this week

NEWS ONLINE

•  GPs in Northern Ireland face “full blown crisis”

•  Patients are being let down by lack of electronic health records

•  New York University medical cadavers found in mass grave

Medical boss “failed patients”

KEVI

N E

RITL

ANT/

ALAM

Y

The medical director of an NHS trust repeatedly failed to take action to protect patients from the risk of harm posed by a bungling consultant obstetrician and gynaecologist, the General Medical Council has alleged.

In a hearing that opened on 6 June and is listed to � nish on 1 July, Paul Upton is accused of having not properly investigated or intervened from January 2010 to October 2011 as concerns mounted over the practice of Rob Jones.

The case is thought to be the � rst action by the regulator to go to a hearing that focuses on a doctor’s managerial role rather than on his clinical practice. A spokeswoman for the GMC said that it was not aware of any such earlier cases. A case against four doctors in management positions at the scandal-hit Mid Sta� ordshire NHS Foundation Trust was dropped a� er legal advice in 2013.

Jones was appointed a consultant at Royal Cornwall Hospitals NHS Trust in 1992, and the � rst concerns about his practice appeared in a � le note in 1997. Since 2000 his practice had been formally investigated eight times. Jones retired in 2012 a� er he was suspended by the trust, and he removed himself voluntarily from the GMC

register. More than 200 of his patients have made negligence claims against the trust.

Upton, who was medical director of the trust from December 2009 to August 2013, is accused of not having investigated thoroughly enough to make an informed judgment on whether Jones’s practice should be restricted a� er a serious untoward incident in January 2010.

From March to December 2010, the GMC alleges, Upton should have met “as a matter of urgency” with two colleagues who had reported concerns and carried out investigations. He is also accused of failing to meet urgently with another doctor who had raised concerns in April 2011 or to instigate an investigation.

A� er further concerns identi� ed from August to October 2011, the GMC alleged that Upton did not take appropriate steps by not instigating an investigation, did not take advice from the National Clinical Advisory Service, did not restrict Jones’s practice, and then excluded him from practice.

Upton stepped down from the trust board in 2013 but continues to work as a consultant anaesthetist for the trust. Clare Dyer, The BMJ Cite this as: BMJ 2016;353:i3195

Paul Upton (inset) is accused of not investigating or intervening as charges against obstetrician and gynaecologist Rob Jones mounted

the bmj | 11 June 2016 421

PAGE 424 Public health targeted • PAGE 425 Women in surgery

SEVEN DAYS IN

Global health WHO is open to business “lobbying” The World Health Organization has been warned that it has made itself open to undue influence from commercial interests after member states agreed a framework for its relations with industry, bodies from academia, non-governmental organisations (NGOs), and philanthropic organisations. These non-state actors can now attend WHO meetings and consultations; provide financial or other types of contributions; provide evidence; advocate on health issues; or provide technical support. However, 60 NGOs said that the framework did not protect WHO from influence from the private sector and would “once and for all, legitimise lobbying by business associations.” (Full story doi: 10.1136/bmj.i3134 )

Technology Wristband that logs drinking wins award BACtrack, a medical device maker in San Francisco,

took the $200 000 top prize in a competition run by the US National Institutes of Health (NIH) with a wristband that measures blood alcohol concentrations through sweat on the skin. The device, BACtrack Skyn, cannot be used to test real time alcohol concentrations because it takes 45 minutes for ethanol to be transmitted through the skin. But it does provide a log of recent alcohol use. The NIH’s George Koob said, “It can help doctors accurately measure a patient’s drinking history and not just depend on the most recent tests. This can help a lot with the treatment.”

UK news GPs acquitted of manslaughter Two GPs who were prosecuted for the manslaughter of a 12 year old patient have been

acquitted after the judge at Cardiff Crown Court ruled that there was no case for them to

answer. Lindsay Thomas, 42, and Joanne Rudling (above), 46, were charged with gross negligence manslaughter over the death of

Ryan Morse from Addison’s disease on 8 December 2012. The prosecution argued that Ryan would have lived had either GP visited him or summoned an ambulance after

a phone call the previous evening from his mother. But Justice Nicola Davies

ruled that there was insufficient evidence

on which a jury could convict either doctor.

(doi: 10.1136/bmj.i3098 )

F ree vitamins for pregnant women in Scotland

Every pregnant woman in Scotland is to be offered free vitamin supplements

from next year as part of a drive to improve the health of mothers and

babies. The announcement is part of a package of measures that includes a “baby box” for every

newborn, with clothing, bedding, books, toys, and a toothbrush, and the box itself can be converted into a basic crib. A similar initiative has been running

in Finland since the 1930s, where it has been seen as an important support for new mothers. (doi: 10.1136/bmj.i3129 )

End “chemical restraint” of people with learning disabilities New guidance from NHS England and the Royal College of General Practitioners is urging GPs to review prescriptions for patients with learning disabilities or autism and to make sure that psychotropic drugs are continued only when the person poses a severe risk to themselves or others and all other alternatives have been exhausted. A review published last year found that between 30 000 and 35 000 UK people with learning disabilities or autism were taking an antidepressant or an antipsychotic despite not having the conditions for which the drugs are indicated. (doi: 10.1136/bmj.i3137 )

Four board members of the UK National Obesity Forum have resigned aft er the organisation published a controversial report advising people to eat more fat, cut down on carbohydrates, and not bother counting calories.

The report, which was co-written with the Public Health Collaboration, argued that saturated fat does not cause heart disease and that full fat dairy foods can protect the heart. It also said that public health messages should not focus on calories and that a bad diet cannot be fi xed by increasing exercise.

Matt Capehorn, the charity’s clinical director, resigned over the report, as well as Deborah Cook, deputy chair; Jen Nash, a clinical psychologist; and Sangeeta Agnihotri, a consultant obstetrician and gynaecologist.

The rest of the forum’s board emphasised that they had not had the opportunity to see the document or give any input and that some members’ opinions diff ered from those in the document.

The board stated, “The National Obesity Forum is a forum that welcomes debate and discussion, even when opinions diff er from or challenge widely held beliefs. This paper has some interesting arguments for future discussion, some of which are the opinions of the authors, and not all of the board members.”

Four members of obesity forum resign

Jacqui Wise, London Cite this as: BMJ 2016;353:i3192

422 11 June 2016 | the bmj

New complaints authority must be independentThe body created to oversee and improve the complaints system for the NHS in England must be allowed proper independence outside NHS control, MPs on the parliamentary public administration and constitutional affairs committee have said. The new Healthcare Safety Investigation Branch, which began in April, would succeed only if the government brought forward legislation making it fully independent of the NHS, to help secure a statutory “safe space” in which clinicians, patients, families, and carers could speak frankly about serious risks to patient safety, the MPs said. (doi:10.1136/bmj.i3100)

WorkforceConcern over bullying of BME staffSimon Stevens, chief executive of NHS England, described as deeply concerning the results of a survey that found that black and minority ethnic (BME) staff

were more likely to be bullied than their white colleagues. Three quarters of the 153 acute care trusts surveyed reported a higher percentage of BME staff being harassed, bullied, or abused by staff in comparison with their white staff. Most acute trusts (86%) had a higher percentage of BME staff who said that their organisation did not offer equal opportunities for career progression or who said that they had experienced discrimination from a manager, team leader, or colleague. (doi:10.1136/bmj.i3124)

Research newsHealthy fats not linked to weight gainAn unrestricted calorie Mediterranean diet enriched with healthy vegetable fats (olive oil) does not increase weight gain or waist circumference any more than a low fat diet does, concludes a study published in Lancet Diabetes & Endocrinology. The authors concluded that the study indicated that current health guidelines that recommend a low fat, low energy diet create unnecessary fear of healthy fats. But Susan Jebb, professor of diet and population health at the University of Oxford, said, “The strongest finding . . . is that to successfully lose weight you need to limit overall food (calorie) intake.” (doi:10.1136/bmj.i3171)

Long term treatment cuts breast cancer recurrenceExtending the use of adjuvant aromatase inhibitors from five to 10 years in women treated for primary breast cancer significantly increases rates of disease free survival and the risk of cancer occurring in the other breast, shows a study published in the New England Journal of Medicine. However, extended use of the drugs was not found to affect overall survival or to increase fractures. (doi:10.1136/bmj.i3153)Cite this as: BMJ 2016;353:i3177

GOVERNMENT RESEARCH? THAT SOUNDS BORINGDon’t be such a cynic. A new report by campaigning organisation Sense about Science has discovered that the government commissions lots of research but results are “held back when the findings are politically awkward.”

RESEARCH INTO RESEARCH?Yes, it sounds odd but it’s important. Former lord justice of appeal, Stephen Sedley, found that evidence on the effects of minimum alcohol pricing, reducing sugar consumption, food banks, immigration, choice of GP, and drug policy had been suppressed. The report said, “Publication of research has been manipulated to fit with political concerns, but poor records conceal the extent of this behaviour.”

WHO ARE THE WORST OFFENDERS?Everyone, basically. “Weak” rules governing publication allowed ministers to bury unwelcome evidence, and there is lax and variable record keeping by Whitehall. Only four out of 24 Whitehall departments maintain a database of research they have commissioned. The fab four who do are the Department of Health, the Department for Environment, Food and Rural Affairs, the Department for Transport, and the Department for International Development. But this doesn’t mean they’re off the hook.

WHAT A WASTE OF MONEYIndeed. With £2.5bn to spend you’d think there would be some sort of record keeping so civil servants would know how many studies are commissioned or were published. But no.

WHAT DOES “SIR HUMPHREY” MAKE OF THIS?A bit confused. Government employees end up having to Google their own research to find it. Poor records create “ghost research”—existing only in the memories of Whitehall officials, says the report.

SIXTY SECONDS ON . . . GOVERNMENT RESEARCH

Anne Gulland, London Cite this as: BMJ 2016;353:i3159

the bmj | 11 June 2016 423

MEDICINE

FGMThere were

1242 new cases of female genital mutilation reported in England between January and March 2016; more than half, about

55%, were in London

Around a third of the 1.7 million deaths of people under the age of 75 in the European Union in 2013 were avoidable, with heart attacks (184 800 deaths) and strokes (94 000) accounting for nearly half (48%) of all premature deaths, show data from Eurostat, the statistical office of the European Union.

The UK ranked 16th of 28 member states in terms of premature mortality, with 34.2% of deaths among people under 75 deemed by Eurostat as avoidable. This was just above the European average of 33.7%.

Eurostat defines avoidable deaths as those that could have been prevented had timely and effective medical treatment been available. It said that the data were not meant to be a definitive measure of the quality of healthcare in member states but that they did offer an indication of the

quality and performance of healthcare and public health policies.

France had the lowest proportion of avoidable deaths (23.8%), followed by Denmark (27.1%), and Belgium (27.5%). Other countries that had lower than average numbers of preventable deaths included Spain (31.3%), Poland (31.4%), Slovenia (33.1%), and Cyprus (33.2%).

% of avoidable deaths0 10 20 30 40 50

Hungary 41.5%Malta 42.0%

Romania 49.4%

Ireland 34.6%UK 34.2%

Slovenia 33.1%Poland 31.4%France 23.8%

EU 33.7%

A new report has forecast that 250 000 people in the UK will die from preventable conditions by 2025 unless major action is taken.

The report, by a coalition of UK health and social care charities, identifies 12 interventions that could reduce deaths and disability caused by long term illnesses

424 11 June 2016 | the bmj

Report calls for bold action to prevent early deathssuch as coronary heart disease, type 2 diabetes, cancer, chronic lung disease, and dementia. The interventions target smoking, alcohol consumption, poor diet, and physical inactivity.

The World Health Organization has set a target for a 25% reduction in the numbers of early deaths

from common long term conditions between 2010 and 2025. The Richmond Group of Charities, a coalition of 12 organisations led by Diabetes UK, commissioned a research project looking at the WHO target as a benchmark against which to measure UK trends. The report said that without further action the

The UK ranked 16th of 28 member states in terms of premature mortality

UK rate of avoidable deaths is higher than EU averageRomania had the highest rate of

avoidable deaths (49.4%), followed by Latvia (48.5%) and Lithuania (45.4%).

After heart disease, the main causes of avoidable deaths were colorectal cancer (67 000 deaths (12%)), breast cancer (50 800 (9%)), hypertensive diseases (28 700 (5%)), and pneumonia (24 100 (4%)).

Commenting on the figures, Katherine Murphy, chief executive of the UK Patients Association, said, “These statistics are indicative of a failing and underfunded service. We urge the Department of Health to ensure that the NHS is properly resourced and managed so that it can provide the care that patients need and deserve.”Zosia Kmietowicz, The BMJCite this as: BMJ 2016;353:i3196

Action to improve the nation’s health must focus on children if it is to make a real impact, said the RCPCH’s Russell Viner

“We need to make healthy choices easy choices”

“The critical thing now is that we have just hit the landmark of 30% of surgical trainees being women. That’s a critical number because all those surgical

trainees will be eligible to become consultant surgeons in the future. It’s fantastic news, and it shows that women do want to be surgeons. When I qualified in 1988 people assumed that women didn’t want to do surgery, but actually they do. This landmark has dispelled that myth.

“Things have changed in surgery during my career. It is now much more team based, and night time operating is now only for life threatening or limb threatening conditions.

That change came about because of patient safety issues, but a byproduct of it has been that you don’t have to operate all night. It is a much friendlier way of working: you’re always working in teams, which is better than the historical

macho image of the surgeon as the hero rushing around saving lives, not getting much sleep, and always being perfect.

“We need to encourage women into surgery because 57% of the people at medical school are women. Because it’s quite new having so many women in surgical training, we need to make people realise that less than full time (LTFT) training is an option and that the people who are doing LTFT training are doing it well and turning out to be excellent surgeons.

“Doctors have a whole range of experiences of surgery. For some of them the last time they saw a patient in a hospital was when they did their last house job. I don’t want senior doctors inadvertently putting off their trainees because they think it’s still like that.

“How we manage patients is changing; how care is delivered is changing. The people who are coming through training now have to be diverse and flexible and able to adapt for the next 30 years.

“Surgery is a fun and rewarding career. You often see results very quickly, and you’re making a massive difference in a very small amount of time. We get laughed at: people say it’s like carpentry or plumbing, but you have something in your hands that you can usually make better.” Abi Rimmer, BMJ CareersCite this as: BMJ 2016;353:i3197

FIVE MINUTES WITH . . .

Scarlett McNally The consultant orthopaedic surgeon says more needs to be done to encourage women into the specialty

Report calls for bold action to prevent early deaths UK would narrowly miss the WHO targets. It added that these targets were unambitious and called on the UK government to take bold action.

Food, tobacco, and exercise The report modelled four possible interventions in depth to assess their effect on mortality and disability over 10 years. It found that there would be 26 000 fewer deaths if food was reformulated to reduce salt, sugar, and portion sizes and 2450 fewer deaths if tobacco tax was raised. In addition, brief advice on physical activity delivered through general practices could result in the avoidance of 98 000 years lived with disability. A further restriction on alcohol marketing would result in 86 000 years lived with disability being avoided, the study showed.

The report’s lead author, Peter Scarborough, joint programme lead for diet and nutrition at Oxford University’s Nuffield Department of Population Health, said, “This report shows how maintaining a strong focus on public health—which has led to important breakthroughs like salt reduction in processed foods, banning

the bmj | 11 June 2016 425

Mental health delays too long

smoking in public places, and the introduction of front-of-pack food labelling over the last 15 years—will result in us nearly achieving the WHO targets for premature mortality by 2025. But to achieve these targets we need to be even bolder and increase our efforts to improve public health and make healthy choices easy choices.”

Healthy early years vital Russell Viner, officer for health promotion at the Royal College of Paediatrics and Child Health (RCPCH), commented, “Today’s report acts as a stark reminder of just how poor the nation’s health will be if action isn’t taken now. But this action must have an emphasis on children and young people if it is to make a real impact.

“We know that if children lead healthy lives, they are much more likely to continue on that trajectory as they transition into adulthood. So policies like reformulation of foods to reduce salt, sugar, and portion size as recommended in today’s report is something we would support.”Jacqui Wise, LondonCite this as: BMJ 2016;353:i3172

Children and adolescents with mental health difficulties are forced to wait an average of 10 years between first becoming unwell and getting help, a report has found.

An evidence review by the Centre for Mental Health charity found that only a quarter of school age children with a diagnosable problem received any intervention despite most parents seeking professional advice. And it warned that, when children and families do seek help, they are “frequently confused by a maze of largely fragmented services and often face lengthy delays to get the help they need.”

Lorraine Khan, associate director for children and young people at the centre and the report’s author, said, “Good mental health is shaped very early on at the first spark of

life . . . Most common childhood mental health problems can be treated effectively. Early help is vital to have the best chance of success. Waiting for a child’s mental health to deteriorate until it hits crisis point causes untold distress and damage to their lives and carries a heavy social and economic cost.”

Khan and her colleagues called for “whole system ownership of and investment in children and families’ mental health, from the first spark of life through to early adulthood.”

They also highlighted the importance of raising awareness and mental health literacy among families, schools, and young people and of making help more accessible, more proactive, and more responsive.Helen Mooney, LondonCite this as: BMJ 2016;353:i3199

426 11 June 2016 | the bmj

Behind the Smile is a new exhibition born out of artist Toby Brown’s own experience of mental illness.

The exhibition, which is being held in support of the mental health charity Mind, features 18 portraits of people who have experienced mental illness, including Alastair Campbell (bottom right), Tony Blair’s former press secretary, the late singer Amy Winehouse (top right), the musician Matt Deighton (left), and Sandi Thom (right middle).

Brown began the series of paintings with three self portraits in 2011, with the aim of showing what was “going on behind false smiles.” Brown showed them at an exhibition in 2012, where he met a psychiatrist with whom he began discussing the power of art as therapy.

Brown has only 35% vision in his left eye, so his paintings have a blurred quality, an effect he says gives his work an interesting twist.The exhibition is being held at the Debut Contemporary gallery in Notting Hill, London, until 30 June. See www.debutcontemporary.com.Anne Gulland, London Cite this as: BMJ 2016;353:i3207

Behind the Smile

the bmj | 11 June 2016 427

428 11 June 2016 | the bmj

Before global activities to eradicate smallpox were intensified in 1967 an estimated two million people were dying each

year of the infection, with blindness affecting up to 30% of survivors. A thermostable vaccine made eradication possible and stopped sickness and death from smallpox. By eradicating smallpox, the vaccine has also avoided the need for antibiotics to treat associated secondary bacterial infections and removed the potential of resistance developing to any antiviral drugs that might have been developed. Promoting and developing vaccines is therefore rightly among the 10 main recommendations for tackling drug resistant infections that are

Identify a few key interventions to begin the long process oftackling antimicrobial resistance

CDC

outlined in the final report of the Review on Antimicrobial Resistance chaired by Jim O'Neill.1

The report’s 10 recommendations follow the two World Health Organization global work plans and associated reports on antimicrobial resistance released in 2001 and 2015.2 3 By providing additional evidence of the urgency of the problem, supported by epidemiological and economic modelling, the report is attracting the attention of government leaders and top level officials. At the same time it provides a rational way forward for this serious problem.

Other recommendations in the report include better incentives to promote investment in new drugs and to improve existing ones. It recommends a global innovation fund for research and development of new antimicrobial drugs, vaccines, and diagnostic tests in order to build on existing bilateral and multilateral funds, and to pool and coordinate research spending.

Behavioural changesChanges in behaviour and better use of existing diagnostic tests figure prominently in the recommendations for national or regional action, such as decreasing demand for, and better use of, existing antimicrobial drugs. These and other recommendations pose difficulties that are clearly outlined in the report. For example, one way to ensure global public awareness is through campaigns and education about hygiene. These will require government recognition of antimicrobial resistance as a major public health problem among other competing public health priorities and then political engagement to provide the necessary funds.

Another more local recommendation is the establishment of robust regulation.

The report also emphasises the need to have political and government engagement for agricultural measures. This industry uses antimicrobial drugs—whether in plants, animals, or fish—not just to cure infection but to provide livelihoods and profit. It is therefore important to ensure that interventions to reduce antimicrobial use in this sector can be clearly shown to be cost effective so as not to decrease profit.

Under the 10 recommendations there are 39 sub-recommendations to tackle antimicrobial resistance. As in previous action plans and reports, this panoply of recommendations risks being so overwhelming that it discourages or slows down action.

But other public health initiatives, including tobacco control, may indicate a way forward. The Framework Convention on Tobacco Control identified and focused on a few interventions to jump start tobacco control in signatory countries. Consensus on advertising bans, taxation, and labelling became part of the treaty, and they have steadily contributed to decreased tobacco consumption in countries where they are being effectively implemented. Identifying a few key interventions to begin the long process of tackling antimicrobial resistance—could lead to a similar framework convention.

Development of a framework with only a handful of key recommendations—across many different sectors, and possibly within the UN itself—could help to ensure cross-sectoral working and consensus on key problems that are currently ignored because they are considered thorny.

Many will determine a treaty to be unworkable, but others may take up the call. Lessons from the past should not be ignored.Cite this as: BMJ 2016;353:i3087Find this at: http://dx.doi.org/10.1136/bmj.i3087

EDITORIAL

What to do about antimicrobial resistanceSuccessful eradication of smallpox and the treaty to reduce smoking may suggest the way

David L Heymann, head and senior fellow, Centre on Global Health Security, Chatham House, London, UK David.Heymann@lshtm.ac.uk

Condition critical

the bmj | 11 June 2016 429

Most cases of autosomal dominant polycystic kidney disease (ADPKD) come to

medical attention during adulthood. However, clinically important morbidity such as hypertension and cardiovascular disease occurs much earlier. Screening children could detect those affected, and trials have shown that early intervention reduces disease progression. Despite this, very few children from families with the condition are currently assessed in the United Kingdom.

ADPKD is the most common inherited kidney disease and accounts for 10% of people under 65 years on renal replacement therapy in the UK.1 Often asymptomatic during the first three decades of life, the condition typically presents with abdominal pain or an incidental finding of hypertension. Renal disease is characterised by gradual

Satyamaanasa Polubothu, academic clinical fellow, Great Ormond Street Hospital, London WC1N 3JH, UK mpolubothu@gmail.comAmanda Richardson, paediatric nephrology specialist trainee, Department of Paediatric Nephrology, Evelina London Children’s Hospital, London, UKLarissa Kerecuk, consultant paediatric nephrologist, Department of Paediatric Nephrology, Birmingham Children’s Hospital, Birmingham, UKManish Sinha, consultant paediatric nephrologist, Department of Paediatric Nephrology, Evelina London Children’s Hospital, London, UK

EDITORIAL

Autosomal dominant polycystic kidney disease in childrenScreen now to save later?

the 50th percentile using angiotensin converting enzyme inhibitors halts the progression of left ventricular hypertrophy and fall in renal function.6 The addition of pravastatin substantially reduces the progression of structural kidney disease. 7 8

The National Institute for Health and Care Excellence (NICE) recently approved the first targeted therapy, a desmopressin antagonist, for ADPKD adults with chronic kidney disease stages 2-3.12 We believe that children would poorly tolerate the side effects of this class of drug. However, other disease modifying drugs are currently in development. This important shift from symptomatic to preventive treatment makes it a good time to question the current expectant approach to childhood ADPKD.

We urgently need UK guidelines to inform medical practitioners and to optimise and standardise management, which will ultimately improve long term health outcomes and quality of life.

There are ethical considerations regarding genetic testing in children who are unable to give informed consent, compounded by the negative insurance implications of a confirmed diagnosis. These factors notwithstanding, we must stop ignoring children with ADPKD. A few pounds spent now on screening and early intervention could save many thousands later by delaying hypertensive complications and chronic kidney disease.Cite this as: BMJ 2016;353:i2957Find this at: http://dx.doi.org/10.1136/bmj.i2957

bilateral cystic dilation of the renal tubules, with eventual compression of normal renal parenchyma and kidney enlargement. After patients develop hypertension, the disease has an accelerated trajectory, with a relentless and progressive decline in renal function, and around half of patients develop end stage renal failure by age 60 years (figure).2

To date consensus has dictated deferring investigations in asymptomatic children who are at risk, driven by both the belief that it is an adult disease and the absence of treatments to modify the disease course. In support of this approach, the Kidney Disease Improving Global Outcomes Consortium recently recommended against presymptomatic screening of children.4

Modifiable risk factorsHowever, a growing body of evidence suggests that early measurable morbidity—specifically hypertension, cardiovascular dysfunction, and increased kidney volume—predates the development of symptoms in affected children. Furthermore, several studies have shown that early targeting of modifiable risk factors halts disease progression.

Up to one third of children with the disease are now known to have overt hypertension. Left ventricular hypertrophy occurs both in hypertensive children and normotensive children with blood pressure between the 75th and 95th centile.5 Regulating the blood pressure of normotensive children to

Age0 10 20 30 40 50

Systolic blood pressureApproximately 25% of children are hypertensive by thetime they reach adolescence, rising to 67% by 30 yearsGlomerular �ltration rateGFR typically remains stable until around 40 years,followed by a rapid decline

A few pounds spent now on screening and early intervention could savemany thousands later

The disease’s effects on blood pressure, glomerular filtration rate, and cyst size

430 11 June 2016 | the bmj

Would British doctors no longer be able to work elsewhere in Europe? The European Union’s Mutual Recognition of Professional Quali� cations Directive passed into UK law in January. It is the key regulation allowing doctors to practise in other EU states, as well as in Norway, Iceland, and Liechtenstein, and promotes the automatic recognition of professional experience. The directive also allows EU regulators to check language skills and includes an early warning system advising when a doctor is banned or has restrictions.

The number of UK trained doctors practising in Europe is thought to be low, although nobody collects statistics. They can expect that any barriers the UK puts up if it leaves the EU will be matched by EU countries.

Would European collaboration in medical research change? According to a House of Lords report the UK pays out £5.4bn to support EU research activities but gets back £8.8bn in grants. Access to researchers from across the EU is another boon to UK medicine, says the remain camp.

According to Mike Galsworthy, programme director of Scientists for EU, 62% of the UK’s science research output is in the form of international collaboration.

“And that � gure has grown enormously over the years. It’s up because international collaboration and research papers have 50% more impact than purely domestic research.

He points to a range of Europe-wide collaborations such as the 4C cancer screening programme based in 13 institutions across Europe and the EuroCan Platform,

a European Commission funded project bringing together 28 European cancer institutions.

Gordon McVie, professor of cancer studies at King’s College London, says that the UK does well in terms of winning EU research grants. “This would probably diminish, but I doubt it would disappear if Brexit triumphed because of the critical mass of top science here,” he says.

How would access to healthcare be affected? T here will be no change for EU citizens already lawfully resident in the UK. They will be granted leave to remain and will have access to services such as healthcare.

For UK citizens living in the EU the rami� cations of Brexit are unclear. Derrick Wyatt, QC, emeritus professor of law at the University of Oxford, told a House of Lords inquiry that rights to healthcare would probably be reciprocated—so, if European citizens living in the UK get access to healthcare so would UK citizens already resident in the EU.

P eople from outside the European Economic Area (EEA) in the UK for more than six months have had to pay a “health surcharge” of £200 per person. This could be applied to European nationals in the event of Brexit, and UK citizens living in the EU might � nd they are charged in a similar way. Anne Gulland, journalist, London, UK agulland@bmj.com Cite this as: BMJ 2016;353:i3138

EU REFERENDUM AND HEALTH

Would Brexit end freedom of movement for doctors, patients, and researchers? Anne Gulland examines the likely e� ects on freedom of movement if the UK leaves the European Union

Be the first to knowwhat is happening inyour specialty

Followus

journals.bmj.com/twitter

the bmj | 11 June 2016 431

One manifestation of too much medicine is inappropriate polypharmacy in older people. Polypharmacy

is usually defined as taking more than five regular prescribed medicines.3 It can be appropriate (when potential benefits outweigh potential harms)4 but increases the risk of older people experiencing adverse drug reactions, impaired physical and cognitive function, and hospital admission.5‑7 Systematic reviews of medication withdrawal trials (deprescribing) show that reducing specific classes of medicines may decrease adverse events and improve quality of life.9‑11

Patients and clinicians typically overestimate the benefits of treatments and underestimate their harms.14 When patients engage in shared decision making they become better informed about potential outcomes and tend to choose more conservative options (eg, fewer medicines), facilitating deprescribing.15 However, shared decision making in this context is not easy, and there is little guidance on how to do it.16

We draw together evidence from the psychology, communication, and decision making literature (see appendix on thebmj.com). For each step of the shared decision making process we describe the unique tasks required for deprescribing decisions; identify challenges for older adults, their companions, and clinicians

(figure); give practical advice on how challenges may be overcome; highlight where more work is needed; and identify priorities for future research (table).17 18

Process for deprescribingStep 1: creating awareness that options existThe clinician and patient acknowledge that a decision can be made about continuation or discontinuation of medicines, and that this requires input from both clinician and patient.

When to initiate discussionsPrescribing new medicines is often straightforward, driven by a new diagnosis, symptom, or test result. When to consider ceasing medicines is less clear.12 Possible triggers include the number of medicines taken (perhaps ≥10); a new symptom that may be an adverse effect of a medicine; identifying high risk, ineffective, or unnecessary medicines; apparent non‑adherence; or changed treatment priorities.19 Most of these situations can be identified only by a medicines review. Reviews can be triggered by life transitions (such as hospital admission, a new diagnosis, or seeing a new doctor) and can be initiated by the clinician or patient, but they are often underused.20 21 Importantly, qualitative research suggests that older people may not be aware that deprescribing is possible so it is essential to explain this.16

ANALYSIS

Deprescribing in older peopleCan shared decision making tackle inappropriate polypharmacy? Jansen and colleagues discuss

KEY MESSAGES

•  Deprescribing is a process of planned and supervised tapering or ceasing of inappropriate medicines

•  Shared decision making should be an integral part of deprescribing •  Factors affecting this process include trust in clinicians’ advice,

contradictory patient attitudes about drugs, cognitive biases favouring the status quo and positive information, and information processing difficulties

•  Older people’s preferences for discussing life expectancy and quality of life vary widely, but even those who wish to delegate their decisions still appreciate discussion of options

432 11 June 2016 | the bmj

Attitudes towards medicinesClinicians may be reluctant to initiate discussions about deprescribing with older people, believing that they value medicines highly,21 22 would resist deprescribing,23 and may interpret attempted deprescribing as withdrawing care or “giving up.”22 Substantial evidence shows that older people’s attitudes can be internally contradictory: they may be positive about both taking their medicines24‑26 and taking fewer medicines.27

Older people’s willingness to either tolerate polypharmacy or discontinue a medicine seems to be influenced by the communication skills24 27 and perceived experience of the clinician,28 and the degree to which the older person trusts them.24 Experiencing adverse effects may increase openness to deprescribing.24 26 In a US study, 62% of older patients (aged ≥65 years) who received a direct‑to‑consumer educational leaflet about benzodiazepine cessation brought the topic up with their clinician.29 In an Australian study,23 over 90% of participants were hypothetically willing to stop a medicine if this was recommended by their clinician.

Cognitive biasesA well recognised cognitive bias is status quo bias: a preference for continuing with the status quo, especially if it has been the default for many years.30 A related concept in the medical literature is clinical or therapeutic inertia: “recognition of the problem, but failure to act.”31 Omission bias—being more willing to risk harms arising from inaction than from

action—is another well recognised problem.33 Paradoxically, once people are taking a medicine, continuing it unchanged is perceived as inaction, while ceasing it is perceived to be an action. Patient resistance to change (as perceived by the clinician) was the most commonly expressed barrier in a recent systematic review of qualitative studies on this topic.32

Patients may presume medicines are important if they have been taking them for many years.28 The language used by clinicians when starting a medicine can be very important. For example, if patients have been told that they would need the medicines for the “rest of their lives,” discussion of possible discontinuation can make them anxious.26

Step 2: discussing the options and their benefits and harmsThis involves ensuring that the patient knows what options are available (including the option to continue medicines) and understands the process of deprescribing, the expected benefits and harms of each option, and how likely they are to occur.

Understanding optionsAge related changes in cognitive and affective processes38 and comorbidity may influence how older people process and understand information about their medication options.39‑41 Studies suggest that compared with younger people, older people pay attention to fewer options,42 disproportionately focus on positive information,41 seek less information,39 and have greater difficulty

understanding information about available options.43

Understanding potential benefits and harms of different optionsMany adults have poor literacy and numeracy skills and have difficulty interpreting quantitative and probabilistic information. Older adults who take multiple medicines often report not being fully informed about the reason for taking their medicines or the potential side effects.28 One study among people aged ≥75 found a wide variation in their understanding of information on benefits and harms44; numerical risk information was especially challenging, suggesting that visual formats such as pictographs may be helpful.44

Communicating uncertaintyOne of the challenges of deprescribing decisions is the limited evidence for its benefits and harms. Although randomised clinical trials support deprescribing certain medicines,9‑11 for most medicines used by older people the evidence is still limited. GPs have reported lacking confidence in risk communication, particularly communicating uncertainty.22 Communication tools such as verbal labels, numbers, or graphics45 46 may help to explain uncertainty and encourage deeper consideration of personal values.

Step 3: exploring patient preferences for the different optionsThe aim of this step is to help patients identify their preferences, goals, and priorities regarding deprescribing.

Steps for shared decision making (SDM) about deprescribing in older peopleStep Practical advice Priorities for future researchCreating awareness that options exist

• Regularly review medicines; ask about problems /concerns to identify deprescribing opportunities• Explain that there are medication options to consider, including tapering or ceasing• Recognise bias towards the status quo rather than deprescribing; acknowledge this discomfort• When companions are present check and agree on their role in decision making

• Develop and evaluate deprescribing decision aids for older people

Discussing the options and their potential benefits and harms

• Improve general understanding: use plain language, avoid medical jargon, face the person when speaking, provide written information, use visual aids, verify comprehension (eg, teach back)• Explain the difference between medicines for prevention v symptoms, and health v quality of life as this may be unclear

• Identify optimum methods for communicating benefits/harms of medicines and deprescribing• More randomised controlled trials of medicine discontinuation

Exploring preferences for (attributes of) different options

• Explore preferences and goals in relation to deprescribing after providing information about potential benefits and harms• Frequently review preferences, as they are likely to change over time

• Develop and evaluate goal setting/values clarification methods for older people

Making the decision • Collaborate to find option that best fits preferences• Support autonomy by eliciting goals and values and offering the opportunity to be involved in or make the final decision• Respect those who want to defer the final decision to others, but encourage them to consider reasons for the decision• Reinstating medicines is one of several possible outcomes of the discontinuation trial and not a failure

• Develop and evaluate strategies for monitoring and reviewing deprescribing decisions

Clinicians may be reluctant to initiate discussions about deprescribing with older people, believing that they value medicines highly

the bmj | 11 June 2016 433

Preferences in older people varyElicitation of preferences is complex and debated.47

Older people may have a stronger sense of what is important to them because of accumulated healthcare experience. This may make it easier to come to clear agreement on their values.48 At the same time it has been suggested that preferences are more variable in older than younger people, influenced by factors such as current health and mood.49

Weighing up benefits and harms is more complex in older peopleDecisions about deprescribing need to take account of the evidence on potential benefits and harms in light of decreasing life expectancy. Discussions about this trade‑off with older people can be challenging, partly because of lack of evidence.32 35 Estimates of life expectancy are at best imprecise. Prognostic tools do, however, exist,50 and self rated health is a good predictor of mortality,51 so these may be useful guides for clinicians to incorporate in shared decision making.22

Step 4: making the decisionDeciding whether to deprescribe requires integrating the patient’s preferences and priorities with information on benefits and harms. Decisions may be made by the patient, made collaboratively, or deferred to the clinician. Algorithms exist to guide the process of deciding which medicines to stop first.12 13

Preferences for involvement and patient autonomy Most older people prefer to participate in medical decision making,54 although this is influenced by their health.55 Even those who prefer to delegate decisions to their clinician often want to discuss options, attitudes, and preferences, and receive information.16‑56 Moreover, some may believe they have inadequate skills to participate in decision making, leading to a stated rather than actual preference for lower participation.16 57 Clinicians and companions can support older people’s autonomy by eliciting their goals and values and inviting them to participate in decision making, whether or not they make the final decision.

Deprescribing is an ongoing process Decisions to cease medicines must be made using a staged approach, with careful monitoring for withdrawal or adverse effects.13 It is important to clearly communicate that medicine cessation is provisional, not final, and should be continuously reviewed.12 26

Where to go from here?Shared decision making should be an integral part of the deprescribing process, but its implementation in clinical practice is complex. Our advice is to, at minimum, inform older people (and their companions) about the option to deprescribe, and invite

and support them in expressing their preferences and making the decision. This requires careful tailoring, as preferences for different options and willingness, and ability to be involved in decision making vary widely. Clearly this can be a time consuming process. Protected time, more dedicated resources, and even specific remuneration for medicine reviews may be needed. New evidence is urgently needed to better support clinicians to reduce inappropriate polypharmacy among older adults. In particular, we need to identify better ways to communicate benefits and harms information and to elicit older people’s preferences in ways that support shared decisions.Jesse Jansen, senior research fellow, Screening and Test Evaluation Program, Sydney School of Public Health and Centre for Medical Psychology and Evidence Based Decision Making, University of Sydney jesse.jansen@sydney.edu.au See thebmj.com for full author detailsCite this as: BMJ 2016;353:i2893Find this at: http://dx.doi.org/10.1136/bmj.i2893

Step 1Create option awareness

Step 2Discuss bene�ts and harms options

Step 3Explore preferences

Step 4Make the decision

Shared decision making about deprescribing

Limited awareness ofopportunity to be involved

Lack of understanding distinctionpreventive v symptomatic medicines

Preferences vary withinand between older people

Preferences for involvement vary

Attitudes vary and o�en contradictory Information processing challenges

Preference for status quo

Companion involvement

Sensory di�culties

Assumption clinicianknows preferences

Willingness to discusslife expectancy varies

Contrast between statedand actual preference

Multiple health providers

Absence of external triggersfor decision making

High reliance on clinicianto make decision

Older person

Both bene�ts and harmsare important to discuss

Discomfort discussing trade-o�between quality and quantity of life

Lack of con�dence risk communication

Preference for status quo Uncertainty of evidence

Little guidance available forpreference elicitation in older people

Describing decisionsinclude monitoring

Discomfort with older patientswho do not want to be involved

Clinician

Challenges for clinicians and older patients are associated with each step of the process of shared decision making about deprescribing

Once people are taking a medicine, continuing it unchanged is perceived as inaction, while ceasing it is perceived to be an action

ELEN

A EL

IACH

EVIT

CH/G

ETTY

IMAG

ES

434 11 June 2016 | the bmj

New international accounting conventions suggest that the UK is spending much more on healthcare, both

publicly and privately, than previously thought. The latest spending figures for 2014 published by the Office for National Statistics (ONS), adjusted to comply with the Organisation for Economic Cooperation and Development’s (OECD) system for health accounts,1 have added around £21bn to health spending—an overnight leap of 13% from the previous estimate for 2014. It also means that total public and private spending on health jumps from 8.7% of gross domestic product (GDP) to 9.9%. Can this be true, and what does it mean?

What it doesn’t mean is any material change in actual spending. The budget for the NHS, for example, has not suddenly increased. But it does have implications for how UK health (and social) care spending compares with that in other countries and raises the tricky issue of the boundary between health and social care (and even perhaps whether there should be one at all).

Applying the new accounting rules has meant that around £8.7bn of spending previously counted as health spend is now not counted but that £29.4bn previously counted elsewhere in the national accounts (and in part as private spending) is now considered as spending on healthcare. The net effect is a £20.7bn increase in health spending. As figure 1 shows, among the 11 changes in accounting (including a transfer of spending within out-of-pocket spend that in effect cancels out), the big movements are a fall in capital spending (£5.6bn) and the addition of spending on privately funded long term care (£9.5bn) and publicly

DATA BRIEFING

Is the UK spending more than we thought on healthcare (and much less on social care)?John Appleby assesses the latest figures on UK health spending

Total health spend (old method)

Capital expenditure

Changes to expenditure by NPISH

Other changes to out-of-pocket expenditure

Compulsory insurance expenditure

Healthcare provided by non-NHS government bodies

Other changes to government expenditure

Enterprise financed expenditure

Other changes to insurance expenditure

Carer’s allowance

Long term care

Health related social care

Total health spend (new method)

0 20 20 20 20 100 120 140 160 180

£ billions

£158.8 bn

–£8.7 bn

£179.5 bn

+£29.4 bn

Fig 1 | Changes in accounting for health spending: Total (public+private) UK healthcare spending, 20141 (NPISH=non-profit institutions serving households)

funded health related social care (£13.5bn).

The upshot of these changes is that, excluding capital spending (0.3% of GDP), the UK has added 1.5 percentage points of GDP to total current spending to healthcare. This boosts spending from 8.4% to 9.9% of GDP in 2014. Roughly, allowing

Are health and social care inseparable?

for some rounding in the figures, this is equivalent to public spending increasing from 6.9% to 7.9% and private spending from 1.5% to 2% (fig 2).

The bulk of these changes are down to reclassifying a big chunk of publicly funded social care spending as healthcare spending. This means

PAUL

A SO

LLO

WAY

/ALA

MY

the bmj | 11 June 2016 435

0

2

4

6

8

10

12

1997

1998

1999

20002001

20022003

20042005

20062007

20082009

20102011

20122013

2014

% G

DP

Total New method(dotted line)

Public PrivateShould we move to simply considering health and social care as inseparable—that is, as “care”?

Fig 2 | Current UK healthcare spending: old and new accounting methods, 1997-20141

United States

Netherlands

Switzerland

Sweden

Germany

France

Denmark

Japan

Canada

Belgium

Austria

United Kingdom (new method)

New Zealand

Greece

Portugal

Norway

Spain

Italy

Australia (2012)

Iceland

Slovenia

Finland

United Kingdom (old method)

Ireland (2012)

Slovak Republic

Israel

Hungary

Chile

Czech Republic

Korea

Luxemburg (2012)

Poland

Mexico

Estonia

Turkey

0 2 4 6 8 10 12 14% GDP

16 18

Countries using new accounting methodCountries not using new accounting method

that the increase in the UK’s combined public spending on health and social care under the new accounting methods remains largely unchanged, with the main addition being the inclusion of the carer’s allowance, worth £2.4bn in 2014.

Although the new health accounts now include spending on local authority nursing and residential care as well as other health related aspects of social care spending, at the level of individuals it can be difficult to make the distinction between these sorts of consumption. An ageing population and changing patterns of disease are making it much harder to demarcate health from social care needs, as the Barker commission pointed out.2 Should we move to simply considering health and social care as inseparable—that is, as “care”?

The new health accounts are likely to change the UK’s position in international health spending rankings (fig 3). Several other countries that are either already using the new accounting framework or have piloted the new system report little or no change in their health spending. Some, notably Sweden, report a big jump—from 8.5% to 10.6% of GDP between 2010 and 2011—largely as a result of the accounting changes. The full extent of the new system of accounts for other countries will be known later this year when the OECD publishes the latest data on spending.3

International health spending comparisons (and arguments for increased UK health spending based on its relatively low ranking) were never straightforward. However, moves to a more commensurate set of international data should improve comparability. Meanwhile, back home, and away from the ins and outs of international health accounting conventions, short and medium term financial pressures on public health services remain the reality.4 5

John Appleby, chief economist, King’s Fund, London, UKCite this as: BMJ 2016;353:i3094Fig 3 | Total (public+private) current health spending in OECD countries, 20131 3

436 11 June 2016 | the bmj

The proposed new contract for junior doctors in England is being changed to ensure that trainees who work

less than full time (LTFT) receive a fair level of pay for working at the weekend, the BMA has said.

The chair of the BMA’s Junior Doctors Committee, Johann Malawana, said that the Department of Health and NHS Employers had confirmed on Thursday 2 June that changes would be made to the proposed contract in regard to LTFT trainees. Writing on Facebook on Saturday 4 June, Malawana said, “On Thursday the DH/NHSE side were able to confirm a few modifications as to the intent with LTFT trainees. Particularly in regard to pro rating the weekend supplement for LTFT.”

A BMA spokesperson confirmed that the government had agreed to respond to concerns that the association had raised over LTFT pay. “The terms and conditions are being updated, and junior doctors will be informed about the changes at the 120 contract road shows taking place around the country,” the spokesperson said.

Under the proposed new contract, when a junior doctor’s work schedule involves rostered work at the weekend the doctor will be paid a weekend allowance. The allowance will be set as a percentage of their basic salary and will increase as the number of weekends worked increases, starting at 3% and rising to 10%.

Preserving equalityJunior doctors have previously raised concerns that, because of this

Junior contract will ensure fair weekend pay for part time trainees, says BMA

“This change preserves equality between full time and LTFT doctors” —Kaanthan Jawahar

1BETTER ROTAS

NHS Employers and the BMA will review rostering practices, including the use of technology, to help increase flexibility for junior doctors and employers. The work will involve “rostering experts” and is due to be completed by January 2017.

2PERSONAL LEAVE

The BMA and NHS Employers will develop joint guidance on rotas to help doctors to balance work and personal leave and support those who have caring responsibilities or want to work flexibly.

3MOVING REGIONS

By 31 March 2017 Health Education England will review the processes that allow junior doctors to transfer between regions and married couples or those in a civil partnership to submit joint applications for training places. It will also look at the process that provides placements for doctors with caring responsibilities.

4CHANGING SPECIALTY

The GMC will review the process for changing training programmes. It should speed up progress through training for doctors who change training path, for reasons other than a disability or caring responsibility or to transfer to a shortage specialty (these already have pay protection). This will be finnished by 31 March 2017.

FIVE PROJECTS TO IMPROVE JUNIOR DOCTORS’ WORKING LIVES

As part of the agreement for a new contract for junior doctors in England, a range of projects will be launched to support various aspects of junior doctors’ working lives.

arrangement, LTFT trainees could lose out on weekend pay. Ben Dean, a junior doctor in Oxford, explained, “Because of the relationship between the weekend supplement percentage and the number of weekends worked, there may be a problem in that in some instances LTFTs will be paid differently than non-LTFTs for working the same numbers of weekends per year.”

Commenting on the situation, Rachel Clarke, a second year core trainee in infectious diseases, said, “To my mind this is inexcusable. This has no place in a 21st century NHS.”

Kaanthan Jawahar, a first year core trainee in psychiatry, explained that the changes announced by Malawana would prevent LTFT trainees being paid less for working an equivalent number of weekends. “The clarification in the contract’s

the bmj | 11 June 2016 437

Consultants who supervise trainees could see an increase in their workload under the proposed new contract for junior doctors in England, doctors have warned.

Under the proposed new terms and conditions for junior doctors, educational supervisors, who oversee the education of trainees, will agree to a personalised work schedule with their trainees and regularly discuss their progress.

In changes to the way that junior doctors’ hours are monitored, educational supervisors will also be required to process exception reports submitted by trainees who have worked too many hours, and discuss what action is required.

Nirmal Kumar, director of medical education at Wrightington, Wigan and Leigh NHS Foundation Trust, said that the proposed new contract was likely to increase the workload placed on educational supervisors.

“Junior doctors will have much more stringent working regulations, so educational supervisors will need to increase their involvement with supervision and monitoring,” Kumar said. “So it is going to increase but by what factor it is difficult to say. It would only be an estimate at this time: maybe [by around] 20%, but it’s a complete estimate.”

The work of educational supervisors was not fully recognised in their job plans, Kumar said, and they often received the same amount of supporting professional activities (SPA) time as their colleagues without such responsibilities.

Kumar said that he hoped the new contract would help educational supervisors to argue for more SPA time for trainee supervision.

Partha Kar, a diabetes and endocrinology consultant, agreed that the new junior doctor contract could lead to additional work for educational supervisors. He said that, formally, consultants should be awarded 0.25 of an SPA for every trainee that they looked after. Since most consultants had around four trainees this left very little time out of their 2.5 SPAs for any other activities. “That’s why consultants end up taking on four trainees and actually having very little time to do it,” he said.

He added, “If you give people 0.25 SPAs per junior doctor that’s fine, because one hour a week is more than enough to do the supervision and everything else that is asked. The reality is that nobody gets it.”

Kar said that consultants would not “jump up and down straight away in anger” over the changes because it would take time to realise what was going on. “But once they do I think there will be some issues being raised,” he said.

Ben Dean, a junior doctor in Oxford, said that the rise in workload could stop consultants from becoming educational supervisor role. “It’s going to push people out,” he said. “Potentially some consultants are going to say, ‘Stuff this I’m not going to be an educational supervisor.’ That would be terrible.”

Dean warned that even the most engaged educational supervisors would find it hard to deal with the increased workload, and it was unlikely that trusts would give them more SPA time.

“In the current financial climate there’s zero chance [that trusts would change job plans] because they just don’t have the money,” he said.Abi Rimmer, BMJ Careers arimmer@bmj.com

Consultant workload may rise under junior contract

wording confirms that an LTFT trainee on a rota where full time doctors receive a 10% uplift for working one in two weekends would also receive the 10% uplift pro rata,” he said. “The previous confusion centred around this same LTFT trainee being paid a different percentage uplift for working fewer weekends, which would have resulted in a lower hourly rate for the same work as a full time colleague. This [change] preserves equality between full time and LTFT doctors.”

Debate moves onDespite this change, however, Jawahar said that plans to remove junior doctors’ incremental pay progression would mean that LTFT trainees’ pay would fall overall. “The debate now moves on to what is right: equality or equity. This is likely to be a philosophical battle entrenched in personal belief and experience. It may well prove a red line for many junior doctors voting in the contract’s referendum,” Jawahar said.

On Friday 27 May NHS Employers published the full terms and conditions of service for NHS doctors and dentists in training in England. On the same day the Department of Health published an equalities statement for the proposed new contract.

Between 17 June and 1 July the BMA will hold a ballot for junior doctors to vote on whether they accept the proposed new contract. The result will be announced on 6 July. Since the new contract was published, junior doctors have called for more clarity on how LTFT trainees would be paid under it. Abi Rimmer, BMJ Careers arimmer@bmj.com

“Potentially some consultants are going to say, ‘Stuff this I’m not going to be an educational supervisor.’ That would be terrible”—Ben Dean

5BETTER CONDITIONS

The BMA and NHS Employers will commission a review of the effectiveness of the junior doctor contract in August 2018, to identify areas for improvement to its terms and conditions.

FIVE PROJECTS TO IMPROVE JUNIOR DOCTORS’ WORKING LIVESO

LI S

CARF

F/ST

RIN

GER

438 11 June 2016 | the bmj

BMJ CONFIDENTIAL

Richard FieldhouseSessional GP supporter

Richard Fieldhouse is a GP who champions the role of sessional GPs as a viable option for those who prefer practising medicine to wading through administration. He believes that the future of general practice depends on a symbiotic relationship between well organised groups of locums and established practices. In 1997 he founded the National Association of Sessional GPs (NASGP), which he still chairs, and which spawned the idea of a support system for locums. Convinced by the model, he and like-minded colleagues set up Pallant Medical Chambers in 2004. It functions as a “virtual practice” for its GPs, all working within a shared clinical governance framework and creating a supportive environment.

What was your earliest ambition?The first one I remember was to own a sombrero. I was 5.

Who has been your biggest inspiration?My A level physics teacher, who said that I was too insular to become a doctor. I had to prove her wrong.

What was the worst mistake in your career?Early on, not trying hard enough to fit in with the other GPs in my partnership.

What was your best career move?Early on, not trying hard enough to fit in with the other GPs in my partnership.

Bevan or Lansley? Who has been the best and the worst health secretary?Bevan was the best. We now know so much about the health effects of exercise, diet, and early life that I wish the political vision for health would shift from interference in the NHS to a grander, Bevan-style, vision of long term health improvement, crossing all areas of government. Ideally, any policy would be scrutinised for its impact on the health of our people and future generations.

Who is the person you would most like to thank, and why?Judith Harvey, who for the past 10 years has been writing thoughtful and incisive articles for the NASGP magazine that celebrate medicine as the coming together of science, art, and the human condition. Each one reminds me of why I became a GP.

If you were given £1m what would you spend it on?My partner and I have spent the past two years working on a massive NASGP project to create an online standardised practice information portal (Spip), like an information air traffic control for each general practice. So much information flies around in emails, conversations, inboxes, websites—but it’s rarely there when we need it, and practices waste two hours a day on average trying to find it. So, £1m would help us to make Spip and improve the working lives of all in general practice.

What single unheralded change has made the most difference in your field?The internet, both good and bad. On the one hand, we’re all much better informed about health and disease, but the flipside is a huge increase in demand on the NHS.

Do you support doctor assisted suicide?I’ll be in a better position to answer that once every patient has the best possible access to end of life care, mental health services, and social care.

What book should every doctor read?Thinking, Fast and Slow by Daniel Kahneman. It’ll teach you to doubt every decision you make.What is your pet hate?It’s a close tie between the overuse of the word “awesome” and sentences composed almost entirely of the word “like.”

Do you have any regrets about becoming a doctor?None—in fact, I still have to pinch myself occasionally, in case this is all a dream.

If you weren’t in your present position what would you be doing instead?If I hadn’t got into medical school through clearing, I had a place at a polytechnic to do a degree in brewing. Being an idealist, I’d probably be working on the dream pint of Ballard’s Best.Cite this as: BMJ 2016;353:i3095

ILLUSTRATION: DUNCAN SMITH