Health’s doom loops and why they matter

A “doom loop” means different things in different sectors. It’s a term I’m new to, is rarely used in health, but carries an instant attraction. Its application to the climate crisis is most relevant. The climate doom loop refers to how the failure to tackle the climate emergency and its consequences “draws focus and resources from tackling its root causes” (en.wikipedia.org/wiki/Doom_loop).1 Perhaps doom loops in health deserve more attention.

Doom loops are everywhere. They are in the humanitarian crisis in Gaza that demands an urgent ceasefire and peace (doi:10.1136/bmj.p2470).2 In the way racism affects maternal health (doi:10.1136/bmj-2023-07609).3 In the faltering struggle against non-communicable diseases, such as the rise of type II diabetes in young people (doi:10.1136/bmj.p2490).4 In the alarming drop in childhood vaccination rates (doi:10.1136/bmj.p2426).5 When a pandemic hits (doi:10.1136/bmj.p2454 doi:10.1136/bmj.p2524).67 When caring for older people (doi:10.1136/bmj.p2508)—and younger people (doi:10.1136/bmj.p2283).89 When reducing deaths from sepsis (doi:10.1136/bmj.p2502).10 When tackling research misconduct (doi:10.1136/bmj.p2529).11

The Institute for Government believes that the UK’s health services are stuck in a doom loop through years of “quick fix policy decisions and years of underinvestment” (doi:10.1136/bmj.p2530).12 Its annual report argues that health and care services are performing worse than before the pandemic and much worse than in 2010. Two key factors are workforce—pay, conditions, and retention (doi:10.1136/bmj.p2481)13—and capital underinvestment, which has left healthcare facilities unfit for purpose and the NHS lagging behind similar nations in diagnostic capacity. An obvious effect is the growing backlog in elective care.

One solution to the workforce crisis is the planned expansion of physician associates. Although it is perfectly logical that the population’s growing health and wellbeing needs cannot be met by doctors alone, the rapid introduction of physician associates hasn’t been thought through clearly. The quick fix of ramping up physician associate numbers announced in the UK’s workforce plan fails to tackle major problems of role clarity, professional regulation, and training needs in an ecosystem of limited training opportunities (doi:10.1136/bmj.p2454 doi:10.1136/bmj.p2499).1415 The UK’s General Medical Council and Royal College of Physicians are calling for clarity and an end to the perception that doctors are being replaced by physician and anaesthetic associates (doi:10.1136/bmj.p2507).16

Another workforce solution is to recruit doctors from overseas. International medical graduates play an essential role in delivering health services (doi:10.1136/bmj.p2422),17 but quick fixes can be problematic. A BMJ investigation finds that doctors from Pakistan on an official training scheme in the UK are being employed on the basis of unfair pay and working conditions (doi:10.1136/bmj.p2427).18 Although the training these doctors receive can be beneficial when they return to work in Pakistan, that isn’t a sufficient excuse for them to be underpaid on substandard employment contracts in the UK. An employment lawyer described the scheme’s conditions as “exploitative.”

Once you’ve seen doom loops it’s hard to unsee them—everywhere—which creates a perfect moment to restate our commitment to patient partnership, a genuine response to doom loops (doi:10.1136/bmj.p2505).19 Unfortunately, the UK’s covid inquiry is confirming our worst fears that the welfare of the public wasn’t top of mind in the government’s doomed and loopy covid response. There may be little surprise that Boris Johnson, then prime minister, believed that covid-19 was “nature’s way of dealing with old people” and was less than convinced that the NHS was overwhelmed, but it is shocking, nonetheless (www.theguardian.com/uk-news/2023/oct/31/boris-johnson-favoured-older-people-accepting-their-fate-covid-inquiry-hears).20

With a nod to Scottish folk band Stealers Wheel—and Quentin Tarantino’s Reservoir Dogs—it feels as if there are clowns to the left of me, jokers to the right, here I am stuck in a doom loop with you. The question for all of us at a loss over the state of our doom looped world is: how do we escape mostly intact?