harms of medical “banter” page 46 • eteplirsen for ... cosmetic surgery college counters...

this week

All NHS doctors to be trained in UK

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Expanding the number of medical student places by 25%, announced by England’s health secretary at the Conservative Party conference in Birmingham on 4 October, will take at least a decade to have an effect on the NHS, doctors’ leaders have warned.

In his speech Jeremy Hunt announced that “from September 2018 we will train up to 1500 more doctors every year” in England in a bid to expand the number of home grown doctors and to replace the 25% of doctors recruited from overseas. “By the end of the next parliament we will make the NHS self sufficient in doctors,” he said.

Doctors’ leaders have welcomed the planned rise in student numbers, which currently stands at 6000 a year, but have warned that they will not replace the need for foreign doctors for some time.

Taj Hassan, president of the Royal College of Emergency Medicine, said, “Medical student expansion is a helpful step in the right direction, but will not have an effect at all in the short or medium term. Any meaningful impact will be at least 10-12 years away, once these training programmes deliver fully trained physicians.”

In a statement, the Royal College of Radiologists said that though it supported “all measures to maintain the long term

sustainability of the NHS . . . urgent stopgap measures are crucial to ensure there is an NHS to sustain in 15 years’ time.”

The expansion in student numbers is expected to cost roughly £100m for the period up to 2020, but the government said that savings would come from charging international students “the full cost of their medical training” and through cutting the medical locum bill, which is £1.2bn a year.

Chandra Kanneganti, chair of the British International Doctors Association, said that students from other countries already paid extra fees. He told The BMJ, “I do have concerns about plans to charge international doctors for clinical placements, which has not been done before. There should be a recognition that international doctors contribute to the NHS enormously.”

Hassan also criticised the proposal to make newly trained doctors work for the NHS for four years or repay part of the £220 000 it took to train them. “The key to keeping doctors in the country is to create the right training environment for them,” he said. “They need to be well supported and feel valued so that they can deliver.”Ingrid Torjesen, LondonCite this as: BMJ 2016;355:i5399

In his speech Jeremy Hunt questioned whether it was right that the UK, as the fifth largest economy, continues to import doctors from poorer countries

the bmj | 8 October 2016 43

HARMS OF MEDICAL “BANTER” page 46 • ETEPLIRSEN FOR DUCHENNE page 50

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SEVEN DAYS IN

General practiceCCGs must engage with public on “tough decisions”Clinical commissioning groups must engage with the public, clinicians, and politicians as early as possible when taking potentially controversial decisions such as closing local services, new guidance has advised. Commissioners should also ensure that “tough decisions” about funding, prioritisation, and possible closures are safe, cost effective, and backed by robust evidence, said the report from NHS Clinical Commissioners, the CCG membership body. (Full story doi:10.1136/bmj.i5297)

CBT reduces visits to GPs by frequent attendersPatients who visit their GP frequently over the long term—at least 30 times over two years—found cognitive behavioural therapy acceptable, and it more than halved the frequency of their visits, showed a feasibility study. Just under a fifth of the 462 patients invited to take part in the study agreed to the treatment, and 32 underwent CBT. The number of contacts fell from eight in three months at baseline to three in three months after a year (n=18). (doi: 10.1136/bmj.i5350)

Food retailers and restaurant chains in England will be expected to remove 20% of the sugar from food they sell and reduce portion sizes as part of government led efforts to reduce the prevalence of childhood obesity. Companies will also be publicly named and shamed if they fail to commit themselves to the reduction and reformulation programme, which was outlined in the government’s childhood obesity plan in August.

Jeremy Hunt, the health secretary, emphasised the importance of reducing sugar in commonly consumed foods in a meeting with industry representatives on 29 September.

Although the government’s obesity strategy was criticised for not recommending legal powers to enforce the changes, the Times newspaper has quoted Hunt as saying that he was determined to “shine a light” on individual companies’ performance. He told firms, “You want to be on the right side of this debate.”

All sectors of the food and drink industry will be expected to take part in the programme, including restaurants, cafes, pubs, and takeaway outlets.

Public Health England said that it would host further meetings with the industry.

Industry is urged to cut 20% of sugar from food

Gareth Iacobucci, The BMJ Cite this as: BMJ 2016;355:i5348

44 8 October 2016 | the bmj

Mental healthWomen are more prone to mental illnessWomen are more likely to have mental health problems than men in England, with young women at particularly high risk, a detailed survey has found. The Adult Psychiatric Morbidity Survey, which is carried out every seven years through interviews with adults aged 16 or over, found that 17% of adults had a common mental disorder (21% of women and 13% of men). Common mental disorders were generalised anxiety disorder, depression, phobias, obsessive compulsive disorder, panic disorder, and non-specified disorder. (doi:10.1136/bmj.i5320) (See Five minutes with . . . p 47)

Quarter of a million children receive specialist careData compiled from 60% of mental health trusts in England show that in June this year 235 189 children and teenagers aged 18 or under were receiving specialist

care for mental health problems, including depression, anxiety, and eating disorders. In the same month around 12 000 boys and girls aged 5 years or under, 54 000 aged between 6 and 10, 100 000 aged 11 to 15, and 70 000 aged 16 to 18 were in the care of specialist mental health services.

Frozen embryosWidow wins right to use frozen embryosA widow has won a High Court battle to use the frozen embryos she created with her husband, who died suddenly in 2014 from a brain haemorrhage.

Samantha (left) and Clive Jefferies signed consent forms in July 2013 agreeing to have their embryos stored for 10 years. But someone at the Sussex Downs Fertility Centre, the clinic treating them, changed the maximum storage time to two years, the period for which they had NHS

funding. The case was filed after the clinic told Samantha that the embryos

were due to be destroyed. The law states that embryos cannot legally be stored once consent

has expired.

Abortion rightsProtests escalate in Poland over proposed lawPolish women boycotted their jobs and students their lectures on Monday as part of a nationwide strike against proposals by the conservative government of the Law and Justice party to ban all abortions, scrapping the three exceptions in which terminating pregnancy is currently legal (pregnancy after rape, pregnancy that endangers a woman’s life, and when the fetus is malformed). Men joined the protest, dubbed “Black Monday,” at which women wore black to represent their loss of reproductive rights and the deaths of women should backstreet abortions become their only option. The bill is currently being debated in parliament.

Research newsPill is linked to depression in young womenUse of hormonal contraceptives was associated with an increased risk of having a diagnosis of depression for the first time and of antidepressant use, a large study in JAMA Psychiatry has found. The Danish prospective study of more than a million women aged 15-34 years between 2000 and 2013 found that women who used combined oral contraceptives had a 23% higher relative risk of using an antidepressant for the first time, when compared with non-users, with an 80% higher risk in women aged 15-19. Risks were higher with progestogen only pills. (doi:10.1136/bmj.i5321)

Patients have unrealistic hopes of cancer trialsMore than 80% of UK patients with cancer who consider taking part in phase I drug trials do so expecting a clinical benefit, shows a study reported in Cancer. Around half of the 402 patients questioned in the study expected to see their tumour shrink, and a 10th hoped for a cure, even after consultation with specialists. But response rates in such trials typically range from 4% to 20%, and the median survival time is only six months. The researchers said that their findings underlined the challenges in discussions between patients and doctors about these studies. (doi:10.1136/bmji5321)

Mediterranean diet reduces CVD in UKEating a Mediterranean-type diet high in cereals, fruit, and vegetables and low in red meat is linked to a lower incidence of cardiovascular disease and mortality, a study carried out in the UK population has found. The research, in BMC Medicine,

included 23 902 healthy people who were followed for 12-17 years. People with greater adherence to a Mediterranean-type diet had a 6-16% lower risk of future cardiovascular disease and death than those with poor adherence, the study found. The researchers estimated that 12.5% of cardiovascular deaths could potentially be avoided if people ate a Mediterranean diet. (doi:10.1136/bmj.i5286)

Cosmetic surgeryCollege counters “aggressive marketing” on cosmetic surgeryThe Royal College of Surgeons has urged patients to “think carefully before cosmetic surgery” in new online information to counter what it says is the “‘aggressive marketing” campaigns and “ruthless” sales techniques used by some private companies. The information on the college’s website offers advice on how to choose the right surgeon and hospital, explains the risks and possible complications of surgery, and presents questions to ask a surgeon. In the next few months the college will publish a register of certified surgeons who have the appropriate training.Cite this as: BMJ 2016;355:i5366

WHY IS YOUR HEAD IN YOUR HANDS?I’m a social psychologist.

SO?Our whole profession is under assault from critics who say that it is little more than “tabloid fodder,” full of glamorous and widely publicised but irreproducible claims reached by underpowered studies and “p-hacking” (mining data to find significant patterns without first having a specific hypothesis). It’s very wounding.

IS IT TRUE?Some big claims have lost a bit of their swagger, certainly. One of the authors of a 2010 study showing that adopting a powerful pose made you feel more powerful and boosted hormones now says she thinks that the conclusion was unwarranted. Dana Carney of the University of California at Berkeley said that the original study had shortcomings, including p-hacking.

DID ANYONE EVER BELIEVE IT?Lots of people did, including George Osborne. Another of the coauthors, Amy Cuddy of Harvard Business School, still does. She did a TED talk about it that has been downloaded 35 million times (http://bit.ly/2cNnsef).

HANG ON: GEORGE OSBORNE?Yes, he struck a power pose once when making a speech. It looked very awkward.

WHO ARE THESE CRITICS?The prime mover is Andrew Gelman, a statistician from Columbia University. But the real damage to power posing was done by an attempt to replicate the findings, using five times as many participants (100 rather than 21) and finding no effect at all. Funnily enough, nobody’s done a TED talk on that.

IF POP PSYCHOLOGY IS GOING POP, DOES ANYONE BUT PSYCHOLOGISTS CARE?Publishers. It’s no coincidence that Cuddy’s lengthy rejoinder to the criticism came through her publisher, Hachette. Psychology books are big business. Readers want a simple shortcut to success and happiness, endorsed by science. Life, alas, is usually a bit more complicated.

Nigel Hawkes, LondonCite this as: BMJ 2016;355:i5354

SIXTY SECONDS ON . . . POSING

MENTAL HEALTHMore boys

(130 395) than girls

(104 522) were under the care of mental health specialist services in England in June

MEDICINE



Medical school “banter” denigrating GPs and psychiatrists must stop, say leaders

Two of the UK’s most senior doctors have called for an end to the damaging “banter” in medical schools, which they claim is dissuading students from applying to general practice and psychiatry.

Maureen Baker, chair of the Royal College of General Practitioners, and Simon Wessely, president of the Royal College of Psychiatrists, said that “the systematic denigration” of their specialties was putting patient safety at risk by contributing to a shortfall of GPs and was stifling efforts to achieve parity of esteem between physical and mental health.

In a joint editorial in the British Journal of General Practice, the two leaders highlighted research showing that general practice and psychiatry were the two most “bad mouthed” specialties within medical schools, which had a tangible impact on medical students’ choice of specialty.

The call follows the launch of a campaign by the Royal College of Psychiatrists earlier this year designed to expose the negative effects of “bashing” and badmouthing of psychiatry.

In the editorial Baker and Wessely

“The NHS will only function properly when we have sufficient numbers of doctors practising all specialties”

Sites to test how to keep patients near homeNHS England is to test new approaches to delivering mental health services in a bid to end the practice of patients being sent a long way from their home for inpatient treatment.

Six pilot sites will be tasked with redesigning young people’s mental health services and secure mental health services, with the aim of reducing psychiatric hospital admissions, shortening stays, and eliminating “clinically inappropriate” placements out of patients’ local area.

The number of mental health patients sent out of area for treatment has risen in recent years because of a shortage of inpatient beds.

NHS England said that the £1.8m investment across the six sites would help reduce the need to send vulnerable people across the country to be treated.

NHS mental health trusts, independent sector providers, and charities will be asked to work together to reorganise services in the pilot site areas. Two of the six sites will focus on increasing the level of crisis care available in the community for children and teenagers, with the aim of reducing admissions to hospital.

The other four areas will look at relocating people in secure mental health services closer to their home and improving their social care to help them leave inpatient care and reintegrate into their community.

Jeremy Kenney-Herbert, clinical director for secure services and offender health at Birmingham and Solihull Mental Health NHS Foundation Trust told The BMJ that the organisations wanted to provide a more consistent service across the region. To achieve this, he said that the trust and partners were considering the idea of a single accountable care organisation with the aim of reducing fragmented pathways in secure care and expanding services in the community, such as forensic or assertive outreach teams, residential rehabilitation, and supported housing.Gareth Iacobucci, The BMJCite this as: BMJ 2016;355:i5339

Doctors in South Africa are demonstrating against the dangers of working long hours by wearing different coloured wristbands according to the number of hours they have worked.

In the campaign, organised by the South African Medical Association and largely involving junior doctors, red wristbands were worn by doctors who had worked for more than 30 hours in one shift, orange by those

who had worked between 24 and 30 hours, and green by those who had worked fewer than 24 hours.

Mark Sonderup, vice chair of the association, said that the campaign launched a week ago and would run until mid-October. It was sparked by the death of Ilne Markwat, a young doctor from Cape Town who died in a car crash on her way home after working a 30 hour shift and apparently falling asleep at the wheel.

South African doctors protest long shifts by wearing coloured wristbands

The campaign aims to trigger an overhaul of the health service

“The figures [from the Adult Psychiatric Morbidity Survey] are very stark and concerning. Women have historically had a higher incidence of common

mental disorders and have always been more likely to suffer from anxiety and depression than men. There are a number of hypotheses about this. Women are more likely to be subject to interpersonal and relationship violence, they are more likely to be financially dependent, and they are more likely to have responsibilities and burdens related to child rearing.

“In the 2007 survey the rate of mental disorders among middle aged women increased, and we wondered whether that was to do with the ‘sandwich generation’: women were feeling burdened about caring for parents and children.

“We don’t have a complete answer as to why there’s been an increase in the rate of mental health disorders among younger women. One of the theories

is that young women now are the first generation to come of age with social media. Are young women feeling more under scrutiny in terms of their appearance?

“Young people do feel pressured—there are academic pressures. There is also research showing that common mental disorders are more likely to be associated with physical health conditions.

“One of the things the report highlights is the desperate need to do more mental health research. Although mental health conditions account for around 25% of the disease burden in the UK, the research funding for mental health is about an eighth of what it is for physical health. We know that when we put money into mental health research the returns are just as great as for physical health research.

“Overall the number of people with common mental disorders receiving treatment has gone up. We’re hopeful that a lot of the work we are doing on combating stigma is starting to have an impact. However, two thirds of people are not receiving treatment, and we need to research this more.”Anne Gulland, London Cite this as: BMJ 2016;355:i5349

FIVE MINUTES WITH . . .

Kate Lovett The dean of the Royal College of Psychiatrists discusses the “stark” rise of mental disorders in women

said that the call wasn’t about censorship or banning banter within medical schools but was about fostering respect and breaking down the hierarchy that suggests one medical specialty is worth any less than another.

“This [hierarchy] must be replaced by respect and understanding throughout medicine that all specialties are important, that all specialties have their own set of skills and values, and the NHS will only function properly when we have sufficient numbers of doctors practising all specialties,” they wrote.

Baker said, “I first studied attitudes towards general practice in medical schools almost 20 years ago, and it’s really depressing how

little things have changed. It’s so frustrating when we know that the things people are saying about general practice are simply untrue.

“It’s also very concerning that this ‘banter’ is yet another barrier we are up against when trying to recruit enough GPs to ensure a safe and robust service for the future of patient care.”

Baker said that although NHS England had pledged to train more GPs, and Health Education England had set a target for 50% of all medical students to enter general practice, such milestones “will not be possible when forces from within are working against our efforts.” She said, “It’s clear that more needs to be done from within medical schools, and medicine as a whole.”

Risks to patientsWessely added, “It’s not that we can’t take a joke, but often, the ‘banter’ directed at psychiatrists isn’t a joke on us, it’s a joke on our patients, and that isn’t acceptable.”

The editorial concluded, “Some will say that we are blowing the issue out of proportion; that banter is part of tradition within medicine, that we all do it to some degree, and that in some cases it even performs a ‘bonding’ function. This might be true, but we question the logic of protecting a tradition that stigmatises mental health, contributes to a shortfall in GPs, and ultimately puts our patients at risk.”Gareth Iacobucci, The BMJCite this as: BMJ 2016;355:i5316


South African doctors protest long shifts by wearing coloured wristbands

Sonderup said, “It is intended to raise awareness of the situation.”

He hoped that the campaign would trigger a much needed overhaul of the health service in South Africa.

He said, “It’s the start of a long journey that involves the whole system: staffing, unfilled posts, and the burden of disease. It has been

happening forever, but that does not mean it is OK.”

The national government has not responded to the protest, although the Western Cape Government (where Cape Town is situated) has said that from January doctors will not work shifts longer than 24 hours.Pat Sidley, JohannesburgCite this as: BMJ 2016;355:i5338

THERE IS A DESPERATE NEED TO DO MORE MENTAL HEALTH RESEARCH

SOCIAL MEDIA “LIKES”The campaign has so far had 182 000 “likes” on Facebook and Twitter

Banter at medical schools, such as Imperial College in London, stigmatises mental health and

dissuades doctors from entering general practice, ultimately

harming patients, said Maureen Baker and Simon Wessely

The doctor in charge of the World Bank has spoken out against governments that fail to act on malnutrition and to make progress on eradicating the “humanitarian disaster” of stunting.

Nearly a quarter (159 million) of the world’s 667 million children aged under 5 are stunted—too short for their age.

India is home to two thirds of the world’s stunted children. Stunting is associated with an underdeveloped brain and a raised risk of developing chronic disease such as diabetes and hypertension. Good nutrition and care during pregnancy and up to a child’s second birthday prevent stunting.

A new World Bank study of poverty and shared prosperity says that one of the most effective policies for tackling inequality is to focus on early child development and nutrition.

The World Bank’s president, Jim Yong Kim, said that national economies increasingly depend on digital and higher level competencies and so investments need to be in “grey matter infrastructure.” He added, “We give concessional loans, and finance ministers say we aren’t using this money for women but for hard infrastructure, roads, and energy. But we’re telling them to look to the future: it’s digital, digital, digital. The most important infrastructure you can invest in is grey matter.

“With stunting, learning outcomes are worse, and people earn less. It all starts with healthy young women: delaying pregnancy, and making sure that every single woman has sufficient access to healthcare. And we should take care of those children as if they are the most precious infrastructure you could ever buy.”

But the new Global Nutrition Report 2016 (http://globalnutritionreport.org/the-report) does contain some good news: many countries are on course to meet global targets on nutrition and non-communicable diseases, and the prevalence of stunting among the under 5s has fallen in every region except Africa.

Brazil was put forward as a success story. The country built strong political commitments to nutrition and saw the rate of stunting fall from 19% in 1989 to 7% in 2007.Rebecca Coombes, The BMJCite this as: BMJ 2016;355:i5361

“With stunting, learning outcomes are worse, and people earn less. It all starts with healthy young women: delaying pregnancy, and making sure that every single woman has sufficient access to healthcare”–Jim Yong Kim


THE BIG PICTURE

World Bank leads charge against stunting

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A girl is weighed as part of a nutrition clinic in Michemire, in the Mao region of Chad. At

51.9% the country has one of the highest rates of child

stunting in the world.


Woodcock’s vision of an FDA that is more responsive to patients’ demands, especially those with currently untreatable diseases, even if the data to prove efficacy are lacking.

The battle within the agency has been seen as a bellwether for the likely prospect of a slew of approvals of high priced drugs for rare diseases, backed by skimpy data but supported by patients desperate for hope.

Sarepta is largely owned by institutional investors, who saw the value of their holdings nearly double 24 hours after eteplirsen’s approval.

In a survey by RBC Capital Markets of 101 neurologists who treat patients with Duchenne muscular dystrophy, 40% of the respondents expected to recommend it to all or most eligible patients, while 54% would start with a smaller group and then expand use if it proved effective.

Definitive proof of eteplirsen’s clinical benefit was still lacking, the FDA acknowledged, and must be shown in a postmarketing study or the approval could be revoked. The original phase III study submitted in the approval process, with just 12 participants, was heavily criticised by FDA scientists who visited the researchers and found failings in the study’s methods before failing to replicate their results.

“Blinded experts assembled by the FDA fundamentally debunked this study, which has yet to be retracted

and continues to be cited,” wrote commissioner Califf in his report.

Califf wrote in his report that Sarepta “exhibited serious irresponsibility” by “publishing and promoting selective data” from this trial that did “not withstand proper and objective analyses of the data.” He added, “Sarepta’s misleading communications led to unrealistic expectations and hope for DMD [Duchenne muscular dystrophy] patients and their families.”

But, the report continued, “Dr Woodcock cautioned that, if Sarepta did not receive accelerated approval for eteplirsen, it would have insufficient funding to continue to study eteplirsen and the other similar drugs in its pipeline. She stated that, without an approval in cases such as eteplirsen, patients would abandon all hope of approval for these types of products and would lapse into a position of self-treatment.”

Other top FDA scientists made a rare formal appeal to an FDA scientific dispute resolution board, complaining about Woodcock’s role in the approval.

But the board’s chairman, Robert Califf himself, wrote that he had ultimately decided to “defer to Dr Woodcock’s judgment and authority” and approve the drug.

The company plans to file for European drug approval soon.Owen Dyer, MontrealCite this as: BMJ 2016;355:i5346

Duchenne muscular dystrophy drug looks set for commercial success despite questions over clinical effectsA newly approved drug to treat Duchenne muscular dystrophy seems likely to be used by most US neurologists, even though its benefit has yet to be proved, treatment costs $300 000 (£230 000) a year, and the head of the Food and Drug Administration has said that the main clinical study on which it rests “should probably be retracted by its authors.”

Eteplirsen, made by Sarepta Therapeutics and marketed as Exondys 51, was approved in the US in September after a long internal battle between FDA scientists who doubted its efficacy and the director of the FDA’s Center for Drug Evaluation and Research, Janet Woodcock. The details of this dispute, which led to formal complaints against Woodcock from several top agency scientists, are laid out in an unusually frank report by the FDA’s commissioner, Robert Califf.

The drug’s approval has been widely interpreted as a victory for

The drug’s approval has been widely interpreted as a victory for a vision of an FDA that is more responsive to patients’ demands

CLINICAL DOUBT

Although 21% of neurologists surveyed said that they doubted that the drug offered

a clinical benefit, only 5% said that they would not recommend it to patients, indicating that physicians, like the FDA, are feeling the pressure from patients

The FDA’s Robert Califf and Janet Woodcock disagreed over the approval of eteplirsen, whose share value doubled 24 hours after the endorsement


Carbon dioxide and short lived climate pollutants (SLCPs) are the main contributors to climate change.1

SLCPs—methane, black carbon, ozone, and hydrofluorocarbons—are super pollutants since they are 25 to 2000 times more potent than carbon dioxide in warming the climate.1 SLCPs, especially black carbon particles, are also super-pollutants in terms of health.2 About 40% of the global black carbon emissions are from cooking and lighting with solid biomass fuels and kerosene; the smoke particles from these household fuels along with household use of coal cause about 4.3 million deaths annually.4

Existential threatMore widely, fine particulate pollution from burning fossil and solid biomass fuels for energy contributes to around seven million premature deaths a year, mostly from ischaemic heart disease, stroke, and chronic obstructive airways disease.4 However, the biggest threat of CO2 and SLCPs comes from climate change, since if past decadal trends in emission growth continue beyond 2050, our grandchildren will witness around 4°C warming,1 3 with potentially devastating consequences that threaten to disrupt our existence.5

The planet has already warmed by 1°C since pre-industrial times,

and climate models are projecting an unprecedented acceleration in warming some time soon, exceeding our ability to adapt. The 2015 agreement in Paris6 was a major milestone but insufficient to protect the Earth’s ecosystems or humanity.

Two sets of policy levers must both be pulled vigorously now to bend the emission curve7 downwards and stabilise climate change within one generation 2 3: the CO2 lever and the SLCP lever. In the next 20 years, at current rates of warming, we will shoot past the 1.5°C increase in global temperature.3 However, we can delay this by two or more decades by pulling the SLCP lever.2 3 Without decisive action, by 2050 we will have passed the 2°C mark and be driving fast towards the 4°C cliff.2 3

To stabilise the climate below 2°C, we must also pull hard on the CO2 lever and make the planet carbon neutral this century. However, CO2 molecules persist in the atmosphere for more than a century, so we will not see the major climate benefits until the second half of the 21st century. SLCPs have a much shorter lifespan, measured in weeks up to a decade or so. Pulling on the SLCP lever now will cut pollution in the near term and reduce the rate of warming by as much as 50% by 2050.3 In so doing, we would also prevent around 2.4 million premature deaths annually, at current population size.2

The large number of extra deaths associated with projected increases in extreme events such as heat waves, droughts, floods, and fires and threats to food production provide good

evidence supporting WHO’s assertion that “without adequate mitigation and adaptation, climate change poses unacceptable risks to global public health.”8

Doctors’ ordersHealth professionals have key roles in fighting climate change caused by both SLCPs and carbon dioxide. They must advocate effectively to influence policy, educate peers to be champions in their workplaces and their communities, and persuade the wider public to put pressure on governments. The direct effects of climate change on health must be documented better. In addition, health professionals need to show how destruction of ecosystems, declines in crop yields, and acidification of the oceans could reverse recent advances in global health. Special attention must be paid to the populations of low income countries who have insufficient resources to cope with or adapt to these challenges.5

Health professionals can and should emphasise the health benefits of a decarbonised economy10-12 and engage fully with industry leaders to achieve this goal. Industry leaders must become part of the solution, to safeguard future economic prospects.

The recent WHO conference8 on climate change and health concluded with a clarion call to the health community: it is imperative that health professionals worldwide show strong leadership in tackling climate change.Cite this as: BMJ 2016;355:i5245Find this at: http://dx.doi.org/10.1136/bmj.i5245

EDITORIAL

Why we must take the lead on climate changeShort lived climate pollutants and carbon dioxide emissions are a serious threat to health

Without decisive action, by 2050 we will be driving fast towards the 4°C cliff

Veerabhadran Ramanathan, distinguished professor of climate sciences, University of California at San Diego, San Diego, California [email protected] Andy Haines, professor of public health and primary care, London School of Hygiene and Tropical Medicine, London


Last week, a High Court rejected arguments over the legality of the actions of the health secretary, Jeremy Hunt,

in connection with a new contract for doctors in training.1 The claims, brought by five junior doctors in England through Justice for Health, a group resourced by public crowdfunding, were threefold: the health secretary had no lawful power to impose a contract; his decision was made in a manner so opaque and confused that it violated the principles of transparency and good administration; and his decision was irrational and based on inadequate evidence.2

In a rather surprising turn of events, the action clarified that, in the words of counsel for the claimants, “Mr Hunt is not imposing a contract on junior doctors; he never was; he did not suggest he was; he never thought anyone thought otherwise.” Mr Justice Green agreed that the health secretary’s statement to parliament on 6 July

2016 did lead the junior doctors to conclude that he intended to “impose,” but employers correctly “understood the statement as the minister intended it to be understood.” Counsel for the claimants also noted: “This case is all about what happens when loose language is used and meanings [are] imperfectly conveyed and the very serious consequences which can flow from those words”2

The consequences are indeed serious. The ruling was the latest twist in a long drawn out, damaging dispute. The legal action clarified that employers are not legally compelled to adopt the proposed contract and that negotiations can continue. However, the impasse, the frustration, and the anger of junior doctors driven to industrial action for the first time in many decades remain unresolved. The total breakdown of trust between government and junior doctors represents a catastrophic failure of senior leadership at all levels. The important question is where this leaves patient care.

Save our NHSDuring protests, junior doctors’ placards carried multiple versions of the cry, “Save our NHS,” with not a word about workers’ rights, union demands, better conditions, or more pay.

Why does the NHS need saving? Funding is at an all time low, services are being withdrawn, workforce numbers are inadequate, children and the most vulnerable are falling between the cracks; meanwhile, the pace of costly, untested reorganisation is extraordinary. The dedication of junior doctors and all other frontline healthcare staff has shielded the public from the consequences of this chaos.

Junior doctors know the true state of the health services only too well; they work the longest hours

delivering direct patient care, and are called on to make life-and-death decisions in challenging conditions. As trainees, however, they are treated not as professionals but as children at school, obliged to tick boxes to show progression, document feedback on performance, demonstrate written evidence of reflection, and comply with burdensome bureaucracy. Their protest is both an expression of breaking point frustration with their training and a clarion call to the country to wake up and recognise the true state of the nation’s health services.

So what next? Firstly, there is an over-riding need to re-establish trust, restore morale, and respect young doctors as professionals. This will not be easy and requires maturity, frank acknowledgment of mistakes, honesty of purpose, and a trusted space for dialogue and reconciliation. Secondly, the contract will forever be damaged goods, and should be replaced with one drawn on a clean sheet. Thirdly, patients and the public must be part of a conversation, conducted with integrity, about the nation’s health services. The country is still reeling from the betrayal of honour in public service by the false assertion that £350m a week would be available to the NHS after the UK left the European Union.3

The questions are clear. Do we want healthcare that is efficient, effective, and equitable, delivered by a modern public sector organisation driven not by financial incentives but by pride in outcomes measured to rigorous standards? Do we consider health a commodity or an essential component of a just society, crucial to the economic wellbeing of the nation? The painful political awakening of a generation of young doctors may ultimately prove the catalyst to find a way forward.Cite this as: BMJ 2016;355:i5342Find this at: http://dx.doi.org/10.1136/bmj.i5342

There is an over-riding need to re-establish trust, and respect young doctors as professionals

EDITORIAL

Junior doctors’ dispute leaves big questions Time to acknowledge the deep malaise in medical training and for honest public debate

Neena Modi, professor of neonatal medicine, Imperial College London, Chelsea and Westminster Hospital Campus, London SW10 9NH, UK [email protected]

DAN

IEL

LUCA

S/PA


BMJ CONFIDENTIAL

Ahmed KazmiStanding up for medicine

Ahmed Kazmi, a GP from Coventry, has turned his experience of general practice into comedy, appearing this year at the Brighton Festival and the Edinburgh Fringe. Born in Canada, he grew up and qualified in England before moving to Australia, where friends found his anecdotes funny enough to inspire him to try stand-up under the name Dr Ahmed. While he likes the variety, he doubts that he’ll ever give up medicine altogether: “It took me 11 years to train as a GP, so it would be a bit of a shame to leave it.” The money raised from his UK performances went to Macmillan Cancer Support in memory of his father, who died of lung cancer last year. Kazmi has now returned to the UK.

What was your earliest ambition?I remember being obsessed with maps and atlases as a child in the hope that I’d get to visit all of the places, especially remote islands. I’ve managed 39 countries at my last count. St Helena and Easter Island remain unconquered as yet.Who has been your biggest inspiration?I’d have to say my father, Alamdar Hussain Kazmi. He was pragmatic and academic in equal measure. He taught me that forgiving and forgetting yielded a better return than an eye for an eye.What was the worst mistake in your career?I subscribed for too long to the traditional notion of being a doctor. Historically, they usually had other interests that they practised alongside medicine. I’ve recently tried this approach: sabbaticals, periods abroad, social media, performing arts, business ideas—opportunities that doctors should feel at liberty to enjoy.What was your best career move?Choosing general practice. It’s afforded me job satisfaction, the space to nurture special interests (family planning and dermatology), a good work-life balance, and the means to pursue some other interests, particularly comedy and cabaret.Bevan or Lansley? Who has been the best and the worst health secretary?Suddenly gone very political, haven’t we? The Jeremy Hunt run really has been a dark time for everyone, sadly. Enough said.Who is the person you would most like to thank, and why?Fleming, for penicillin.What is your guiltiest pleasure?I’m addicted to fizzy drinks. I know that they’ll rot my teeth, but they taste so good!If you were given £1m what would you spend it on?The usual stuff: pay off my debts, buy a nice house, go on a holiday, give some to charity, put some in savings. I love art, so I’d buy a Mughal miniature and some medieval Quranic calligraphic scripts.Where are or were you happiest?Being in the safety, warmth, and love of my family and friends.What single unheralded change has made the most difference in your field?Online availability of clinical guidelines and patient information leaflets.Do you support doctor assisted suicide?You don’t hold back with the questions, do you? No, I don’t support it, but this doesn’t mean that it shouldn’t be discussed and debated openly.What book should every doctor read?The Bell Jar by Sylvia Plath. It’s the best description of depression I’ve read.What is your most treasured possession?My dermatoscope.What is your pet hate?When people say “prostrate” instead of “prostate.” Arrgh!If you weren’t in your present position what would you be doing instead?I’d probably be a bar singer in an exclusive holiday retreat on some tropical island, involved in medical education, or doing a PhD. Cite this as: BMJ 2016;355:i5298

ILLUSTRATION: DUNCAN SMITH


“Why is Down’s syndrome the disability it is socially

acceptable to terminate?” actor Sally Phillips asks in the BBC2 documentary A World Without Down’s Syndrome? this week.

Phillips has an 11 year old son, Olly, who likes chocolate ice cream, Barcelona football club, and has Down’s syndrome. He is a funny, loving, engaging child, and Phillips says: “My big question to the world is what is so very dreadful about Down’s syndrome? It’s not a catastrophe. Why is everyone behaving like it’s a catastrophe?”

The NHS will soon offer non-invasive prenatal testing (NIPT), and Phillips fears that this will lead to more terminations for Down’s syndrome, even though the health, life expectancy, and wellbeing for people born with the extra chromosome continues to improve. The simple blood test at 10 weeks of pregnancy can be used to predict the presence of Down’s syndrome and other genetic disorders. The

MEDICINE AND THE MEDIA

The end of Down’s syndrome?A BBC documentary asks questions about the ethics of screening for a condition with improving prospects, Jacqui Wise reports

test is already widely available in the private sector, but in January the UK National Screening Committee proposed it should be offered as a second stage of screening to women who have a higher than 1 in 150 chance of having an affected baby.1 The committee recommended against offering the test to all women as initial screening because of cost and said that implementation should be evaluated.

Researchers at Great Ormond Street Hospital who carried out the RAPID (Reliable Accurate Prenatal Non-Invasive Diagnosis) evaluation study found that the test is about 99% accurate in detecting Down’s syndrome, which compares with an accuracy of 84%-90% for the conventional combined test.2 It is estimated to reduce the number of women who need to have a confirmatory amniocentesis or chorionic villus sampling by 3368 and as a result will cut the number of miscarriages by 17 (from 30 to 7) a year.3 It may also reduce the number of late terminations because trisomy disorders are more likely to be picked up before the 18-20 week scan.

Up to 90% of women who are found to have a pregnancy affected by Down’s syndrome decide to terminate.4 Statistics are disputed, but some argue that since non-invasive testing became available in the private sector terminations have gone up by a third.5

In the documentary Phillips visits Iceland, where over the past five years 100% of people with affected pregnancies have chosen to terminate. She argues that we are sleepwalking into a world where we could eliminate Down’s syndrome without having had a proper ethical debate about the issue. She asks: “What kind of society do we want to live in and who should be allowed to live in it?”

It has been suggested that screening for conditions such as Down’s syndrome could be in conflict with the United Nations Convention on the Rights of Persons with Disabilities, which sets out the equal human rights and place in society of people with disabilities. Campaigners argue that disability discrimination is apparent in the fact that abortion on the grounds of disability can

“What is so very dreadful about Down’s syndrome?” Sally Phillips, mother of Olly, 11, who has the condition


take place right up to birth whereas in other cases there is a limit of 24 weeks. Lord Shinkwin’s private members bill, which seeks to end abortion up to birth on the grounds of disability, is getting its second reading later this month.

However, in the documentary Lynn Chitty, professor of genetics and fetal medicine and head of the RAPID study, says her pilot study has shown that NIPT testing will not significantly change the live birth rates. “We found a lot of women using the NIPT test to find out if the baby has Down’s syndrome inform themselves and carry on with the pregnancy.”

Alan Cameron, the Royal College of Obstetricians and Gynaecologists’ vice president for clinical quality and a consultant obstetrician in Glasgow, told The BMJ that he didn’t think there would necessarily be an increase in terminations: “I am seeing a proportion of women who are choosing not to terminate the pregnancy, particularly as there is much more support for Down’s syndrome nowadays. NIPT is a better test that will offer an earlier choice for women.”

“Women should be supported to test, but also not to test; to terminate, but also not to terminate”—Tom Shakespeare, professor of disability research at Norwich Medical School

Around 775 babies are born with Down’s syndrome each year in England and Wales. Life expectancy has increased substantially and is now around 60 years. Although certain health conditions are more common in people with Down’s syndrome, poor health is not inevitable. All people with Down’s syndrome will have a learning disability, but this could be mild or severe and most children now go to mainstream school.

Negative portrayalThe documentary is critical about some of the NHS leaflets about screening for Down’s syndrome, which feature a long list of possible health problems.

In January the Nuffield Council on Bioethics held a round table meeting on the effect of non-invasive testing, and one of the concerns raised was about the potential for it to become seen as routine; women may then be criticised for choosing not to take the test or even for not aborting an affected baby.6 Several participants suggested that an extensive education programme for healthcare professionals is needed to enable pregnant women to make a genuine choice. The council is producing a report on the issue early in 2017.

Tom Shakespeare, professor of disability research at Norwich Medical School and chair of the working group producing the report, told The BMJ: “Diagnosis is not always well communicated. There needs to be more balanced information available, particularly about the lives of people with Down’s syndrome—the joys as well as the difficulties. Women should be supported to test, but also not to test; to terminate, but also not to terminate. This is what full, free, and informed consent means, and what the NHS is committed to.”

Elizabeth Marder, consultant paediatrician at Nottingham Children’s Hospital and member of the UK Down Syndrome Medical Interest group, told The BMJ: “In theory people have a choice about whether

to opt into screening, but in practice I think participation is often assumed. Those who have had screening results indicating a high chance of Down’s syndrome frequently tell us that they were given the result and then asked ‘So when do you want to come in for a termination?’”

Disability campaigners expressed anger earlier this year when the Royal College of Obstetricians and Gynaecologists (RCOG) seemed to suggest that the costs of testing should be assessed in relation to the lifetime costs of caring for children and adults with Down’s syndrome. Peter Saunders, chief executive of the Christian Medical Fellowship, comments: “The suggestion that the value of disabled people to society might be reduced to the economic cost of their care is the sort of cold calculus that one might expect from a despotic totalitarian regime. That it should come from a British royal college is chilling.”

However, Lesley Regan, president of the RCOG, says the quote was taken out of context. The college’s submission to the UK National Screening Committee said that if the decision not to offer testing as a primary screen was based on cost then a more rigorous economic analysis has to be made that includes the lifetime costs of caring for children and adults with Down’s syndrome. “It is important that a rigorous economic analysis is done when any new screening test is brought in,” she said.

As screening for different health conditions in pregnancy becomes more common, we clearly need a wider debate about the ethics of screening. Shakespeare wonders what will be the next step. “Will there be panel testing of common or rare single gene conditions? Will there eventually be whole genome sequencing? This is probably five to ten years away, but this field is moving quickly, and the major driver is the commercial sector.”Jacqui Wise, freelance journalist, London, UK [email protected] this as: BMJ 2016;355:i5344Find this at: http://dx.doi.org/10.1136/bmj.i5344

What a patient with a learning disability would like you to know, p 75


It’s time that general practitioners became NHS employees to end the anomaly that left GPs and their staff independently employed when the NHS was created in 1948.1

Currently, two main types of GPs work in the NHS: independent contractors (GP partners) and salaried employees. An increasing proportion of GPs are salaried employees rather than self employed independent contractors: about 28% (10 063/35 586) of GPs in England were salaried in 2015 compared with just 4% in 2002 (1085/29 202).2 3 However, salaried GPs are rarely employed by the NHS; generally, they are employed by other GPs or commercial companies.

A recent survey of 573 GP partners by Pulse magazine found that 51% would become salaried for the right deal.4 The employment contracts of salaried GPs vary hugely, and they often have worse terms than doctors employed by the NHS—for example, less maternity leave or sick leave provision. Salaried GPs would therefore benefit from a transfer to NHS employment contracts, as would GPs who are currently self employed.

Most stressedPrimary care in England’s NHS is in crisis.5 6 Recruitment of GPs is difficult throughout England, with many practices reporting vacant posts; many GPs are considering retiring early, and others want to cut down on their clinical work.7

In a survey of primary care carried out by the Commonwealth Fund in 11 countries GPs in the UK were the most stressed.8 UK GPs also reported high levels of dissatisfaction with their style of work—for example, the short consultation lengths and high number of patient consultations a day in the UK (92% of GP consultations in the UK were less than 15 minutes compared with just 27% in the other 10 countries).8 Our current model of primary care is failing, and we will see a gradual implosion of

general practice in many parts of England, notwithstanding the recent recognition of this problem by NHS England and the promise of increased investment in the NHS Five Year Forward View.9

The problems faced by GPs are partly due to the contracts that general practices have to provide NHS services and the way secondary care is organised. These contracts encourage the NHS to transfer work to primary care with the expectation that GPs will pick up this work at little or no extra cost. Most GPs would have no problem with taking on such work if they were given time to deal with it during their current working week. If GPs had employment contracts similar to NHS hospital consultants they could have job plans, with time allocated for clinical work and for activities such as administration, teaching, training, and research.

Better career structureFurthermore, we could develop a better career structure. For example, it may be possible to create posts for GPs who specialise in the care of elderly people or in child health and for GPs who take on clinical leadership, quality improvement, and NHS management roles.10

As NHS employees, GPs would lose many of the responsibilities that make their work stressful. They would no longer be personally liable for meeting the requirements of the Care Quality Commission,11 and their hours of work would be protected by the European Working Time Directive. Any time spent working at evenings or weekends as part of extended hours schemes would have to be part of their contracted hours rather than in addition to their current work.

As employees, GPs would also no longer be the target of criticism from politicians, managers, the media, or the public when waiting times to see GPs increased or for not offering patients with complex health needs sufficient time. The NHS, as the employer, would be responsible for ensuring there were enough GPs to meet the demand for primary care and to address people’s clinical needs.

yes As NHS employees, GPs would lose many of the responsibilities that make their work stressful

HEAD TO HEAD

Azeem Majeed, professor of primary care, Department of Primary Care and Public Health, Imperial College London, London W6 8RP [email protected]

Should all GPs become NHS employees?


noEvery year someone suggests that the UK’s family doctors should become NHS employees. Although many GPs choose to be salaried or to work as locums, a steadily shrinking majority still prefer to run their own practices as subcontractors to the NHS. There is little evidence to inform this debate because few countries have such well established primary care systems and fewer still have salaried family doctors. Those who want to change the status quo have not shown the advantages.

The junior doctors’ dispute with the English NHS graphically shows why GPs are much better off in semi-autonomous businesses, working for their patients in their own practices. It is far harder for the government to impose something on professionals who are more distant from direct NHS employment. GPs’ hard won freedoms have been progressively curtailed, but the changes would probably have been greater if they had been directly employed by the NHS.

What is clear is that an employed service will cost more and be less efficient than the independent one. Sick pay costs will rise and working patterns will change, possibly resulting in reduced patient access as GPs limit how hard they work as employees.

Unsurpassed autonomyMany independent GP contractors enjoy their status even in these dog days for the NHS. If they did not, they would leave or become sessional employees. Indeed, in a recent survey of 573 GP partners, 36% said that they would not consider becoming salaried.4

GP partners have the freedom to run their practices as they wish—as long as they deliver a safe and effective service; to choose who works with and for them; and to operate from premises that they control and for which they are locally accountable. Few employees have this much autonomy or such ability to innovate.

If all GPs became NHS employees, they may well have to work to tougher performance indicators with less cover (as we have seen with hospital and district nursing colleagues)

and with whomever the NHS decides. Because GPs would have less incentive to control costs such a move could cost the NHS rather than save money.

The stability of general practice is largely down to the GP owned nature of the business and premises—a workforce will always act to deliver the best service if it has shares in that service. Ownership of premises is becoming less attractive for many as property prices exceed the reach of younger GPs and profits fall for older ones. But even renting your place of work gives you more control over your working environment.

Advocacy for patientsThe greatest benefit for independent contractors, however, is the ability to make agreements with patients without the need for anyone else’s approval. All doctors value their relationships with their patients, but employed doctors always have someone that they answer to (whether clinical or managerial) who is monitoring their activity and outputs. GPs are on a slightly longer leash, in time and distance, and can be more fearless advocates for their patients. If an independent GP and a patient agree on a course of action the response can be immediate, at least for the 84% of contacts that are resolved by GPs without recourse to other parts of the NHS. Even with multiple layers of regulation of the GP, the patient benefits faster and with more ease. Good care is encouraged when GPs personally depend on patients’ satisfaction.

Despite the steady erosion of taxation benefits over the past 20 years, and even with the reducing benefit of property ownership, it remains economically beneficial to be part of an NHS independent contractor practice because it is possible to partially contain the economic damage of incessant “reform” on the business.

How many independent GPs would have preferred to have been in the position of our junior colleagues over recent months? I decide the rights that I have, as long as I deliver to my patients. No one can take that away while I employ myself.Competing interests: AM is a GP principal and LB was chair of the BMA’s GP committee from 2007 to 2013.

Cite this as: BMJ 2016;355:i5064

HEAD TO HEAD

How many GPs wish to place their entire income at the mercy of a corporate health service that seems not to care about its staff?

Laurence Buckman, GP partner, Temple Fortune Medical Group, London NW11 7TE [email protected]

Independent contractor status creates unnecessary stress, writes Azeem Majeed, but Laurence Buckman values his autonomy and distance from a non-benign employer


General practice is in crisis. Many posts lie empty and many older doctors are due to retire soon. The current system is failing, with patients waiting weeks for appointments. Something radical has to be done.

Currently we are small groups of self employed doctors with limited career progression, a blank cheque of responsibility, and seeing in excess of 30 patients a day in 10 minute appointments.1 The combination of acute and routine work required means that GPs often finish surgeries then do house calls over lunchtime. Paperwork is done in the margins of the day. Increasing pressure is making general practices dysfunctional, chaotic, unhappy, and lonely places. A sickness absence can make an already unmanageable workload impossible. Personalities clash. GPs need a better working environment and more opportunities. Paradoxically paying doctors more means they elect to work less. So what’s the solution?

A salaried service might appeal to many: secure, no management responsibility, study leave, limits to workloads, and protected administration time. GPs could have similar contracts to consultants (although I don’t recall consultants being especially happy). But such a radical change might have unforeseen consequences.

Unforeseen circumstancesWould the system become more inefficient? Might we undermine continuity, stifle innovation, and increase bureaucracy? Would such a radical change see large numbers of GPs retiring? Nationalising general practice would also mean purchasing many buildings. And the current system has much to commend it; it is local, flexible, innovative, accessible, and cost effective. Importantly, clinical staff are in control.

There is a third way that delivers the benefits of salaried service while preserving the elements of local clinical control. This

model is based on my experiences building a practice from 5000 to 35 000 patients in the past two decades. This requires practices to become much larger, with groups of 20 or more doctors.

Economies of scaleScale means that practices can run on-call systems and offer extended hours and Saturday opening. Scale offers more oversight and standardised care and prescribing patterns. Scale affords more advocacy when dealing with other medical institutions such as hospitals or medical schools. These large practices could become training hubs with multiple registrars. They would also be more social and happier places to work in.

From a commercial perspective, practices need far fewer partners and many more flexible employed salaried options. Pay should be capped for partners and salaried positions paid agreed national rates. All staff should have a stake in the partnership, including nurses and reception staff. Practices should be run as local not-for-profit social enterprises that reinvest profits in developing services, similar to the commercial positions of housing associations and academy school chains. This is not utopian nonsense but works in the real world. We find it easy to recruit staff, have provided private physiotherapy and podiatry services through the practice, open 7 till 7 and Saturdays, and generally have a happy workforce.

There is an increasing trend for larger practices,2 and this needs to be accelerated, facilitated, and prioritised through a new contract with a new vision of general practice. More of the same just isn’t working. For all the fears of loss of continuity and less personalised care, the benefits of bigger and better organised practices far outstrip these anxieties and can save general practice.Des Spence is a general practitioner, Maryhill Health Centre, Glasgow [email protected] Cite this as: BMJ 2016;355:i5329

COMMENTARY Des Spence

Independent or employed? There is a third way . . .An increasing trend for larger practices needs to be accelerated through a new contract with a new vision of general practice

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