Transcript

The difficulty of delirium diagnosis, the lack of agency in the 10 year plan, and Gaza wounds

From The BMJ · Episode page · Watch on YouTube

· 44 min · 7,655 words · 80 timestamped sections

This is the full, timestamped transcript of "The difficulty of delirium diagnosis, the lack of agency in the 10 year plan, and Gaza wounds", an episode of The BMJ published October 9, 2025 (44 min, about 7,655 words). It mentions 13 people, works and ideas, including NHS, Cameron Abassi, BMJ, Bob Clayber, Helen Ssbury.

What this episode is about

The discussion focuses on the challenges of diagnosing delirium as a critical brain condition, the shortcomings of the NHS's 10-year health plan for England, and a recent study that highlights the urgent health needs of the population in Gaza amid ongoing injuries and trauma. Experts emphasize the importance of supporting healthcare personnel and addressing systemic issues for the plan to succeed.

Key takeaways

  • NHS's 10-year plan: a masterpiece of confusion, leaving GPs wondering who moves the chess pieces.
  • Delirium as an acute brain failure—it's not just patients who seem lost, but also our diagnosis systems.
  • With 1.3 million NHS staff feeling neglected, good luck navigating health reform without rallying the troops!
  • Investing in community care? Make sure you're not setting a fire in hospitals to keep the lights on outside.
  • Implementing change at breakneck speed creates a high-speed chase; without clarity, who’s actually in the driver’s seat?

Who speaks in this episode?

What is discussed, and when

  1. – 5:00: Bob Clayber, Cameron Abassi, Helen Ssbury, NHS
  2. – 10:00: Nigel Chris
  3. – 15:00: NHS
  4. – 20:00: Dementia, BMJ
  5. – 25:00: Dementia, Elizabeth Samson, Alistister McClullik
  6. – 35:00: Dementia, BMJ, 4 AT test, Amir Ali
  7. – 40:00: ICD10 codes
  8. – 44:15: Cameron Abassi

Notable quotes from "The difficulty of delirium diagnosis, the lack of agency in the 10 year plan, and Gaza wounds"

  • Welcome to the Medicine and Science podcast from the BMJ. I'm Cameron Abassi, editor-inchief. This week, we'll be hearing why the NHS 10-year plan is unlikely to succeed.
    about Cameron Abassi · at
  • In July of this year, the government published their 10-year health plan for England. A new analysis just published on bmj.com takes an in-depth look at the chances of that plan succeeding and.
    about NHS · at
  • I think it's really not clear what this means for general practice. I mean they set forward this model of neighborhood health hubs which sounds a bit as if they're.
    about Helen Ssbury · at
  • Say that but actually the key messages here are really good and I think are really important on it. So one of the joys of doing this work was hanging out with Nigel Chris. But…
    about Nigel Chris · at
  • And you only need to look at the funding gap between the two to get us this sort of indication of quite how much more work there is to be done. So you since the millennium.
    about Dementia · at
  • Science of delirium and the insider perspective for how the NHS handles the condition. I spoke to Elizabeth Samson, professor of liaison psychiatry at Queens University of London.
    about Elizabeth Samson · at
  • Guidance that says very clearly that older people or anyone at risk of delirium should be screened with a nationally required screening test, the 4 AT test. It's a quick and…
    about 4 AT test · at
  • So, my name's Omar Elaji. I'm a urology resident and PhD fellow based between Manchester and Liverpool. This study came off of the back of some of my discussions with air following.
    about Omar Elaji · at

Who and what is mentioned in this episode?

People

  • Cameron Abassi — Person · Host · 3 mentions · first at
    Introduces the episode’s three segments and leads the interview on the NHS 10-year plan.
  • Bob Clayber — Person · Main guest (segment: NHS 10-year plan) · 3 mentions · first at
    Co-author of the BMJ analysis; critiques the plan’s lack of a clear theory of change and emphasizes staff motivation and prioritization.
    And resources. So to discuss this, I'm joined by two of the authors of that paper. Bob Clayber who's a pediatrician and director of strategy research and innovation. It's quite…
  • Helen Ssbury — Person · Main guest (segment: NHS 10-year plan) · 2 mentions · first at
    Co-author and GP perspective; argues the plan is unclear for general practice, poorly consulted, and risks worsening relationships with GPs.
  • Elizabeth Samson — Person · Main guest (segment: delirium science/clinical practice) · 2 mentions · first at
    Explains delirium as 'acute brain failure,' discusses mechanisms, multicomponent interventions, and the need for routine screening (4AT).
  • Omar Elaji — Person · Main guest (segment: Gaza injury patterns study) · 1 mention · first at
    Co-author describing motivation, methods (survey + ICD-10 standardization), and key findings on polytrauma and burns in Gaza.
  • Amir Ali — Person · Main guest (segment: Gaza injury patterns study) · 1 mention · first at
    Co-author explaining aims (clinical preparedness + documentation), recruitment challenges, and the human impact seen in free-text responses.
    So, my name is Amir Ali. I'm a opthalmology resident based in Yorkshire. And as Omar was saying, this research was kind of based on his experiences, but just our kind of wider.
  • Nigel Chris — Person · Referenced expert · 1 mention · first at
    Cited as a key contributor to the paper, providing institutional memory from a prior NHS plan and emphasizing prioritization and execution.
  • Alistister McClullik — Person · Referenced expert (delirium screening) · 1 mention · first at
    Named as the developer of the 4AT delirium screening test, used as an example of practical diagnosis tools.
    He is a Scottish researcher, a really strong delirium advocate who believes that we need to do more for this and it's just asking simple questions at the point of admission or during a hospital.

Companies & orgs

  • NHS — Company · Business focus · 2 mentions · first at
    Central topic of discussion regarding its 10-year plan and challenges
  • BMJ — Company · Host · 3 mentions · first at
    Publisher of the podcast and involved in the NHS Commission
    Welcome to the Medicine and Science podcast from the BMJ. I'm Cameron Abassi, editor-inchief. This week, we'll be hearing why the NHS 10-year plan is unlikely to succeed.

Concepts & topics

  • 4 AT test — Concept · Key argument · 1 mention · first at
    Highlighted as a simple test for diagnosing delirium
  • Dementia — Concept · Related concept · 6 mentions · first at
    Compared and contrasted with delirium in the discussion
  • ICD10 codes — Concept · Framework · 1 mention · first at
    Used to standardize injury reporting in the Gaza study
    A way by using ICD10 codes. And so we had a deli informed consensus which had two rounds where we identified ICD10 codes and how the structure of the questionnaire or survey…

Full transcript with timestamps

Welcome to the Medicine and Science podcast from the BMJ. I'm Cameron Abassi, editor-inchief. This week, we'll be hearing why the NHS 10-year plan is unlikely to succeed.

We have this extraordinary asset that is 1.3 million people. If we don't lead and behave in a way where we're supporting them, nurturing them, encouraging them, and actually just winding them up, and feeling like they're disenfranchised, that's really not clever.

Why delirium is still so hard to diagnose just in the same way that someone can have an acute kidney injury or acute renal failure, we are really seeing that delirium is this acute failure of an organ, the brain. and what a recent study published by the BMJ tells us about the patterns of injuries in Gaza and the needs of its population.

Even trying to analyze this stuff, you have to take a minute every time just reading through these stories, it's like I I you can't believe and fathom how these things happening to people. In July of this year, the government published their 10-year health plan for England. A new analysis just published on bmj.com takes an in-depth look at the chances of that plan succeeding and where the government needs to focus time and resources. So to discuss this, I'm joined by two of the authors of that paper. Bob Clayber who's a pediatrician and director of strategy research and innovation. It's quite a title Bob you've got there at Imperial College Healthcare and Helen Ssbury GP and columnist for the BMJ. So first of all thanks for joining us and Bob tell us a little bit about the gestation of this paper.

Yeah, thanks Cameron. And um we'd been having conversations across a wider group around with the BMJ Commission and I think thinking about some very critical areas that health and care in this country needed to be thinking about in the runup to the 10-year plan and then as you say in July the plan landed. it seemed sensible for us to sort of get back some of the people who've been involved in that commission if you like on an ongoing basis to h have a bit of a deep and critical think about things. So I hope we've pulled together some analysis that is both sort of realistic in its critique but also sort of has a forward look and a and a sort of a hopefulness. And I hope that readers and listeners to this will get a sense of perhaps some of the things that those of us working and leading in the service can crack on and uh you know make a difference on whilst also being realistic perhaps about some of the

limitations of the plan. Okay. Uh Bob, thank you. Uh let's first of all go to Helen then. I mean Helen, one of the obvious areas of discussion if I can put it politely uh in the plan itself was around what this means for general practice. Uh having reflected on it for a couple of months and contributed to the paper, how do you feel about it now?

I think it's really really not clear what this means for general practice. I mean they set forward this model of neighborhood health hubs which sounds a bit as if they're replacing GPS or GPS will work in them but they'll replace the traditional um general practice but then when all GPS thought really I mean tell us more we weren't expecting this and they said no no no the GP contract is safe and then basically we have no idea And it's not even clear that the people who wrote it have a very clear idea what these new structures will be where they will be physically or what actually they will do. I think the other thing that is difficult to work out how it's going to happen is that if we want to invest more and do more in the community and that may be great to have you know so the patients are not traveling so much to hospital and that would be lovely and to have more resources on our doorsteps

where we can use them that would be great if there's no more money then that means shutting things in hospitals.

Yeah. And the idea that you'd be able to do the shutting at the same time as doing the opening or in fact you'd need to really overlap them to make sure the new thing works before you shut the old thing. And with no more resources, it's really difficult to see how that's going to work. So I know Bob wanted us to be optimistic about this. Bob will get his kind of great, but how?

Yeah. I mean, I'll be honest with you. I feel you're being quite reserved here, Helen. I know that the reaction I've heard you say some strong things about this plan and when I've spoken to other GPS about it, some of your colleagues, they've been pretty angry about it.

Yes, I think they are. I think they're very angry. They feel they weren't consulted. Um they had no was coming. They have no idea what it means. And then there was this kind of rush to implement some some of it where it was kind of put a plan together, put in a bid, do it now, do it in the next two weeks. If you don't join in now and show that you're interested, you're likely to be taken over. At least that was what that was the message people got. And it was it it seemed quite threatening and not in the least bit collaborative

and for government and they've said they want to work with us. They want to improve the NHS with its staff. You know, we will you will help us build this great new improved NHS and they're kind of I think they're they're making everybody so

there's not a good start to it. Bob, can I bring you in at this point? Um, so I think the thing that frustrated me a bit about the plan and having, you know, genuinely read 168 pages of it and spent quite a bit of time kicking it around with lots of people, it's very technocratic. So the the sort of theory of change, you know, h how is this actually going to happen? I just I couldn't get a sense of that. The bit that misses a trick for me is my experience of working in the health service all my career is every single person I've ever met wants to try and make a difference. They want to play their part. How you tap into that intrinsic motivation. Then at a national level thinks about well you need to look after people. You mustn't you know leaving people feeling in the way that Helen has described how she and colleagues feels. It's just not it's not a smart approach. M I mean Helen, how do

you think we kind of move forward here with this? Cuz I think there's there's there's a big disconnect, isn't there?

There there's a big disconnect. I think there's some really interesting stuff. There's a slight uh I would say obsession. That's maybe too strong a word, but there's a there's a definite interest in this idea that somehow technology will save us and will reduce demand. The the small steps towards being more tech. So in this week there's been variations in the GP contract so that everyone can contact their GP practice all the time online and GPS have been actually saying for a long time but hang on a second because if we're sifting through lots and lots and lots of queries which might be about a stubbed toe or a slightly sore eye that's going to take us away from having face-to-face appointments from the patients who are actually ill. We've not been listened to and it's been very much coming from from government that no no no no no we want this easy access to GPS.

These doctors are just being selfish. They don't want to work. You're going to have that access.

Yeah. And that and that's what they're saying to patients. The the problem with this is it has so soured what was possibly shaping up to be quite a collaborative relationship between the new Labor government and the general practice community and that has been trashed

really sorry but it's the relationship has never been worse I don't think than it is now and it's on that background it's difficult to see how we how we make this plan work

um and if they did want to work from the bottom them up and engage us and involve us and have all our ideas. Well, they kind of just spine that a bit.

Yeah. Bob, what are we going to do here? I mean, you you wanted to be optim We all want I think we all want to be optimistic constrictor. I think we came into it all pretty hopeful. That's

But then the realism, the sort of pragmatism of, you know, what's actually in the plan kind of hit us, didn't it?

Yeah. I think I think that's and that's possibly been a a doubly hard journey if that's a thing of you know it's I mean Cameron I know like me you you know you love your sport it's always say it's the hope it's the hope that kills you isn't it

exactly yeah exactly everyone but you know genuinely everyone who who plays or supports particularly supports a team will sort of know exactly what you and me mean and I but I I I think to Helen's point there was a moment in time where actually the health service in its broadest sense it sort of felt very hopeful and there was a sense of freshness about uh possible sort of new approaches. I mean I think it's I was smiling I was looking back at what we sort of put the key messages in the paper and you know sometimes you know you look back and think oh did I really say that but actually the key messages here are really good and I think are really important on it. So one of the joys of doing this work was hanging out with Nigel Chris. But Nigel he was the chief exec of the NHS when the 2000 plan and and so what Nigel brought to this paper as well was was a fantastic sort of if you like organizational memory

that went back and and one of the things that I remember him talking to us and Helen myself and and the wider group about was this bit about prioritizing and actually as a director of strategy you learn this stuff you know you have to prioritize. Yeah,

I think that that we've got to focus on our top priorities and then we've got to be very clear about what is our theory of change. How is that going to happen? And then let's be honest about the prioritization of funding to support it. There's a second bit about says look we have this extraordinary asset that is 1.3 million people. they're part of our team and if we don't lead and behave in a way where we're supporting them, nurturing them, encouraging them, then we we're and you know and actually just winding them up and feeling like they're disenfranchised, that's really not clever. It's not good psychology. It's not a good way to think. So, we have to get back to stopping this sort of divisive approach which sort of says, you know, the staff don't care as much as we No, you know,

you've said that a couple of times. It's something you're really feeling. Yeah. Yeah. I think I I just look at it. I think it's been a really poor tactic. I understand the essence of it that that there's a piece around it, but ultimately it's just such a poor idea. You want to get people on board and the language and the narrative actually does the opposite. It's just left people feeling arms folded. Well, you know, you you'll go away soon and we'll carry on doing

just on that. I mean, if I was to critique West Street, I think he clearly understands the NHS. He clearly cares. He gets the principles. He's a very clear communicator. I think he sometimes kind of starts barking up the wrong tree. And I think then where where I think I have a particular problem with how he goes about it is that he can get very aggressive and negative with staff. And I think if I was to extend your analogy, you brought you you introduced sport here, Bob. I didn't. Let it be known. um is that you know if a manager or a coach in you know starts criticizing their own players that never ends well and he does that a lot and I think he should stop doing that. Sorry Helen

Mr. Streeting came to a BMA meeting uh very recently and basically said that anyone who didn't like his online plan

would expect that we were GP lagards. He used the word lagards twice. not a winning strategy.

It's not a winning strategy. It really is not a good way to win friends and influence people. And

by the way, I mean, you know, if you look at general practice, general practice is streets ahead of the rest of the NHS in terms of tech. And, you know, we had completely electronic paperless systems, you know, decades before hospitals.

No, I agree with you. that also I think it's a pretty poor thing to do actually where you've got um you know a a group of professionals who are I mean you've got to say are smart motivated dedicated I mean you know in any profession you got some people who don't fit all of those criteria that I've mentioned but you know largely that's what you'd say about uh GPS and doctors and health professionals particularly GPS and you're overworked there's too much demand you want to do a good job and the health secretary comes in and tells you your lag guards and actually I think the other problem with it is that he's won over by tech but actually some of us care about the evidence and whether these things actually improve outcomes uh and the running of the service and so you're actually being in my view on the side of patients if you say well I'm not sure this is the right thing to do and and also I think I think

we keep seeing report after report I was just reading a paper last week I can't remember what it was from yet another paper which was saying the thing that people are most bothered about is continuity of care in primary care and general practice. Yeah. And Cameron in in I think one of the things we out very early in the paper is the evidence behind many of the things in the 10-year plan and if you like the sort of smorggas board of of stuff of of ideas and there's a some really interesting ideas but actually some of them have got evidence behind them and others have have actively got evidence that they don't really make a difference and they're sort of slightly rehab. So there's something about us being really smart about about some of these things, but the starting point has to be that the vast majority of our NHS staff are deeply motivated to try and make a difference. How do you ignite that? How

I guess that's the bit where I I get my hopefulness and I the piece we've put about agency feels really really important. So I think this is actually redeemable. It requires a bit of humility from our leaders.

When you say leaders, you mean the politicians. I mean, but I mean both I mean I think political leaders and I I mean um you know clinical and managerial leaders across the NHS and I

you're one of those. Yeah. Yeah. Exactly. And I think I think there is a piece about rubbishing each other. You know we start to get into a really dangerous cycle here. So we've got to big each other up a bit more. We've got to look after each other across. You know Helen and I sit in a hospital and in a primary care setting. How do we work together to build this stuff up? That feels really important. We're going to see at some point a delivery sort of planned. We haven't got that at the moment. I mean, what would you like to see in that?

I don't know. I think we have to be hopeful. I guess I get my hopefulness from the people that I have the privilege of working from, of learning with. As Helen alluded to, I feel incredibly lucky that my clinical work in an elective setting is all out working essentially in what I would call good, you know, neighborhood type spaces, but working from learning with colleagues in primary care. And I think the people are the answer now. Tech can enable people in really smart ways. I think the conversation about continuity technology can also help us with that.

No one's saying tech doesn't have a role. Exactly. I mean, we're not saying that.

But fundamentally, care the essence, it's about relationships. It's about trust. It's about listening. It's about compassion. And I think um let's keep that at its heart. And the hopefulness has to come from people. I mean, care is about people. This is a people industry.

Thank you both. Thank you. Thank you, Cameron. And Helen and Bob are both part of the BMJ's Commission on the Future of the NHS. You can find out more about that on bmj.com. and we'll also add links to the podcast notes. Now, let's talk about delirium. The frequency of delirium is relatively high, between 1 to 2% in the community and as high as 14% of those aged over 85. Despite this, it remains an underresourced condition, especially compared to other age- related mental disorders like dementia. Monkey Louie, the BMJ's features editor, finds out what impact that's having on patients.

I'm Monet Louie. I'm the international news and features editor here at the BMJ and very delighted to have our regular freelance journalist Chris Stok Walker with us to talk about his feature on delirium. Welcome Chris.

Thanks for having me. Just to start off with, I mean, can you tell us in a nutshell what is delirium? Yeah. So, it's this really sudden onset state of basically acute confusion that we don't really know fully why it's brought about. Sometimes it can be because of illness. Sometimes it can be because of infection. Sometimes it can just be because the environment in which a patient exists changes. But it is a kind of alarmingly common illness that often gets bundled into things like um dementia or Alzheimer's and and sometimes gets confused with that and is unfortunately I think often overlooked within the health service because people don't necessarily know how to respond to it.

And I mean the the leading of the feature is it's quite a personal story for you. I wonder if you're comfortable to to kind of talk a bit about your personal experience with delirium.

Yeah. So I've kind of experienced this firsthand and it was part of the motivating factor for wanting to write it. So um around about sort of Christmas time or so last year uh my granddad who was at the time 92 years old started to feel pretty unwell. He had um atrial fibrillation that had been picked up when he had broken his hip at the kind of grand old age of 90 uh and had been put on tablets to try and solve that. but had caused maybe some swelling in his legs. What many of our listeners will know as a kind of classic, I suppose, route for an elderly patient.

But around about Christmas, something seemed to change. They were amping up his medicine to his water tablets effectively to try and get rid of the excess fluid around his legs. And he started to change somewhat. He was becoming more lacadasical. He was getting more confused. And it was really only when he started to actually, you know, see things. So he lives over a park in the northeast of England and started seeing horses running across the fields that he could overlook or imagined that he was in um hospital and waiting for an appointment when he was actually just sat in a chair in his bedroom. That we started to think that was quite concerning. Early this year, uh things took a turn for the worse. He was basically unable to move. He didn't really know where he was. He was admitted to A&E uh by paramedics. And finally, we had a label for this thing, which was delirium. And it basically

looking back, we think that he had had delirium. That kind of onset of confusion and not really knowing what had happened for quite a while. Um he was treated in hospital for you know 3 months or so kept being quote unquote medically optimized ready to be discharged and then suddenly the delirium would flare up. You hospital wards are never really great places to try and recover from delirium which often requires stability, routine calm and a sense of sort of sereness to get yourself mentally back to normal. And unfortunately, um, he ended up basically getting worse and worse. Every time that he was due to come out, he wouldn't, uh, the delirium started getting, uh, more harmful. He started falling and trying to get out of bed. Uh, he wasn't eating.

He wasn't drinking. And eventually, unfortunately, he he died in April. Now, not of delirium. It's kind of sort of similar to COVID. You often die with delirium. he ended up dying of an infection. Uh but you know it was only after he died and I started telling friends and family of that and explaining that he had had delirium that I realized actually basically everybody knows someone who has had delirium.

One of the things that comes out of your feature is the fact that family in particular seem to notice it a bit before but they're not really sure what's going on. But also ref you know crossing with that is the fact that delirium can be not cured but it can be overcome a bit more if you can get notice it earlier and then try to do something to get at the root causes of it.

Yeah. So first things first we need to point out delirium is reversible but the problem is you have to learn what has caused the delirium. Try and figure that out in order to rectify it to kind of correct the problem here. But the way that you often identify delirium in a way that my granddad's delirium was found was through a relatively simple test. It's called the 4. It's developed by a guy called Alistister Mccclullik. Uh he is a Scottish researcher, a really strong delirium advocate who believes that we need to do more for this and it's just asking simple questions at the point of admission or during a hospital stay where you basically try and understand the level of confusion that someone has. So you ask them simple questions like to name the months of the year backwards or uh where they are or what year it is and things like that.

Questions that basically you wouldn't get if you were in a delirious state because you don't really know where you are. You have really bad hallucinations often that then gives you that kind of positive delirium diagnosis and you can then start to work on doing things about it. The problem is that is often not always done. And because it's not always done, delirium often goes untreated. And actually, it's a kind of 10.8 billion pound problem. There's been research done that suggests that actually if we treated delirium better, we could save that amount from the NHS because of the impact that these delirium patients have often filling up hospital beds and causing other issues in terms of getting coverage and care.

You spoke about dementia kind of earlier. I'm thinking in terms of the the funding and the intention aspect, how much is it useful or not useful that it is often bundled into dementia even though it's different? One of the challenges that I think delirium has is that it often just gets rolled in as dementia or Alzheimer's whereas it's actually similar but distinct as well. And you only need to look at the the funding gap between the two to get us this sort of indication of quite how much more work there is to be done. So you since the millennium delirium research has received around about2 million pounds in funding. Now that sounds like a lot if you're not experienced in the world of NHS funding and medical research funding because actually that 27 million is just a smidgen more than the amount that was devoted to dementia research in just 2024 alone. So a quarter of a century of research in delirium,

we've had the same amount of financial outlay as you get for dementia in just 12 months. That I think really tells you its own story. After my conversation with Chris, I wanted to know more about the medical science of delirium and the insider perspective for how the NHS handles the condition. I spoke to Elizabeth Samson, professor of liaison psychiatry at Queens University of London.

So Liz, if you could start by telling us like what do we know about how delirium works?

Well, I think that's one of the fundamental questions really. There's still so much that we don't understand about delirium. But I think increasingly over the last five years, we've come to realize that delirium is not a benign state of confusion. We have increasing evidence of really profound changes that go on in the brain. So uh we can see reduced metabolism of of glucose in the brain. We see disconnection, what we call neur neural disconnectivity between different parts of the brain and increasingly we are conceptualizing and researching delirium as acute brain failure. So just in the same way that someone can have an acute kidney injury or acute renal failure or they can be an acute respiratory lung failure we are really seeing that delirium is this acute failure of an organ the brain.

And two of the things that you said in the in the article were quite striking. I mean the first is that it isn't taken seriously by many health care professionals. But the other thing I noticed was that you know it that it's that it is hard to tackle because people don't understand it. There's not really a cure or treatment. I mean are those two things linked? Is that is the the latter the reason for why it's not taken as seriously because people just don't know what to do about it? They don't even know what it is really.

I think so. So firstly, lots of people don't know what it is. They often see it as kind of a benign syndrome where people become confused or they might even have some psychiatric problems and it can often be misdiagnosed or blamed on that. And it's a very complex issue. But also we do know that there are certain things that are very good for treating delirium, but they tend to be what we call multicomponent interventions. So you need to do lots of things for the person at once. And the underpinning kind of theory and action between behind these multicomponent interventions is that you are decreasing stress on the brain. You are decreasing cerebral stress. So you are making sure someone's got their glasses and their hearing aid. You're treating any pain.

You're orientating their sleepwake cycle by keeping them awake during the day and asleep at night. And those things can be very very difficult to do in an acute hospital environment. And people I think can just get overwhelmed. They don't know where to start when they're faced by someone with a very complex case of delirium. And I think one of the things that we really need to do as a practice and as a research community is to really look at what are the key interventions that you're going to be most effective for treating delirium. You know, which one of these things apart from kind trying to find the underlying cause gives us most bang for our buck when we're treating someone with delirium. And I think all of that collides with very very long-standing ideas that um when someone's delirious, they're just pleasantly confused, which we know isn't the case.

And I got one side question which is that um during the pandemic the COVID pandemic one of the interesting things I remember reporting on was the fact that there there seemed to be increased cases of delirium because there were increased supposedly because there were increased infections and it was COVID was the insult that was causing the onset of lots of delirium. I mean can you speak a bit about that? What have you what do we know about that and is it is it a proven case that that is that happening? Yeah, I mean there was absolutely no um doubt I think at the time that we saw increased delirium cases and we would expect that you know COVID was a severe infection and like all sort of infectious processes you get a release of cytoines and uh inflammatory factors and that's happening in the periphery in the body but the same process is going on in the mind. So what was interesting at that time was that we started seeing

reports in the literature about a whole new condition called COVID enthalopathy from some specialtities as if they discovered a whole new problem and actually most of us in the field instantly recognized that COVID enthalopathy was not a new thing it was delirium and that's what we were seeing in a way COVID really unmasked neurological vulnerability in quite a large population of people and cause them to get delirium.

And it makes a lot of sense as well since that that was obviously the vulnerable population that would have been uh most affected by COVID should they unfortunately get it. I mean, it's interesting because they said that should have highlighted it much more and Chris spoken to us at length about awareness and the fact that it's still not as you said earlier very it's not a very well-known term or condition even though it is so common. Do you think that that has helped at all? Is it better than it was pre2020 or is it are we still basically in the same place?

I think unfortunately we still in the same place. I think the overwhelming nature of COVID for health systems meant that again things like delirium were really um at a lower level of priority. I think what Chris said in his article about um delirium being often encountered but little spoken about is is really powerful and that happens at the levels of patients, hospitals, hospital managers all the way up to sort of health and policy world. We had a very large amount of attention on delirium and dementia in patients in acute hospitals from NHS England and the department of health and social care.

Round about the sort of 2010 to 2016 period. They put in quality markers. Um hospitals were monitoring and collecting data on how many people were being screened for delirium and dementia. Those care quality indicators which were known as sequins were kind of very quietly retired round about 2016 2017. While those care quality indicators were in place, we saw rising recognition and documentation of dementia and delirium. And there's some evidence to say that's slipping down.

And my last question is, what one thing would you change right now if we if we could change it to make things better? test everyone who comes into hospital for delirium if there if there's any suspicion of it. So, we have nice guidance that says very clearly that older people or anyone at risk of delirium should be screened with a nationally required screening test, the 4 AT test. It's a quick and simple test and we're still really struggling to get people to do that at the front door. So that would be my ask if we could just test it and also document it. So then we start seeing delirium properly coming through into NHS data sets. That would be the first step and a foundation for then putting in all the other changes and research that we need.

Finally this week we have some new data on Gaza. We've been reporting on Gaza for the last 2 years and we've seen how difficult it is to get accurate data from a conflict zone. But this week we published some research which aims to document the patterns of war related injuries in the population there. Navdra Lauder, our UK research editor, spoke to the authors. My name's Navdra Larger and I'm a clinical editor at the BMJ and I'm joined now by two authors of a research paper that we've recently published on patterns of war related trauma in Gaza during armed conflict. Welcome to the podcast. Omar and Amir, I'll just start by getting you to introduce yourselves.

So, my name's Omar Elaji. I'm a uh urology resident and uh PhD fellow based between Manchester and Liverpool. This study came off of the back of uh some of my my discussions with air uh following uh returning from Gaza back in May of of 2024.

Great. Welcome. And Amir, tell us a little bit about yourself. So, my name is Amir Ali. I'm a opthalmology resident uh based in Yorkshire. And as Omar was saying, this this research was kind of based on his experiences, but just our kind of wider imperative to try and help what's going on in those over there.

Let's follow up from that about um you know, what prompted you to do this study. Tell us a little bit more about what you were hoping to achieve when you when you set out to do this. um air amir.

So our kind of aim for this study was to just find out what's going on in terms of understanding the kind of clinical implications what people are actually seeing. I think we repeatedly see a lot of um medical doctors and physicians and nurses and healthcare workers uh stationed in Gaza post about these and describe these harrowing stories and I feel like over a period of time that information kind of gets lost in the news cycle. Um, so I think as an effort for our part, we wanted to kind of help assist that description and kind of collect all the different experiences people are having to build a kind of effectively a body map to prepare fellow healthcare workers for when they do go to these places and kind of are prepared to deal with all these kind of different tragedies and different complications.

Okay. Okay. So, from what you're saying, it sounds one part medical literature informing people um that might help further clinical management, I guess, in Gaza, but then also that there's something important there about bearing witness and documenting what's happening too.

Yeah. So, you know, during the time that I was there, you know, we saw a lot of uh difficult clinical situations where sometimes you you'd see injuries that you'd never seen before. And then when you when you look into you know where can I understand what kind of injuries are occurring you start to look around and unfortunately when we looked we found hardly anything. Now what what what's important to note is that there is a formal way of documenting um injury patterns and um you know fatalities and that's through the WH. It's very difficult to get granularity within that data. So they they can mention how many people have been uh killed and how many people have been wounded, but it's a lot more difficult to identify the exact type of injuries. And so when that is lacking within the literature, it's then very difficult for both non-governmental organizations but also for the WHO as well to to plan the health needs for the

region. Yeah. So it sounds like this research was intended planned to fill an important gap. But as we know that um you know doing studies in in any conflict affected area let alone somewhere that the UN attests as a site of a genocide is is really really hard to do. So tell us a little bit about how you went about trying to study this. How cuz you know for for any study design you're always thinking about the methods and making it as rigorous as you can. Um what what did you plan to do Omar? it's it's very difficult to do uh such a study and so we thought okay what would be the best way to try and extract this kind of data and so we thought well we know that health care workers you know keep log books and keep tallies of what kind of injuries that people are um presenting with and and how they're being treated and so it was really air that then came came to me and said well let's do a survey and I think I think

that was a really really good way to try and try and extract this data and the first thing we thought was how can we try and standardize the type of injuries that people are reporting as as good as possible. So we essentially um you know brought together health care workers, experienced healthare workers to try and identify exactly which injuries are the most important and and then standardize it in a way by using ICD10 codes. And so we had a deli uh informed consensus um which had two rounds where we identified ICD10 codes and how the the structure of the questionnaire uh or survey should should be laid out. And I think what we had at the end was really was a really robust survey where we could identify as many of the injuries as possible and and have it in a very structured manner.

And how did you identify who to send it to? There's there's a very large community of healthare workers and we all you know know each other rather well and even if we haven't been deployed at the same time we often you know communicate quite regularly with each other because you want to know you know what kind of things you want to you need to bring in what kind of the injuries are you seeing and so how how to best kind of prepare yourself. So that was that was that was one thing but but I think the way that we structured it a bit better was that we sent it through uh NGO rosters.

Difficulty a lot of people face was actually completing the survey in the sense that where's this data going to go? What's the implications that it's going to have on my personal kind of livelihood cuz I can understand a lot of people once they've been to these places and right at the beginning there was a lot of contentions about what's going on but what is the wide implications of my job role? what's going is there some sort of surveillance things going on. So I think a lot of people were hesitant to filling it out. Uh we did eventually get a reasonable like cohort of uh participants in our study. And I think the other thing we did kind of concentrate on was a lot of international health workers, healthcare workers to kind of provide that global opinion that it's not just one group of people from one area that are seeing these things. It's people from everywhere with a varied experience.

What I would say is that Palestinian health care workers were not included in this survey and the reason for that is because of their safety. We know that Palestinian healthcare workers have been killed and they have been imprisoned and especially those who voice opinion and so we did not want to allow that to happen to any of our our colleagues. M and can you summarize what you found?

Yeah, so um the results were were pretty stark and there was a lot of poly trauma. 70% of healthcare workers reported that they were dealing with poly trauma. Um there was 18% burns and that is a very large amount especially when you compare it to other literature and and from the burns we saw about 30% that were third or fourthderee burns and as you know you know third and fourth degree burns are are are significant burns. They're very deep burns and they require a lot of treatment and rehabilitation for you know years to come. That was really our main finding. But what one one part of the study we also looked at mechanism uh of injuries. So we looked mainly at gunshot and um uh blast injuries. And what we found was that the vast majority of gunshot uh wounds affected the limbs and um the shrapnel injuries affected pretty much every part of the body. it really that that kind of data talks for

itself. Um, and it's it's it was difficult to read and kind of collect the data purely because the fact you're just seeing children with horrendous injuries and there's nothing in the literature that could compare to these things. A lot of these a lot of the kind of um free text responses that we received were cases that you are completely un unimaginable. They they were These would be a case report in any other western country about how a child with multiple fractures, disembowment was managed. But this is something you're seeing on a daily basis in in an environment that's not equipped to kind of manage any of these things. So it was just terrible to read. It's terrible to kind of even even trying to analyze it. You have to take a minute every time just reading through these stories. It's like I I you can't believe and fathom how these things happening to people.

The evidence that we're presenting in this paper is evidence that has been out there but it's just been fragmented. All we have done is bring it together. We know what is happening. We know civilians are being killed on mass. We know that aid has been restricted and you can see in our paper that there are you know m many uh of the healthare workers reported malnutrition and this was at a time before malnutrition uh or before famine was was reported in Gaza you know and so what I what do people think about how these injuries will then heal even if they've had surgery or they've had the treatment that they needed. How is it going to heal over the course of the next year or so? Well, it's not going to heal. These patients, unfortunately, many of these patients, especially the patients with burns or those who have been amputated, they will die because they don't have the adequate nutrition to help their

wounds heal. I think the other point is also if we reissue because if you remember we sent a survey approximately eight months ago from this interview and if we did the same survey now the clinical picture would be completely different if not worse a lot more chronic complications a lot of further disease advancement it's just it's slowly getting worse and worse every day and I think any data we have it's it's time perspect it's time stamped but at the same time you need to have the understanding that it's it's only getting worse. There's no sign of improvement.

That article, patterns of war related trauma in Gaza during armed conflict, is accompanied by an editorial. It also has an opinion article with it from the authors which explains the human cost behind those numbers and it's all linked from the podcast notes. That's it for this week. We'll be back in a Fortnite with more medicine and science. Until then, I'm Cameron Abassi. Thanks for listening.

Questions about this episode

Who speaks in "The difficulty of delirium diagnosis, the lack of agency in the 10 year plan, and Gaza wounds"?

Cameron Abassi (Host), Bob Clayber (Guest), Helen Ssbury (Guest), Monet Louie (Guest), Chris Stok Walker (Guest), Elizabeth Samson (Guest), Navdra Lauder (Guest), Omar Elaji (Guest).

What is "The difficulty of delirium diagnosis, the lack of agency in the 10 year plan, and Gaza wounds" about?

The discussion focuses on the challenges of diagnosing delirium as a critical brain condition, the shortcomings of the NHS's 10-year health plan for England, and a recent study that highlights the urgent health needs of the population in Gaza amid ongoing injuries and trauma. Experts emphasize the importance of supporting healthcare personnel and addressing systemic issues for the plan to succeed.

What is mentioned in this The BMJ episode?

13 people, works and ideas are mentioned, including NHS, Cameron Abassi, BMJ, Bob Clayber, Helen Ssbury, Elizabeth Samson. Each one on this page links to its own page with every episode that mentions it.

How long is "The difficulty of delirium diagnosis, the lack of agency in the 10 year plan, and Gaza wounds"?

The episode runs 44 min; the transcript is about 7,655 words in 80 timestamped sections.

More from The BMJ

About this transcript: the episode's spoken words as captioned on YouTube, split into timestamped sections. Reclip.Me locates every person, work and idea in the text, keeps the time it is first named, and quotes the words around it verbatim. Last updated January 24, 2026.