Global Warming

 

If the Pope is about to utter on global warming – why shouldn’t I?

 

The recent actions, or intended actions, by the G7 are an encouraging sign that the government of the world is beginning to take the problem of global warming and rising CO₂ levels seriously.  The emphasis on developing nuclear energy and other renewable sources of energy such as solar and tidal power are certainly to be welcomed.  On their own, they are however likely to do little more than to slow down the process and to delay the time when the effects of global warming become serious.  The development of effective energy production by nuclear fusion – “creating a mini sun on the earth” -may be an exception to this prognosis. 

 

However, there are two measures that could deal with the situation much more effectively.

 

The first is necessary, whatever other solutions are adopted. This is to arrest the growth of the human population or indeed to secure some degree of decline.  The projections of global population growth have decreased over the last twenty years, The main factor that seems to have been involved is the improvement of living standards and particularly of women’s education in the developing world and, not least, the provision of bathrooms, which make contraception much easier.  However, there are still populations which for religious reasons remain committed to the duty to breed as a primary human concern ; and in some cases such populations aim to outbreed their neighbours for political ends.  This is a problem that needs to dealt with by governments rather than by science. 

The other solution, however, which could deal effectively with global warming, though it would not prevent the exhaustion of other planetary resources that will come about unless the population is controlled,  is to genetically engineer major crop plants so as to increase their efficiency of photosynthesis.  This proposal was put forward by the late Lord Porter, a former President of the Royal Society and a very distinguished photochemist, in his 1995 Rajiv Gandhi lecture.  He pointed out that if the efficiency of photosynthesis could be improved from the present level of 1% to around 5% then this would allow all the food and energy needs of the planet to be met from the amount of agricultural land under cultivation at that time.  This is not an easy problem to solve.  The initial enzyme, Rubisco, is notoriously inefficient and early attempts to increase its efficiency were unsuccessful.  However, with the greatly increased knowledge of molecular biology and of the role of chaperones it does seem possible that this could be achieved if a major effort were put into it.  Although some laboratories are currently involved in this work, it really requires an effort on the scale of the Manhattan Project since this is an innovation which could literally save the planet.  There has been some scepticism of this approach on the grounds that evolution would have achieved an increased efficiency of photosynthesis if this were possible.  This argument is, however, fallacious.  When CO₂ levels are low, there is no evolutionary advantage in raising  the efficiency of photosynthesis.  This would simply lead to the plants running out of CO₂ and being unable to continue photosynthesis.  In other words, increased efficiency of photosynthesis is valuable only when CO₂ levels are high and if we succeed in bringing them right down again using genetically engineered crops then in due course the world’s agriculture will revert to the less efficient crops that we have at the moment.  It might be of interest, if it were possible, to investigate the photosynthesis by  plants in the carboniferous age when there were indeed very high CO₂ levels and the present fossil fuels were being deposited in the ground.  It is, however, so long ago that it may not be possible to recover the genetic information one wants.  Nevertheless, this should be a project that is given huge support and one of the reasons that it isn’t is undoubtedly the irrational, but widespread, opposition to plant molecular biology and to the modification of food plants by genetic techniques. 

 

This opposition is totally irrational and is held largely by people who do not realise that all plant breeding involves genetic modification and that as a technique it is totally morally neutral.  It is, of course, necessary to take precautions about what gene one introduces to make sure that the product is not toxic or allergenic, or that the mode of insertion into the genome does not produce undesirable side effects.  That is already the case with all novel foods however they are produced.  Indeed, a common method of producing genetic variation in food plants, - irradiating the seeds,- produces much more widespread genomic change and is potentially much more damaging and therefore does require very careful control.  However, no-one should doubt that the root and branch opposition to genetic modification of plants is hugely harmful and may one day be seen as one of the main causes why we have been so inefficient in dealing with global warming and its potentially devastating consequences. 

This is an issue on which scientists should speak out.

The European Referendum

 

Now the negotiations with Europe are underway and the press is full of discussions of the referendum and the advantages and disadvantages of the UK remaining within the union.  I find it very surprising that no-one seems to mention that possibly the most important purpose of forming the European Union was to prevent another major European war.  Although it is not possible to say for certain that the EU was solely responsible, it is nevertheless true that Western Europe  has for the last seventy years  been at peace.  Sadly this does not extend to the Balkans, where there have been major conflicts, or to the rest of the world where war seems to be almost continuous.  It does, nevertheless, seem a very powerful reason for maintaining the European Union and for retaining the United Kingdom as one of its important members.   

It does seem highly plausible that not only the free trade area but the free movement of people between the countries of the Union does lead to increased mutual understanding and that this, as well as the attempts that the European Union makes to achieve some degree or integration, have contributed  to maintaining  the peace.  For this reason alone I will vote to stay in the Union – whatever the outcome of the “re-negotiations”

 

 However I am surprised that the criticisms of the Europe Union are nearly always aimed at the European Commission rather than at the European Parliament

The European Parliament was set up by those who wished to see much closer European integration and who envisaged the creation of a European Government and the formation of a United States of Europe rather resembling the United States of America.  In that case, there would indeed be an unarguable case for having a European Parliament to fill the same purposes that are served by the Congress of the United States.  However, we have no European Government even remotely in view but we do have a European Parliament.  This body seems to me to have a certain amount of power but  virtually no responsibility.  .  Its lack of responsibility is really very obvious.  I have had some involvement with the EU, largely through my association for many years with the Federation of European Academies of Medicine, I have carried out an informal survey not only of my British colleagues but of those from other European countries to discover how many people know even the name of their MEP.  The answer is almost none.  Members of the European Parliament do not seem to be responsible to their constituencies and indeed the way that they are elected from party lists means that the candidates have very little contact with their constituencies anyway.  Nevertheless, this unrepresentative body with no obvious function costs the community  large sums of money. In my view too many MEPs  tend to espouse extreme positions on many unreasonable causes, be it opposition to GMOs, and to various reproductive technologies; and enthusiastic support for alternative medicine.  

 

It would surely be an excellent idea to suspend the European Parliament until such time (if ever) as there is a European Government.  In the meantime, the two palaces that it occupies in Strasbourg and Brussels could be used for other purposes and perhaps bring in money rather than spend it; and the amount that is now spent on the MEPs could be used for socially much more useful purposes.   

It is remarkable that even those who reject the European Union , such as members of UKIP, nevertheless hold seats in the European Parliament and are  happy to take its money.

 Perhaps this is what Mr Cameron should be discussing with Mr Juncker and with his fellow heads of state.

Electing a New Labour Leader

I am a long-term supporter of the Labour Party who has from time to time been a member of the party and who resigned on the last occasion when Gordon Brown failed to honour his promise to take the NHS out of direct political control.  He had given this undertaking and I wrote a letter to The Times applauding this undertaking.  This elicited a response from Daniel Finkelstein who said the idea was bonkers and that a service spending so much money must be under direct political control.   I doubt whether I am alone in thinking that it is Daniel Finkelstein and not Gordon Brown’s promise that is bonkers. Political micro-management of many highly expensive services, be it the Universities, the Research Councils, the schools or the NHS, has been a marked feature of governments since Mrs. Thatcher and is slowly being recognised to be a thoroughly bad idea,  not least because the management of these services is long term and cannot be tied to the electoral timetable. 

 

  When, in 2010, Ed Milliband was elected to the Labour leadership, despite having the majority of neither MPs nor the constituency members, but solely because he was the choice of the trade union movement, I was not tempted to rejoin the party.  This is not because of any qualities that Ed Milliband did or did not have, but because I could not bring myself to regard him as a legitimate leader of the Labour party.  To his credit, he altered the system but sadly it does seem to me that the system which has now been introduced is even worse.  I had wondered when it was proposed to have a one member one vote system for those who were members of the Labour party and those who were subscribing members to the political fund of  trade unions, that there would be a time limit imposed so that only those who had been members before the last general election would be allowed to take part.  I now read in the newspapers that this is not the case, and that anybody who joins or pays up before August can take part in the leadership election.  This is an open invitation to corruption.  The trade unions may pressurise or even give inducements to members to pay up in order to be able to vote and the possibility that there will be frank bribery to get people to join the Labour Party just for this purpose can by no means be excluded, especially in view of some scandals of this kind in local government in the past.  It again offers the opportunity for large trade union leaders to exert excessive influence in determining the outcome and those of us who remember the terrible damage they did to the Labour Party in the 1970s will not be tempted to see a recurrence. 

The Full Time NHS

It is five years since I raised the topic of a 24 hours a day/7 days a week hospital service with Mr. Lansley. (see previous blog) It is good to see that the present government is showing an interest in the idea and some determination to bring it about.  It is less encouraging that the response from our medical colleagues has on the whole been negative. 

At the base of the opposition, I think, is a misunderstanding.  If the whole hospital service were to go from working on average, say, in the region of 10 hours a day and five and a half days a week (which is a guess, not an accurate estimate) this would amount to  55 hours a week.  To make all the hospital facilities work 24 hours a day and seven days a week would raise this to 168 hours, i.e. it would expand the hospital service threefold!  Whereas this might be thought desirable in theory, it is quite clearly impossible in practice and the proposal to go to a “168 hour per week service” is quite different. 

 

If in a large medical centre a number of services -  the operating theatres, the diagnostic departments and the acute medicine departments were to go to 168 hours per week, then it would need to follow that a much of these services currently provided on the 55 hour a week model in reasonably nearby hospitals would have to be discontinued.  One can envisage that some hospitals might close altogether, thereby making large savings on the maintenance of the estate and on the administration which are both expensive.  The relevant staff  would be transferred to the 168 hour a week hospital to enable it to function at that level. 

 

However, there is also a real need for “low intensity” hospital facilities which used to exist and have largely disappeared.  There has been much discussion of bed-blocking by patients who have no need for intensive facilities but for whom there are no facilities in the community, and there are also other patients who still require some degree of medical care but who do not require the expensive facilities of an acute hospital.  For such patients, it would be desirable to have low intensity hospitals which provide accommodation, nursing care and basic medical care but without the expensive facilities to be found in the large hospitals.  Some years ago it was estimated that a high intensity bed cost £500 a night and a low intensity one £100 a night, so that there are also large savings to be made here. 

 

Quite clearly, changes of this description cannot be brought about nation-wide, or all at once.  In urban areas, or in regions where there is a large hospital within reach, such changes may be made without the need for training new staff and the added expense of paying staff for unsocial hours would be more than recompensed by the savings that can be made by reducing activity in the surrounding hospitals.  Where this looks feasible, it could be initiated quite quickly.  In other areas where the distance of travel would make for serious problems, the arrangements may be more difficult to bring about. In any case gradual introduction of change with the old and new systems running side by side, will allow comparisons to be made - seeing where the benefits and  the difficulties  lie and seeing  which delivers more QUALYS per £. Sad experience has shown clearly enough that this is always preferable to trying to introduce  nationwide, untested changes tied to an electoral timetable!

 

The situation with regard to general practice is quite different but here also one can envisage changes being gradually brought in which would reduce the existing work-load while allow seven day a week access. 

A major change that has occurred in general practice since the introduction of the NHS, has come with major advances in medicine which have led not to the cure of chronic diseases but to their management.  There are now large numbers of patients, and not only the elderly, that suffer from chronic conditions such as diabetes, hypertension, asthma and chronic lung disease, angina and chronic heart disease, rheumatoid arthritis and related rheumatological diseases among others, who require regular assessment and care over many years. This care has increasingly been put onto general practitioners.  This, however, is contrary to the clinical evidence.  There is good evidence most of these diseases, that patients’ outcomes are significantly better when they are cared for in specialised clinics set up for their particular disease.  This is by no means surprising.  Not only it is probably advantageous for  doctors to see many instances of these diseases rather than a few, but such clinics will also have access to specialised ancillary services (for example dieticians and podiatrists for diabetes, as well as the diagnostic services that are required.  Furthermore clinical trials on newer treatments are easier to carry out in this environment., There is therefore be a strong case to be made for establishing diabetic clinics, hypertension clinics, chronic respiratory disease clinics etc in large central hospitals where outpatient care is provided  for the management of long-term conditions.  It is almost certain – and could be properly evaluated -  that this would improve outcomes.  It would also save a great deal of time in general practice which would allow GPs to concentrate on their other functions and to provide a seven day a week service.  Again, such changes cannot be brought in all at once and would have to be allowed to develop slowly where the conditions are favourable.  All these changes should be closely monitored so that, again, their value in QUALYS per £ spent can be evaluated. 

Going onto European Time - a public good

It is encouraging that another attempt is being made to change the British time zone so as to increase our use of daylight. It will save energy and reduce road accidents at virtually no cost.

When this was last considered in 2007 I wrote to Sir David King the Scientific Adviser to the Lbour Government as follows:
Dear David
It was good to talk to you - albeit briefly.
You asked for more information on the use of Double Summer Time,  particularly as a virtually cost-free method of saving energy. It was used for this purpose in the Second World War (when we were effectively what is now European time) and a trial of just keeping single summer time throughout the year was performed in the UK in 1968 - 1971. The extent of energy saving seems not to be exactly known (at least to me) but the figure of 1% of electricity use is bandied about. That is not an entirely trivial amount. Just think how many wind turbines would be needed to do that - and how much they would cost (in energy as well as money) to build.

It is beyond question that at most times of year except in the two months round the winter solstice, hours of daylight in the early morning are exploited by fewer people than hours of daylight in the evening because we rise and go to sleep according to clock time and not according to sunlight hours. Therefore putting the clocks forward must - and does - reduce energy use. Some people dislike the idea of changing the clocks at all but we are, in any event, committed to this by European directive. So it is only the "time zone" that is in question.

There is also substantial evidence that road accidents are reduced by the change in spite of the fact that some newspapers campaigned shamelessly in 1968-71 by showing pictures of children involved in morning road accidents. Those not involved in the evenings cannot of course be pictured. ROSPA is convinced that the net effect is accident reduction.

I append for you a link to a debate in the House of Lords this spring where Lord Tanlaw proposed to reintroduce "Double summer time".  To its shame our (your!) government failed to support the bill and to provide the time for it to be enacted. The Scots are apparently hostile to the idea but now there is devolution they could keep their own time zone and there could then be a proper, controlled trial measuring both energy use and accidents.

I also append some extracts from a web-site giving some US data and an article which gives both sides of the arguments from the student British Medical Journal which is referenced.

I hope you can persuade Ministers that this is really will save some energy and cost nothing - and that you will persuade them to get the Tanlaw bill through parliament this session!

Best wishes

Yours ever

Peter










This year's debate in the House of Lords

http://www.theyworkforyou.com/lords/?id=2006-03-24b.459.0

____________________________________________________________________________________________________________________________________


However, Daylight Saving Time does save energy. Studies done by the U.S. Department of Transportation show that Daylight Saving Time trims the entire country's electricity usage by a small but significant amount, about one percent each day, because less electricity is used for lighting and appliances. Similarly, in New Zealand, power companies have found that power usage decreases 3.5 percent when daylight saving starts. In the first week, peak evening consumption commonly drops around five percent.

Energy use and the demand for electricity for lighting homes is directly related to the times when people go to bed at night and rise in the morning. In the average home, 25 percent of electricity is used for lighting and small appliances, such as TVs, VCRs, and stereos. A good percentage of energy consumed by lighting and appliances occurs in the evening when families are home. By moving the clock ahead one hour, the amount of electricity consumed each day decreases.

In the summer, people who rise before the sun rises use more energy in the morning than if DST was not in effect. However, although 70 percent of Americans rise before 7:00 a.m., this waste of energy from having less sunlight in the morning is more than offset by the savings of energy that results from more sunlight in the evening.

In the winter, the afternoon Daylight Saving Time advantage is offset for many people and businesses by the morning's need for more lighting. In spring and fall, the advantage is generally less than one hour. So, Daylight Saving Time saves energy for lighting in all seasons of the year, but it saves least during the four darkest months of winter (November, December, January, and February), when the afternoon advantage is offset by the need for lighting because of late sunrise.

In addition, less electricity is used because people are home fewer hours during the "longer" days of spring and summer. Most people plan outdoor activities in the extra daylight hours. When people are not at home, they don't turn on the appliances and lights.

There is a public health benefit to Daylight Saving Time, as it decreases traffic accidents. Several studies in the U.S. and Great Britain have found that the DST daylight shift reduces net traffic accidents and fatalities by close to one percent. An increase in accidents in the dark mornings is more than offset by the evening decrease in accidents.

Oil Conservation
Following the 1973 oil embargo, the U.S. Congress extended Daylight Saving Time to 8 months, rather than the normal six months. During that time, the U.S. Department of Transportation found that observing Daylight Saving Time in March and April saved the equivalent in energy of 10,000 barrels of oil each day - a total of 600,000 barrels in each of those two years.
Likewise, in 1986, Daylight Saving Time moved from the last Sunday in April to the first Sunday in April. No change was made to the ending date of the last Sunday in October. Adding the entire month of April to Daylight Saving Time is estimated to save the U.S. about 300,000 barrels of oil each year.

from:http://webexhibits.org/daylightsaving/c.html
________________________________________________________________________________________________________________________________________

Clockwatching

Impress your mates at the pub with your startling repertoire of esoteric medical knowledge


What happens this year on 26 March in Europe, is delayed until 2 April in America, but doesn't occur in Japan at all? Well, in those countries taking part, it's time to turn the clocks forward one hour, marking the start of daylight saving time (DST), or summer time as it's also known. Now you might groan about losing valuable minutes for partying, studying, or sleeping (your priorities changing as you progress through the course), but are there any tangible benefits to this annual ritual? And what about the health implications of daylight saving that don't often get a mention?

Origins

Benjamin Franklin came up with the bright idea in 1784, to make better use of daylight and so reduce the amount of money wasted on candles in 18th century Paris.^w1 By having the population rise at dawn and go to bed at sunset, as well as rationing candle sales and putting a tax on houses with shutters, he estimated (not entirely seriously) that anywhere between �150m and �400m in today's money could be saved.

The idea didn't resurface until 1907 when a London builder, William Willett, advocated advancing the clocks by 20 minutes on each Sunday in April and reversing the process in September.^w2 It found limited support until the first world war, when Britain, Germany, and other countries adopted daylight saving in 1916 to boost wartime production and save coal. The US followed suit for seven months in 1918, but public opposition led to Congress overriding the measure against the wishes of President Woodrow Wilson�it wasn't until the second world war that Franklin Roosevelt introduced it again across America. At the same time in the UK, political enthusiasm for the energy savings associated with DST led to the introduction of double summer time for the duration of the war, whereby the clocks were advanced two hours ahead of Greenwich Mean Time (GMT) in the summer and stayed an hour ahead of GMT for the rest of the year.

Fast-forward to today, and roughly 70 countries have daylight saving time, although when it starts, how long it lasts and how much of each country is affected varies widely.

Benefits
Accident reduction
A reduction in fatal road traffic accidents is often cited as the major public health benefit of daylight saving time. When Great Britain experimented with maintaining DST all year round between 1968 and 1971, it's thought about 2,500 fewer people were killed or seriously injured during the first two winters of the trial�the equivalent of an 11.7% reduction in casualties for the whole country. Although morning casualties increased, the number was far outweighed by the drop in casualties in the longer evenings.^w3 Smaller studies in the UK have confirmed this trend, with improvements in safety primarily for pedestrians, cyclists, and school children.^{w4 w5} More recently, the Royal Society for the Prevention of Accidents has estimated that 450 deaths and serious injuries occur during the five months of the year when DST is not in operation in the UK.^w6 In the US, the Insurance Institute for Highway Safety estimated that 901 fatal crashes could have been prevented over the years 1987-91 if DST had been retained year round due to the availability of an extra hour of daylight for the busier evening traffic rush.^w7
Unfortunately �unambiguous� and �evidence� rarely go together. The three year British trial of DST coincided with the introduction of random breath testing and new speed limits�powerful incentives for drivers to improve their behaviour regardless of how bright the evening is. Studies have shown an increase in road accidents during the first few days of DST (by as much as 8%)^w8 and unexpectedly following the end of DST^w9 which are attributed diversely to loss of an hour's sleep, alcohol, fatigue, and the fact that the early morning period is intrinsically risky.

Energy savings
Just as importantly for the planet, using daylight more efficiently could mean modest but significant energy savings and reduced pollution. As a result of the Arab oil embargo in the 1970s, the US Congress experimented with extended DST for two years (18 months over that period instead of the normal 12).

When the US Department of Transport evaluated the effectiveness of the trial, it found that roughly 100000 barrels of oil were saved daily in March and April of 1974 and 1975 by having DST.^w10 Extending this finding, energy stricken California estimates that an extension of DST for the winter months could reduce electricity use by 0.5%.^w11 These savings are mainly due to reduced domestic consumption thanks to the extra hour of daylight in the evenings.

However, before we rush to adjust our clocks, a senior official in the US Department of Transport recently
sounded a note of caution: �There have been dramatic changes in lifestyle and commerce since we completed our studies that raise serious questions about extrapolating conclusions from our studies into today's world.�^w10
She emphasised that their work is over 25 years old, was limited in scope, and has had its methods questioned (for example, failing to consider that reduced electricity use could be offset by increased petrol consumption owing to extra evening travel)^w12�so we haven't found an alternative to Kyoto just yet.

General wellbeing
Claims have been made that brighter evenings would increase our exposure to daylight and encourage outdoor activity, fitness and health. Supporters of extended DST also maintain that more time spent in the sunlight would reduce vitamin D deficiencies, especially in children and elderly people, and help people with depression^w13 and seasonal affective disorder (SAD)�a specific type of depression believed to be related to reduced exposure to sunlight.^w14 As low vitamin D levels are a problem for 6-18% of the elderly US population,^w15 rocketing to 57% of the general inpatient population,^w16 and with anywhere up to 500000 suffering from SAD in the UK alone,^w17 the public health benefits of DST could be far-reaching but have not been proved.

Exceptions to benefits

Nevertheless, although we might agree that all these �benefits are worth while, our bodies beg to differ when actually faced with the change. Circadian rhythms, our own biological clocks, regulate behavioural and physiological processes and are synchronised by the daily light-dark cycle. Changing over to DST in the spring is thought to upset this cycle in healthy adults who get less than eight hours sleep (most medics) or are more active in the evenings,^w18 and disruption is also seen for five days after DST ends.^w19 Those few transition days are particularly difficult for anyone with depression20 as well as teenagers and adolescents, whose body clocks are already poorly synchronised to daylight thanks to delayed secretion of melatonin, the body's �sleepiness� hormone.^w21 All in all, the only ones enjoying changeover day itself will probably be those irritating individuals who have never missed a night's sleep and finish a day's work before the rest of us are even out of bed, but, to quote Oscar Wilde, �Only dull people are brilliant at breakfast.�

Conclusion

Despite mixed reports, governments look set to continue tinkering with the issue. George Bush, mindful of his country's addiction to oil, has extended DST in the US by a month, starting in 2007. In the UK, frustrated by a decade of government dithering, the Royal Society for the Prevention of Accidents has called for DST to be in place throughout the winter, with double summer time from March to October (two hours ahead of GMT); a throwback to the war years, this would have the effect of abolishing GMT, putting the UK in the same time zone as western Europe.^w14 While some will be quick to criticise any possibility of change, a chance that hundreds of road traffic accidents could be prevented means that the plans deserve a fair hearing at the very least; whether they will be implemented is a different matter.

Thomas Mac Mahon , intercalating medical student, University College Dublin, IrelandEmail: tmacmahon@gmail.com


studentBMJ 2006;14:133 - 176 April ISSN 0966-6494

1. Franklin, B., "An Economical Project: Daylight Saving." A letter to the editor of the Journal de Paris April 26, 1784 http://webexhibits.org/daylightsaving/franklin3.html (accessed February 10, 2006)
2. Franklin, B., "An Economical Project: Daylight Saving." A letter to the editor of the Journal de Paris April 26, 1784 http://webexhibits.org/daylightsaving/franklin3.html (accessed February 10, 2006)
3. Home Office, "Review of British Standard Time," Cmnd 4512: HMSO, 1970
4. Whittaker, J.D., "An investigation into the effects of British Summer Time on road traffic accident casualties in Cheshire," J Accid Emerg Med 13 (1996): 189-92
5. Adams, J., White, M., Heywood, P., "Year-round daylight saving and serious or fatal road traffic injuries in children in the north-east of England," J Public Health (Oxf) 27 (2005): 316-7
6. Royal Society for the Prevention of Accidents. Lighter Evenings: RoSPA summertime briefing. Birmingham, 2005 http://www.rospa.com/roadsafety/info/summertime_briefing.pdf (accessed February 10, 2006)
7. Ferguson, S.A., et al., "Daylight saving time and motor vehicle crashes: the reduction in pedestrian and vehicle occupant fatalities," Am J Public Health 85 (1995): 92-5
8. Coren, S., "Accidental death and the shift to daylight savings time," Percept Motor Skills 83 (1996): 921-2
9. Varughese, J., Allen, R.P., "Fatal accidents following changes in daylight savings time: the American experience," Sleep Med 2 (2001): 31-6
10. U.S. Department of Transportation. The Daylight Saving Time study. A report to Congress. Washington, GPO, 1975. Cited by: L.L. Lawson, Acting Deputy Assistant Secretary for Transportation Policy, appearing before the House Science Committee, Energy Subcommittee, concerning daylight saving time and energy conservation, May 24, 2001 http://www.house.gov/science/energy/may24/lawson.htm (accessed February 10, 2006)
11. Kandel, A., Metz, D., "Effects of Daylight Saving Time on California Electricity Use," California Energy Commission, May 2001 http://www.energy.ca.gov/reports/2001-05-23_400-01-013.PDF (accessed February 10, 2006)
12. Tellier-Beauregard, F., "PRB 05-18E Daylight saving time and energy conservation," Parliamentary Research and Information Service, Parliament of Canada. July 29, 2005 http://www.parl.gc.ca/information/library/PRBpubs/prb0518-e.htm#2txt (accessed February 10, 2006)
13. Olders, H., "Average sunrise time predicts depression prevalence," J Psychosom Res 55 (2003): 99-105
14. Royal Society for the Prevention of Accidents. Single/Double Summer Time: Position Paper. Birmingham, 2003 (updated 2005). http://www.rospa.com/roadsafety/info/summertime_paper.pdf (accessed February 10, 2006)
15. http://whqlibdoc.who.int/publications/2004/9241546123_chap3.pdf (accessed February 10, 2006)
16. Thomas, M.K., et al., "Hypovitaminosis D in medical inpatients," N Engl J Med 338 (1998): 777-83
17. Seasonal Affective Disorder Association http://www.sada.org.uk/ (accessed February 10, 2006)
18. Lahti, T.A., et al., "Transition into daylight saving time influences the fragmentation of the rest-activity cycle," J Circadian Rhythms 19 (2006): 1 [Epub ahead of print]
19. Monk, T.H., Folkard, S., "Adjusting to the changes to and from Daylight Saving Time," Nature 261 (1976): 688-9
20. Bunney, W.E., Bunney, B.G., "Molecular clock genes in man and lower animals: possible implications for circadian abnormalities in depression," Neuropsychopharmacology 22 (2000): 335-45
21. Carskadon, M.A., et al., "Regulation of adolescent sleep: implications for behaviour," Ann N Y Acad Sci 1021 (2004): 276-91

from: http://www.studentbmj.com/issues/06/04/education/144.php

Further letter to Mr Lansley

	UNIVERSITY OF CAMBRIDGE Sir Peter J Lachmann FRS FMedSci Emeritus Sheila Joan Smith Professor of Immunology	Department of Veterinary Medicine Madingley Road Cambridge CB3 0ES Telephone:  01223 766242
		Secretary:   01223 766242 Fax:            01223 766244 e-mail:        pjl1000@cam.ac.uk

8  November 2010

Rt  Hon  Andrew Lansley CBE MP,

Department of Health

Richmond House

79 Whitehall

London SW1A 2NS

Dear Andrew (if I may),

Thank you very much for your detailed and constructive response to my letter to you.  I have read the various points you raised with considerable interest and I am delighted to see that the Department is taking the issues raised seriously.

 I fully appreciate that if drugs are to be introduced at the end of Phase 2 - as I suggested, initially on a voluntary basis and subject to the patients giving indemnity -  this  may well require Phase 2 trials to be modified in order to provide  satisfactory evidence of efficacy and lack of common adverse effects.  However most clinical trials on the optimal use of drugs already take place after drugs have been licensed and the ethical problems of using a placebo when a drug with some efficacy is already available applies equally to pre-registration and post-registration trials. 

I am much encouraged by your telling me that MHRA is developing a scheme to make some promising new drugs available earlier. I was also pleased to see a report that MHRA are to propose changes to the regulation of Biosimilars. The requirement that a new therapeutic antibody of the same class and subclass and with the identical specificity as an existing licensed antibody still has to go through a full programme of clinical trials before registration has always seemed quite excessive and certainly contributes to the high cost that even antibodies that have been used on many tens of thousands of patients (such as anti-TNF antibodies) still command. A third encouraging development is the issue by the FDA of a call for robust surrogate markers for use in place of outcome measures in pre-licensing trials.

However I would like to remind your colleagues in the Department of Health of Francis Cornford’s famous aphorism from the Microcosmographia Academica:  “there is only one reason for doing something the others are all reasons for doing nothing”.  

Getting drugs into use much more rapidly and much more cheaply is a categorical imperative if health services for the whole population are to survive at all.  Among the responses I have received to the letter I wrote to you is one from a colleague with a close connection to a large pharmaceutical company who tells me that the most recent estimate of the cost of taking a new drug to market is around $1.5 billion. It is also vitally important that drugs can be brought into use by companies other than big pharma and that drugs can profitably be developed for diseases that are neither rare enough to come under the orphan drug regulations or common enough for the drugs to be blockbusters.  The reasons for doing nothing all pale into insignificance by comparison.

 Closely associated problems arise from the litigation culture - suing drug companies and, for that matter, hospitals and primary care trusts, when any adverse effect occurs, whether or not there has been negligence or malfeasance;  and I will copy, as you suggest, this correspondence to the Ministry of Justice in the hope that Kenneth Clarke, whom I still remember as Health Secretary many years ago, will be sympathetic to the arguments that something really does need to be done about it if drug development, and indeed the running of the Health Service as a whole, is to work in the real interest of patients.  There is no doubt that to an increasing degree medical practice is dominated by the fear of litigation and the resulting defensive practices are clearly enough not usually in the best interests of the patient. This also applies strongly to the issues surrounding invasive therapies at the end of life.

I imagine that it would be extremely difficult for any individual NHS organisation to decide to go over to providing far more services on a 24 hours a day, seven day a week basis.  This would require the consent of the Health Service unions to work more unsocial hours. It would involve changing the British implementation of the European Working Time Directive by applying derogation for health staff. There would be longer term implications for the number of doctors required to be trained in the acute specialities.   I would agree that it would be an excellent idea to trial such a project in one region; and to measure quality of care outcomes to see what effects such a change would have on survival rates in various diseases or following various operations.  I would predict that if such an experiment were done, the attractions for doing this on a national scale would rapidly become apparent. 

I am most interested in what you have to say about end of life care and what you say is unexceptionable.  It does not, however, address one of the main problems I was trying to raise which is that large amounts of undignified, painful, and probably useless, intervention is carried out in the last months or weeks of life, not because it is in the best interests of the patient or the patient’s wish, but for a variety of complex reasons in which fear of prosecution by the GMC and fear of litigation play a role.  

 Allowing doctors to take an active role in assisting patients at the end of life is a criminal offence while withholding treatment and/or nutrition is allowed. The categorical distinction that the law makes between these two courses of action is not shared by many of the medical profession to whom inaction is just one option among many.  What can be done to improve this situation is highly controversial, but things should not be allowed to continue just as they are at the moment. 

Yours sincerely,

Peter

Reply from Andrew Lansley