)
http://bmj.com/cgi/content/full/333/7565/407

Exempting mental health units from the ban on smoking in public places would worsen health inequalities for people with mental health problems, warn doctors in this week’s BMJ.

Smoking is the largest single cause of preventable illness and premature death in the United Kingdom, with 106,000 people dying of smoking related diseases in 2002, and more than 10,000 dying each year as a result of passive smoking.

The Health Act 2006 will make all enclosed public and work places in England and Wales smoke-free environments, but may exclude some mental health settings.

This would be a mistake, argue Jonathan Campion and colleagues, as the prevalence of smoking is high among people with mental health problems.

Nearly three quarters of people with schizophrenia, affective psychosis, and other mental health disorders who live in mental health settings are smokers, and they are more likely to be heavier and more dependent smokers than the general population, they write.

As a result, people with mental health problems are at a substantially greater risk of premature death from smoking related diseases than is seen in the general population. This is particularly important given that those with mental illness already experience high levels of social exclusion and health inequality, which are exacerbated by smoking.

Arguments for excluding mental health settings from the new smoke-free legislation are that they are places of residence and that some patients are detained under the Mental Health Act. However, health and safety legislation places a duty on NHS employers to protect staff and patients from exposure to environmental tobacco smoke.

Another argument is that preventing people smoking is an infringement of human rights, particularly for detained patients. But the Human Rights Act 1998 allows an individual choice only if that does not endanger others. Furthermore, this argument is not applied to other forms of drug misuse, and people are not allowed to drink alcohol or use illegal drugs in mental health units.

Research also shows that smoke-free policies have succeeded in mental health settings. Such bans have caused fewer problems than anticipated, and policies applied in a consistent way to all patients were more effective than selective bans.

The health select committee has proposed that psychiatric institutions in England and Wales should not be exempt from the Health Act 2006, say the authors. “We strongly endorse this proposal and suggest that all mental health settings should introduce complete smoke-free policies. These policies should be introduced in a flexible and pragmatic way, with support and treatment available for patients to stop smoking and manage withdrawal.”

“Exemption from the Health Act will exclude mental health patients from mainstream health improvement strategies and exacerbate the inequality they already experience,” they conclude.

Contact:

Dr Jonathan Campion, Specialist Psychiatry Registrar, Queen Mary’s Hospital, London, UK
Email: jonathan_campion@yahoo.co.uk

(2) CERTIFICATION OF UK DOCTORS WOULD IMPROVE QUALITY OF CARE

(Does certification improve medical standards?)
http://bmj.com/cgi/content/full/333/7565/439

Certification of UK doctors would help to improve quality of care, say researchers in this week’s BMJ.

England’s chief medical officer recently recommended certification of doctors to strengthen professional regulation. Specialist certification is a well established process in the United States that allows doctors to demonstrate achievements and competencies beyond the minimum acceptable standards required for licensing purposes. Certified status must be renewed every six to 10 years.

But does certification improve medical standards?

Kim Sutherland and Sheila Leatherman reviewed data on the effect of certification in the US on quality of care. A review of studies published between 1966 and 1999 found that over half showed positive and statistically significant associations between certification and superior outcomes. Since 1999, four well conducted studies have concluded that certification is associated with provision of higher quality care across a range of specialties.

Recent studies have also found that a lack of certification is associated with an increased risk of disciplinary action.

So, most of the available evidence seems to support rigorously conducted certification as a good method to improve quality of care, say the authors. Renewable certification also provides a more transparent process for assessing skills, knowledge, and competence than the opaque principles of professionalism.

Adopting certification as a key regulatory instrument in the UK will have important implications, they add. In the US much of the cost is borne by doctors themselves who are likely to benefit from the process. However, there may be an argument for some of the costs to be offset by the NHS.

As the NHS strives to improve quality of care, it is important to consider the central part played by the professions, they write. Individual professional conduct, along with collective professional values, will always provide a patient with the best quality assurance. Certification, or validation within the UK context, provides a way to strengthen and bolster that vital protection and reassurance.

Contact:

Kim Sutherland, Senior Research Associate, Judge Business School, University of Cambridge, UK
Email: k.sutherland@jbs.cam.ac.uk

(3) WHY ARE SO MANY PEOPLE DYING ON EVEREST?

(Personal View: Why are so many people dying on Everest?)
http://bmj.com/cgi/content/full/333/7565/452

Why are so many people dying on Mount Everest, asks doctor and climber, Andrew Sutherland in this week's BMJ?

It used to be thought that it would be physiologically impossible to climb Mount Everest with or without oxygen. In 1953 Hillary and Tenzing proved that it was possible to reach the summit with oxygen and in 1978 Messner and Habeler demonstrated it was possible without oxygen.

Although Everest has not changed, and we now have a better understanding of acclimatisation, improved climbing equipment, and established routes, it would therefore seem logical that climbing Everest might have become an altogether less deadly activity.

However, this year the unofficial body count on Mount Everest has reached 15, the most since the disaster of 1996 when 16 people died, eight in one night following an unexpected storm.

The death rate on Mount Everest has not changed over the years, with about one death for every 10 successful ascents. For anyone who reaches the summit, they have about a 1 in 20 chance of not making it down again.

So why are there so many people dying on Mount Everest? And more importantly, can we reduce this number?

The main reasons for people dying while climbing Mount Everest are injuries and exhaustion. However, there is also a large proportion of climbers who die from altitude related illness, specifically from high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE).

This year, the author was on the north side of Everest as the doctor on the Everestmax expedition (www.everestmax.com) and was shocked by both the amount of altitude related illness and the relative lack of knowledge among people attempting Everest.

He writes: “On our summit attempt we were able to help with HAPE at 7000 metres, but higher up the mountain we passed four bodies of climbers who had been less fortunate. The last body we encountered was of a Frenchman who had reached the summit four days earlier but was too exhausted to descend. His best friend had tried in vain to get him down the mountain, but they had descended only 50 metres in six hours and he had to abandon him.”

“Some people believe that part of the reason for the increase in deaths is the number of inexperienced climbers, who pay large sums of money to ascend Everest,” he says. “In my view, climbers are not climbing beyond their ability but instead beyond their altitude ability. Unfortunately it is difficult to get experience of what it is like climbing above Camp 3 (8300 metres) without climbing Everest. Climbers invariably do not know what their ability above 8300 metres is going to be like.”

He suggests that climbers need to think less about ‘the climb’ and more about their health on the way up.

No matter what the affliction, whether it be HACE, HAPE, or just exhaustion, the result is invariably the same – the climber starts to climb more slowly, he explains. If you are too slow this means that something is wrong and your chances of not making it off the mountain are greatly increased. But with the summit in sight this advice is too often ignored.

When the author visited the French consulate in Kathmandu to confirm the Frenchman’s death, the consul, not a climbing or an altitude expert, shook his head and said, “He didn’t reach the summit until 12.30; that is a 14 hour climb – it is too long.”

Contact:

Andrew Sutherland, Wellcome Research Training Fellow, Nuffield Department of Surgery, Oxford, UK
Email: andrew.sutherland@nds.ox.ac.uk

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