Is Jolie's surgery a proportionate response to her cancer risk? How many women have the faulty genes BRCA1 and BRCA2? How at risk are you?Is Angelina Jolie's double mastectomy a proportionate response to her risk of developing cancer?
Jolie's surgery is just one of the ways in which she could have responded to learning she had an 87% risk of developing breast cancer and a 50% risk of developing ovarian cancer, says Gordon Wishart, a professor of cancer surgery at Anglia Ruskin University in Cambridge, who is also a breast cancer surgeon. Women in that situation could also opt for being screened more often for breast cancer – every 12, 18 or 24 months instead of every three years – or starting breast screening earlier than usual, from 30 or 35 onwards rather than 50.
The National Institute of Health and Care Excellence (Nice), which advises the NHS in England and Wales on what medical procedures are most likely to benefit patients, is also consulting on whether women at high risk of breast cancer because of their family history should be able to receive the drug tamoxifen, which is currently used to treat breast cancer, to prevent the disease developing. That approach has shown some promise in some trials, prompting Nice to consider it as a possible alternative to risk-reducing surgery.
Dr Richard Francis, head of research at the charity Breakthrough Breast Cancer, says: "For women like Angelina it's important that they are made fully aware of all the options that are available, including risk-reducing surgery and extra breast screening. Though Angelina decided that a preventative mastectomy was the right choice for her this may not be the case for another woman in a similar situation. We urge anyone who is worried about their risk of breast cancer to talk it through with their doctor."
In England about 18,000 women a year undergo a mastectomy while about another 39,000 have some other form of breast surgery, such as a wide excision (lumpectomy). No one knows exactly how many British women have a risk-reducing mastectomy like Jolie, though Andrew Baildam, professor of breast surgery at Barts hospital in London, estimates it to be between 1,000 and 1,200 a year.How many women have a faulty gene that increases their risk of breast cancer?
Only about one in 400 women in the UK carries the faulty version of either of the two genes, BRCA1 and BRCA2, both of which significantly increase the risk of breast or ovarian cancer. But, Wishart points out: "While they are incredibly rare they are also what we call high penetrance genes – that is, if you have one of these genes there's a very high chance that it will cause problems such as breast cancer."
Having the mutated version of either of those genes means a woman's risk of developing breast cancer can be up to 80% and as much as 50% of getting ovarian cancer. These are what are called someone's lifetime risk.
However, mutated BRCA genes cause only between 3% and 5% of all the 50,000 breast cancers a year that are diagnosed in the UK, or between 1,500 and 2,500 cases.
"But there are also risks [from these mutations] of other cancers, such as pancreatic cancer in both men and women and prostate cancer in men. Men carry the genes too," adds Wishart.
If a woman's mother or father has the faulty version of either gene then she has a 50% chance of inheriting it. Although the mutated genes are closely associated with women, both sexes can carry them and their risk of passing it on to a son or daughter is equal.How can you find out if you are at higher risk of breast cancer?
A woman with a family history of breast or ovarian cancer should see her doctor, who may refer her to one of the NHS's 35 regional genetic testing centres around the UK. About 7,500 women a year have a genetic test there to ascertain if they are carrying either of the faulty BRCA genes.
"The genetic test is a blood test. If a family member has breast and/or ovarian cancer they can be tested to see if the have a mutation in BRCA1 or BRCA2 and if so, which mutation they have inherited. Once you know which mutation has been inherited in a particular family, then other family members can be screened for that specific mutation by blood tests," explains Wishart.
"Women will have genetic counselling before being tested to make sure they understand the procedure and have considered their options if the test is negative or positive. In general testing takes about three months in the NHS. If there are no living family members who have had breast and/or ovarian cancer then it is possible to sequence the entire BRCA1 and BRCA2 genes to look for mutations and this blood test is available privately," he adds.
Anneke Lucassen, professor of clinical genetics at Southampton University, says: "Although risks of breast cancer as high as Jolie's are unusual, knowing that you have inherited a factor that dramatically increases your chances of cancer allows such risk-reducing strategies to be taken. Whether or not to have your ovaries removed is another difficult choice women in this situation have to consider.
"Genetic testing for BRCA1 or 2 gene faults is usually undertaken if there is a strong family history of young-onset breast or ovarian cancer in the family, which is the case for Jolie. Genetic testing has been targeted like this until recently, but as techniques improve and get cheaper, anyone will be able to have a whole range of genes tested. We are already seeing an increase in operations to reduce the risk of a condition like breast cancer due to the advancements in gene testing," Lucassen says.
Dr Richard Francis adds: "Thanks to great advances in research we're able to pinpoint when people like Angelina are BRCA carriers and therefore at risk. However, we do need to continue vital research into breast cancer so women at high risk have even more, potentially less-invasive, prevention options."Denis Campbell
Despite the compassion of the call handlers, I believe patients seeking medical advice want to speak directly to a doctor they know
Olive is 82 years old and lives independently in sheltered accommodation. Her chronic heart and chest conditions are compounded by an ever-worsening short-term memory. She didn't know the carer putting on the kettle and preparing her medication was the second one to do so that morning.
Olive drank more tea, ate more toast, and then overdosed on all of her tablets. The carer realised the error when she belatedly read the medication administration sheet. She contacted the district nurse, who called the NHS non-emergency helpline, 111.
The call handler followed the computer generated algorithm, which recommended that an ambulance be dispatched. However, she felt this should be reviewed by a member of the clinical team – predominantly nurses, but also doctors and paramedics.
However, in the light of the historically high proportion of weekend and bank holiday calls associated with medication problems the local 111 service had supplemented its bank holiday team with two pharmacists.
So Khuram and I, resplendent in green sashes, were in the call centre, working the 8am to 4pm and 10am to 6pm shifts. Different clinicians wore different-coloured sashes to signify their role. Ours was to phone the medication-related callers back, or directly assist call handlers when requested, and to support the rest of the clinical team on medication issues.
To summon a pharmacist, the call handler waved a large green card. I took the call from Olive's district nurse. Olive was her usual chirpy self, her blood pressure was fine, and her son was due shortly to take her out for a family lunch. I considered the implications of each of the double doses, thought it unlikely that further harm would be done, advised that no more tablets be taken over the bank holiday, and that Olive would be better off having dinner in the care of her family rather than making a trip to A&E.
Khuram and I responded to an array of questions and concerns very similar to those we deal with in our conventional community pharmacist roles. The mother of a heroin addict wanted to collect more methadone for her daughter who couldn't come to the phone, but had apparently failed to get to her pharmacy before it closed for the weekend. A teenage girl had tried a range of solvents to remove glued-on eyelashes, and sought advise on how to remove the remaining eyelash, quite incidentally describing her sore and swollen eyes. A young man had persistent hiccups after his medication was changed. Babies developed high temperatures and young parents sought reassurance. It was commonplace for elderly people to leave their medication at home when away for the weekend.
Despite the compassion and dedication I witnessed in the call handlers, my experience is that patients seeking urgent medical advice want to speak directly to a doctor – ideally a doctor they know. So why not consider paying GPs to take back out-of-hours telephone triage? Pharmacies could be commissioned to provide out-of-hours support. A simple solution with a minimum of bureaucracy.
The imminent review of the 111 service, which has been beset by problems since its launch in many parts of England earlier this year, may well determine the reasons for its variability. But it is the reclamation of out-of-hours and urgent care by GPs that patients – and over-burdened A&E departments – would most welcome.Peter Dawson
Cost-effective, person-centred, co-ordinated care requires support for local health systems so they can deliver the right care in the right settings, and develop new ways of working
In recent years, the health and social care sectors have both faced a series of unprecedented challenges. These have included the upheaval caused by recent NHS reforms, a tough financial climate, and resulting pressure on services because of an increasing gap between needs and resources.
So, what's the solution?
For many service users, policymakers and service providers the answer is to call for more integrated care to be delivered. At its best, integrated care provides users with better outcomes and experiences and potentially offers providers financial and productivity efficiencies. If integrated care is the solution for improving health and social care, why isn't it happening?
There are many reasons, largely stemming from centuries-old demarcations between hospital, community, primary and social care.
As part of Monitor's new role, we have a duty to enable integrated care. We believe that this means enabling the delivery of responsive, cost-effective, person-centred, co-ordinated care. Therefore, we will support local health systems to deliver the right care in the right settings, and develop new and innovative ways of working.
We believe it is possible to reconfigure services in a way that achieves integration. However, you not only have to change mindsets, but also the way that systems, pathways and organisations operate. You must create a coordinated care system that is flexible enough to meet the needs of individual patients and robust enough to safeguard the sustainability of care provision at a local and national level. The measures we are putting in place will help commissioners and providers do this.
Under our new provider licensing regime, we will require providers to avoid behaviours that would be detrimental to enabling integrated care.
Through our pricing strategy, we aim to remove obstacles that prevent patients moving smoothly from one service to another. In the short term, this will mean raising awareness among commissioners about the flexibilities that exist under payment by results. In the longer term, it means developing outcomes-based payment models where providers are incentivised to ensure that the patient receives the best service for their individual needs – wherever that may come from.
Effective regulation of choice and competition issues will also be vital in enabling integrated care to flourish. We believe that a fair playing field for all providers will enable the best providers of integrated care – public, third-sector or private – to flourish and hence benefit patients.
Monitor has also joined with 12 other organisations to develop the new Integrated Care & Support: Our Shared Commitment proposals. It is a co-ordinated effort by the national partners involved to provide local health and care leaders with the right kind of advice, tools and guidance to help make integrated care happen. This is our recognition that local leadership is a key ingredient for effective integrated care, and, that they can't do it alone or work in isolation.
The unprecedented pressures facing health and social care also create a perfect opportunity to seize the patient and system advantages offered by integrated care. Making progress towards realising these will involve national-level organisations playing their part. It is an opportunity and responsibility that should be relished. Enabling integrated care should be seen as a recognised path to improving care journeys; and helping local economies' limited resources go further.
Toby Lambert is director of strategy and policy at Monitor.
This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.
Most parts of the NHS are only paying lip service to patient engagement, recently hailed as the 'next blockbuster drug'
As healthcare systems the world over continue to groan under the weight of rising expectations, ageing populations and squeezed finances, the search for viable long-term solutions shows no sign of slowing.
For many, the focus remains on system reform – finding new ways to make the money go further by redesigning services to be more efficient. But, increasingly, attention is turning to the people who use healthcare services as the potential saviour of them.
As Maureen Bisognano, president of the influential US-based Institute for Health Improvement, told the International Forum on Quality and Safety in Health in London in April: "Patient engagement is the next blockbuster drug."
Patient engagement is certainly not a new concept but, in truth, most parts of the NHS are still only paying lip service to it. The default position for many health professionals is still to think in terms of, "What's the matter with you?" rather than, "What matters to you?"
It's easy to see why. Most systems, our own included, are heavily geared towards the five hours a year that, on average, we each consume healthcare. However, ccording to a new report by KPMG, called Something to Teach, Something to Learn: Global perspectives on healthcare, the real gains are being made by health systems that understand the importance of the 8,760 hours a year when we are not officially classed as patients.
Technological advances, such as smartphone apps which can speed a patient's hospital discharge by allowing them to measure ECGs at home, or telemedicine systems, which deliver multidisciplinary virtual clinics, offer a partial solution to empowering patients.
But the reason these breakthroughs have not revolutionised care in the way we thought they might 10 years ago is that a more fundamental issue is being missed – that of understanding a patient's needs beyond treating the condition with which they have been diagnosed. Too often, our systems encourage the health professional to treat the illness, not the person. We chase narrow biomedical indicators, which, while important, don't capture all that matters to the patient.
There's now a great deal of evidence which shows that when patients are asked what they really want, they often choose a different (and in many cases less expensive) course of action to the one their doctor or nurse might have recommended. For example, most patients do not want to spend their last hours in hospital, yet the majority do.
Educating patients so that they can make informed choices, not just about their care but about their overall lifestyles, is vital. But it is also only half the battle. The key is listening to, and acting on, those choices – only then do patients become truly empowered.
And that's where system change comes in. The emerging evidence from around the world, as highlighted in Something to Teach, Something to Learn, is that to thrive in the challenging years ahead, healthcare systems will need to reorient themselves around the needs of patients.
Hospitals will have to look beyond their four walls, bridging the gap with primary care and transforming to become part of health systems, taking responsibility for entire pathways of care.
Primary care will need to become more accessible and more time will need to be given to understanding the needs and expectations of the 3% of patients that drive 50% of NHS costs every year.
These patients, often with multiple conditions, need continuity and access to integrated services which combine primary care, supported by specialists and the effective use of telephone and web-based tools and support. For this to work, health system funding also needs to be reshaped. There are already signs, from around the world, that payers – be they private insurers or governments – are becoming more active.
They are gaining a better understanding of what constitutes quality in the eyes of patients and designing new types of contracts that reward "value" rather than "volume".
ParkinsonNet, a ground-breaking patient-led education programme in the Netherlands, is a great example. It has shifted perceptions about what constitutes value for Parkinson's patients and, as a result, has radically changed practitioner behaviour. The programme has already halved the number of hip fractures suffered by this patient group and delivered savings of £13m.
In a system designed around the patient, clinicians need to move from god to guide, focusing their skills on the provision of information and support to help patients make effective choices and manage their own health and wellbeing.
True patient empowerment is not a bolt-on; it should be the centrepiece of the healthcare jigsaw.
This partnership is pivotal and central to an NHS which delivers both high quality healthcare and value too. Is it possible? With our greatest asset – the hundreds of thousands of front-line NHS staff who work with patients every day – yes, absolutely.
Mark Britnell is chairman of KPMG's global healthcare practice.
This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.Mark Britnell
Minister announces proposals to integrate services by 2018 to stop people being passed around hospital and social care staff
The government has announced plans for "joined-up" health and social care by 2018, potentially imposing a financial penalty on services if they ask patients to retell their stories to different layers of professionals.
Under the proposals unveiled by health minister Norman Lamb, hospitals would also be paid based on how patients rate their experiences.
The government has asked the regulator and NHS England to come up with a system that would stop people being passed around between doctors in hospitals and community services.
The government aims to "make joined-up and co-ordinated health and care the norm by 2018" – in effect stealing a march on Ed Miliband who has made integration the cornerstone of Labour's health policy.
NHS England, the quango running the health service, will have a budget of about £1bn to ensure there are integrated projects in every part of the country by 2015.
Lamb said this would help end patients suffering disjointed care and support. In a recent study a third of bereaved people said hospitals did not work well with GPs and other services.
The government also pointed out that patients were facing long waits in hospital before being discharged, in part because of inadequate co-ordination between hospital and social care staff. Delayed discharges cost the NHS £370m a year.
Lamb said that "people are falling through the cracks". He said that he wanted to end the fact that people are "having to retell their story every time they encounter a new service".
"It's a crisis point really," he said. "People not getting the support they need because different parts of the system don't talk to each other; older people discharged from hospital to homes not adapted to their needs, only to deteriorate or fall and end up back in A&E. Cutting emergency readmissions will bring a much better experience for patients."
Chris Ham, chief executive of the King's Fund, said the government's announcement was a step change in the debate. "Feedback from our work with local health and social care leaders indicates that some aspects of current policy and regulation are acting as barriers to delivering co-ordinated care," he said. "This should be addressed by giving pioneer areas freedom and flexibility to overcome these restrictions when they are rolled out from September."
The coalition is attempting to mollify critics of its health policy who claim hospitals will have to compete with each other rather than co-operate to provide patient care. They point out that GPs buying treatment from the NHS's flagship "joined-up hospital" – Torbay's pioneering integrated health organisation – are taking legal advice amid fears they can no longer buy care directly because of a legal requirement to competitively tender some services.
Lamb said he had met Torbay to discuss the problem. "I don't think these will be a barrier at all. We are looking to measure patient experience along a care journey and pay [hospitals] for it. It is a move forward."
The idea of paying hospitals on the basis of patients' ratings has been lifted from President Obama's healthcare programme. In the United States nearly $1bn (£630m) in payments to hospitals a year will be based partly on patient satisfaction. Patients will fill in a 27-question government survey and US hospitals with high scores will get a bonus payment. Those with low ones will lose money.Randeep Ramesh
As MPs debated the NHS in the Queen's speech debate, Europe kept barging its way in like a drunk in a pub
With the Sharif clan back in office in Pakistan and the Castros hanging on in Cuba it seemed appropriate on Monday that one of Britain's own landed dynasties should make a statesman's tilt at a great issue of our time.
Up to history's challenge stepped Nicholas Soames, through whose veins course the blood and brandy of his grandfather and wartime prime minister.
Admittedly Soames had decided to make his Churchillian oration during the NHS stage of the annual debate on the Queen's speech and to do so on the topical but tenuously connected subject of Europe.
But when destiny calls a Churchill the summons must be answered immediately, accompanied by a whisky and soda. In taking on the baying ranks of his own party Soames answered the call as grandpa so often did (sometimes wisely).
Up to that point the debate had been dire. The NHS's new cheerleader, Jeremy Hunt, made a complacent speech on the service's "heroic" performance in tough times, as incumbent health secretaries must. Then Labour's Andy Burnham warned how the arteries of our once-thriving hospitals are being clogged up by Tory policies, as ex-health secretaries usually do. Between the pair of them and eager supporters they blamed each other.
But Europe kept barging its way into the conversation like a drunk in a pub. Labour's Frank Dobson complained that the Tories have opened the NHS to predatory US health firms via EU contract law, Thatcherite Tory Edward Leigh asked Burnham if he would grant the British people a referendum on Europe. "Mad obsessives," was the drift of Burnham's reply. What about the NHS?
So Soames's magisterial intervention came like a burst of Chopin's First Ballade (Opus 23) during Britain's Got Talent, a tiger stalking the Battersea Dogs Home, an Eiger dumped on the gentle North Downs above his Mid-Sussex constituency.
He even boomed in the unapologetically posh way Etonians used to speak before rough trade like the Camerons were admitted and Estuary English became a GCSE subject.
The thrust of Soames's pro-European remarks was that young Cameron had made a promise and that should be enough. His stated EU policy should certainly not be challenged by the "prejudice or pub rhetoric" of some Tory MPs – no names – or their "hysterical, kneejerk, publicity-seeking acts." He spoke of trust and the integrity of government, of a momentous decision affecting generations unborn.
It was magnificent stuff and, like many of grandpa's speeches in his wilderness years (1931-39), was received with thinly-populated indifference and a solitary "hear, hear."
NHS buffs are immune to appeals to history further back than 1948 and Eurosceptics cherish the conceit that grandpa would have been on their side, along with Nigel Farage: for brandy and cigar, read pints.
But Soames's speech certainly raised the dreary tone. Two speeches later Labour's Ann Clywd silenced her chattering audience simply by reading letters sent by voters about poor nursing care of elderly parents.
It was shameful. Hospital buzzer buttons and water glasses deliberately left out of reach, frightened old people left in pain or hunger while nurses chattered about their social life. A man saying goodbye to his father before the life support machine is turned off being asked: "Can we crack on now?"
Hunt and Burnham fell silent along with all the others. It was bad luck that the next speaker was Charles Walker, the self-styled "fruitcake" Tory brave enough to have once admitted to obsessive compulsive disorder.
After genially praising Soames ("a great statesman") he confessed to personal Euroscepticism, then said: "I do want to crack on now." Watch out for the switch on that life support machine, Dave.
Sponsored Q&A: how can higher education better prepare students for a patient-centered NHS? Join our panel of experts on Friday 17 May 12-2pm BST
The inquiry into the unnecessary deaths of hundreds of patients at Mid Staffordshire NHS Foundation Trust earlier this year, has left an unsettling nervousness around patient safety in the NHS.
Between 400 and 1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at the hospital. In response, a report by Robert Francis QC proposed 290 recommendations to improve patient safety and care, and combat what he labelled a "culture of secrecy and defensiveness".
One of those recommendations will see nursing students working up to one year as a healthcare assistant before their training to gain hands-on caring experience. According to health secretary Jeremy Hunt, these "caring values need to be equal with academic training" to equip students to "do the job properly".
Many have criticised this proposal, suggesting there will be an unwanted blurring of roles between nurses and healthcare assistants. Peter Carter, chief executive and general secretary of the Royal College of Nursing, called the idea "stupid", saying students already spend over 50% of their time in clinical areas, that the idea will not benefit patients and only waste taxpayers money.
As the health sector evolves and diversifies so does health education. Learning and teaching is now delivered in a variety of settings including hospitals, clinics and the community, and using a range of techniques that aim to improve clinical practice through an understanding of the 'human factors' that effect it. But what do these changes mean for students and how are new pressures impacting the taught health and social care curriculum in higher and further education?
Along with our panel of experts, we will be addressing these questions and discussing some of the innovative teaching techniques currently being introduced to institutions and their effect on patient care. Join our live chat on Friday 17 May from 12-2pm BST, in partnership with HEA, to debate the changing landscape of health and social care and the role of higher education in preparing students for it.
Share your university's innovative teaching techniques and join us for the discussion in the comments section below.Panel
Wendy Reid, professor and medical director at Health Education England
Jane Priestley, academic development officer and lead for public patient involvement at the Higher Education Academy
Geoff Glover, assistant director and head of health and social care at the Higher Education Academy
Keren Williamson, lecturer at the school of healthcare studies at Cardiff University
Keith Brown, professor and head of post qualification practice-based learning at Bournemouth University
Helen Vosper, lecturer in biomedical sciences at Robert Gordon University
Gerri Nevin, head of department for clinical skills and simulation at Birmingham City University
David Cox, student at Durham Medical School
Asking pregnant women to take breath tests is patronising and fails to take into account that smoking is society's issue too
The Royal College of Midwives has backed NHS guidelines to ask pregnant women to take breath tests to prove if they smoke. While the effects of smoking while pregnant can be devastating for mother and foetus, and education and quitting services should, of course, be readily available to pregnant smokers, the introduction of breath tests feeds into a culture that fails to respect the autonomy of pregnant bodies.
Testing pregnant women to see if they smoke is a myopic solution to a wider social problem, to cycles of addiction tied up in class and family structures. But focusing on the pregnant woman rather than social and economic context is no new thing.
We like to frame things in terms of individual choice – it makes them tidier, simpler, and easier to relinquish responsibility for. Look at that pregnant slattern – puffing away. She is choosing to engage in behaviour that will harm her child. It is disgusting. She ought to be locked up. It has nothing to do with me.
Another reason we focus on the pregnant body rather than on social context is that pregnancy brings the unhealthy behaviours associated with disadvantage into high relief. However, it is important to remember that the pregnant person is a locus of these behaviours, not the cause of them.
Something strange happens to social perceptions of women's bodily integrity when they become pregnant. I have a friend who couldn't believe the licence that people – sometimes even complete strangers – took with touching her when she started to show. She recalls thinking: "Hello! I'm still in here! It's still weird for you to randomly start rubbing my tummy." And, of course, I wouldn't be the first to remark that if society directed even a fraction of the energy it dedicates to concern about the life of the unborn to the basic rights of living children, we'd live in an infinitely more just and caring world.
For those who point out that the autonomy of pregnant women is complicated by pregnancy, I say: sure. But no more and no less so than the autonomy of any parent is complicated by having children. We all have the legal rights to smoke our lungs out and drink gin until our oesophagi bleed. These rights don't disappear during pregnancy, but a moral imperative should take precedence. If you're smoking and drinking, you're smoking and drinking for two, and that's not cool.
But what is the difference between a pregnant mother engaging in these behaviours, and any parent engaging in these behaviours around their children? Passive smoking presents a risk to children, obviously, but even more significant is the increased likelihood of the children of smokers becoming smokers themselves, with all the attendant individual health risks, and, if they happen to be women, with risks for their unborn children. My argument is that, when you look at the bigger picture, there is as strong a moral imperative for all parents to stop smoking as there is for pregnant women.
Perhaps the NHS should set up spot checks on motorways and, when they see a parent smoking in the car, pull them over and breathalyse their children for CO2 levels, before distributing targeted educational material. I can see Mummy or Daddy becoming rather irate in this situation, can't you? It's my fecking car. They're my fecking kids. I'm not doing anything illegal. As much as we might think that Mummy and Daddy are behaving irresponsibly by smoking with children in the car, this NHS intervention would be an inappropriate infringement of personal autonomy. It's OK to do it to pregnant women though, because their bodily autonomy doesn't count.
Testing pregnant women, blaming pregnant women and shaming pregnant women serves to remind them that their bodies, once incubating future humans, are not their own, but the world's to prod and poke and pronounce upon. Did you know that pregnant smokers are more likely to give up if their partners are non-smokers? Should we breathalyse fathers-to-be too? I am not being flippant. People don't smoke in vacuums (no oxygen), they smoke in social and economic contexts. To create pregnant women who do not smoke we need, first and foremost, to create people who do not smoke.
Instead of setting pregnant women tests they won't pass, tests designed to make them feel guilty, we need to look at the reasons – economic, social and individual – that they started smoking in the first place. This involves examining class and family structures and finding ways to change entrenched attitudes to tobacco. It involves recognising that the idea of individual choice in relation to smoking is not a simple one. It involves showing concern for the health of women who are not pregnant and avoiding hysteria and coercive measures we regard to the health of those who are. It's a harder task than breathalysing people, but you're not going to change a society's smoking habits by heaping shame on the pregnant minority.