Power was abused in junior dispute - BMJ E-cigarettes are a “gateway from smoking” Smokers should be actively encouraged to swap their tobacco cigarettes for electronic cigarettes

this week

Power was abused in junior disputeThe government has abused its power as the sole employer of junior doctors, the BMA’s chair of council has said.

Speaking to The BMJ on the eve of the all-out strike by junior doctors on 26 April, Mark Porter said that during negotiations on the new contract for junior doctors the government had abused its position as the only employer in England that could provide specialist training.

“One of the reasons that the government is behaving the way it is, of course, [is] because the NHS is . . . a sole employer of junior doctors,” he said. “You can’t get legitimate junior doctor training anywhere else other than by going abroad.

“So, if you want to progress in specialist training you have to work for the NHS; that’s a power I think that has been abused by government in this, and they didn’t expect the push back from junior doctors.”

Junior doctors undertook full strike action for the first time in the history of the NHS on Tuesday 26 April and Wednesday 27 April, after the government announced in February that it would impose a new contract on junior doctors.

Junior doctors on picket lines outside hospitals on Tuesday were in buoyant mood and confident that enough senior

colleagues had been drafted in to cover emergency care of patients.

Porter told The BMJ that it would be difficult for junior doctors to choose not to sign the new contract if it was imposed from August. He said that it was something that the BMA’s Junior Doctors Committee would consider when it met on 7 May.

Porter said that the most important outstanding issue is “whether or not it’s right for the secretary of state to try to manage this highly skilled group of doctors by effectively telling them what to do regardless of their opinions, feelings, or their contribution to patient care.”

Speaking on BBC Radio 4’s Today news programme on 26 April, Hunt described the contract on offer as a “fair deal.” He added, “Our choice as a government is very stark: do we deliver a manifesto commitment for a seven day NHS? . . . Then we need to be able to offer that same [level of] care every day of the week. I say that no union, however powerful, however good they are at eliciting public sympathy, has the right to stop the government from implementing something that the public has voted for.”Abi Rimmer, BMJ CareersCite this as: BMJ 2016;353:i2382

BMA chair Mark Porter said that junior doctors have only two options for training—the NHS or going abroad

the bmj | 30 April 2016 169

PAGE 174 Why junior doctors are striking • PAGE 171 GPs in A&E departments

NEWS ONLINE

• NICE approves innovative treatment for moderate to severe heart failure

• Supplements such as fish oils improve antidepressant effectiveness, suggests review

• Suicide rates rise sharply in the US, figures show

SEVEN DAYS IN

Take partPutting health inequalities to musicThe first session of a musical project called Song of Contagion, which aims to highlight how some health issues get more publicity than others, took place on 23 April in London. Elizabeth Pisani, an epidemiologist, said, “My idea was something very simple. The amount of disability a disease causes would be the tempo, the amount of money it gets would

be the volume, and the press coverage would be the pitch. Ebola, for example, would be slow because it doesn’t kill many people

[globally], but it would be very high pitch because it generates a lot of press hysteria.” Anyone interested can take part, and a performance of the work is planned for spring 2017 (full BMJ story doi:10.1136/bmj.i2354).

Health committee seeks views on UK leaving EUThe parliamentary health committee is inviting written evidence on the effect of European Union membership

on health policy, to inform the debate ahead of the membership referendum on 23 June. Send submissions of no more than 3000 words by 31 May 2016 to www.parliament.uk/healthcom.

News from the UKSmokers and overweight patients are denied surgeryOver a third (34%) of clinical commissioning groups in England restrict access to routine surgery such as hip and knee replacements until patients stop smoking or lose weight, the Royal College of Surgeons found. The college said that such policies contravene national clinical guidance, and it urged the government to clamp down on the restrictions. Clare Marx (below), president of the college, said, “Blanket bans that deny or delay patients’ access to surgery are wrong. In some instances a patient might need surgery to help them do exercise and lose weight. It is unlikely to be a coincidence that many financially challenged CCGs are restricting access to surgery. Our worry is that smokers and overweight patients

are becoming soft targets for NHS savings” (full BMJ story doi:10.1136/bmj.i2335).

One in 10 consultant radiology posts is unfilled

The Royal College of Radiologists warned of a “looming crisis” in breast cancer screening after a survey found that 13% of consultant breast radiologist posts are unfilled. The survey also showed that 21% of breast radiologists are due to retire by

2020 and 38% by 2025, and it warned that a

quarter of the NHS breast screening programme units that responded operate with just one

or two consultant radiologists and have no cover for sickness or absence (full BMJ story doi:10.1136/

bmj.i2350).

E-cigarettes are a “gateway from smoking”Smokers should be actively encouraged to swap their tobacco cigarettes for electronic cigarettes because “vaping” is much safer than smoking, a report from the Royal College of Physicians said. Since e-cigarettes became available in the UK in 2007, their use has been surrounded in controversy. The report concluded that e-cigarettes are likely to lead to attempts to quit that would not otherwise have happened, some of which will be successful. Any harm from e-cigarettes “is likely to be very small” (full BMJ story doi:10.1136/bmj.i2392).

Research newsPrognosis after acute MI is worse if underweightAfter acute myocardial infarction underweight patients are at higher risk of death than normal weight patients, even after adjustment for comorbidities and measures that assess cachexia and frailty, a study in PLoS Medicine found. The researchers said that

Being admitted to a psychiatric hospital at the weekend is not associated with a higher risk of death than admission during the week, research published in the British Journal of Psychiatry found. However, patients admitted at the weekend had shorter admissions and were more likely to be readmitted, suggesting that weekend patients have ongoing, unresolved treatment needs.

Researchers examined data on 45 264 consecutive psychiatric hospital admissions to a hospital at the South London and Maudsley NHS Foundation Trust, of which 7303 (16.1%) were at a weekend. Most patients admitted during the week were admitted from home (91.9%), whereas those admitted at the weekend were more likely to present through acute hospital services, other psychiatric hospitals, or the criminal justice system.

Patients admitted at the weekend spent around 21 fewer days in hospital than patients admitted during the week and had a 13% higher chance of readmission in the 12 months after discharge. However, inpatient mortality after weekend admission was not greater than after weekday admission (odds ratio 0.79 (95% confidence interval 0.51 to 1.23); P=0.30).

Weekend admission to psychiatric hospital is not linked to increased mortality

Jacqui Wise, London Cite this as: BMJ 2016;353:i2342

170 30 April 2016 | the bmj

The trial looked at patients admitted to South London and Maudsley NHS Foundation Trust

underweight patients may have a decreased physiological reserve, may be treated less aggressively, or may be “fundamentally different,” perhaps with an underlying genetic predisposition to coronary artery disease. Treatments to promote weight gain and survival in patients with cancer or cardiac cachexia may help, they said, but trials were needed (full BMJ story doi:10.1136/bmj.i2276).

Immunotherapy tablets for asthma show promiseTablets containing extracts from two species of house dust mite taken sublingually by adults with dust mite allergy related asthma reduced the risk of a moderate or severe asthma exacerbation when compared with placebo, a study in JAMA found. But the tablets did not change responses

to questionnaires on asthma control

or quality of life with asthma. The researchers said

that theirs was the first controlled trial to show this improvement (full BMJ story doi:10.1136/bmj.i2358).

Mental healthWatchdog questions mental health fundingThe cost of implementing the government’s plans to improve mental health services is not fully understood, a report by the National Audit Office found. The report looked at pledges on waiting times in mental healthcare and aims to improve access to psychological therapies, early intervention in psychosis, and liaison psychiatry. However, the costs of improving waiting times and access are unclear, and, because funding is not ringfenced, it is unclear whether commissioners have spent the money on mental health services (full BMJ story doi:10.1136/bmj.i2330).

News from abroadDutch doctors prompt nuclear weapons debateA “medical appeal” against nuclear weapons signed by 110 prominent figures in Dutch healthcare was presented to MPs in the Netherlands last week. Organised by the NVMP, the Dutch affiliate of International Physicians for the Prevention of Nuclear War, it emphasised the moral and professional duty of doctors to warn society about the unmanageable consequences of nuclear war. A parliamentary debate on banning nuclear weapons, backed by the Dutch Red Cross, was due to take place on 28 April.

Advice for Japan’s earthquake survivorsThe Japanese prime minister, Shinzo Abe, issued advice about the risk of developing deep vein thrombosis to people living in cramped conditions, such as cars and evacuation shelters, after the earthquake on 14 April. More than 90 000 people were made homeless by the earthquake on the island of Kyushu, and hospitals in the affected area have reported around 30 cases of deep vein thrombosis.Cite this as: BMJ 2016;353:i2378

LOTS OF PATIENTS ATTEND ACCIDENT AND EMERGENCY DEPARTMENTS WITH AILMENTS THEIR GP COULD HAVE TREATED. ARE THEY WRONG?Tsk! Patients are never wrong. The service has to adjust to what they want, not vice versa.

THEN LET’S PUT A GP IN EVERY A&EGood idea, on the face of it. The Royal College of Emergency Medicine backed it in a 2014 report, and the college’s president, Clifford Mann, called the argument “compelling.” Many A&Es have followed the advice.

SO WHAT’S THE PROBLEM?Inconvenient evidence in a systematic review published in the Emergency Medicine Journal indicates that co-locating GPs with A&E doesn’t necessarily save money or reduce the numbers of patients turning up with non-urgent complaints.

WHAT DID IT FIND?It looked at 20 studies, including eight in the Netherlands and four in England. There was some evidence that co-locating GPs resulted in shorter waits for treatment, but there was no consistent evidence of reduced admissions or cost savings. Patients’ satisfaction wasn’t greatly affected. There was “paradoxical” evidence of an increase in demand.

IS THIS PARADOXICAL?Not really. As the team itself said, “If you build it, they will come.” Demand increases in line with supply.

THAT’S AN AWKWARD FINDINGYes, and pretty universal. A recent US study in Health Affairs found that walk-in clinics run by nurses in locations such as supermarkets (the likes of MinuteClinic, which runs 1100 such centres across the United States) don’t save money overall, even though the cost of a visit is 40% less than in a doctor’s office. The increase in use trumped the savings from reduced visits to doctors and A&E.

SO THE ONLY WAY TO CUT DEMAND IS TO CUT SUPPLY?That’s the way it looks. I think I may be beginning to understand what England’s health secretary is doing.Nigel Hawkes, London Cite this as: BMJ 2016;353:i2315

Ж FEATURE, p 181

SIXTY SECONDS ON . . . GPs IN A&E

HEART FAILURENew £3 a day drug sacubitril valsartan could cut deaths and reduce more than

30 000 hospital admissions for heart failure that occur every year in England, says NICE


MEDICINE


Junior doctors held a candlelit vigil outside Jeremy Hunt’s office in Whitehall, London on the eve of the first ever all-out strike by junior doctors on 26 April. Despite pleas from many quarters for talks over junior doctors’ contract between the Department of Health and the BMA to resume, the chair bearing Hunt’s name remained empty. Four pages of coverage follows.

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Junior doctors hold NHS vigil


Three years of negotiation have failed to produce agreement between the BMA and the government on a new contract for the 53 000 junior doctors in England. The bitter dispute has led to the first comprehensive strike in the history of the NHS, with juniors refusing to provide even emergency care. Despite the disagreement, Jeremy Hunt, health secretary for England, said that the contract would apply to junior doctors starting new jobs from August.

Doctors are demoralised and suspicious that the contract will leave them worse off financially and that the new system won’t protect them from having to work unsafe hours, ultimately endangering patients.

Pay structureThe pay structure will change, disadvantaging those who currently work unsocial hours, although basic pay will rise on average by 13.5%. At the moment work done between 7pm and 7am and at weekends is considered out of hours and is paid at a premium rate. Under the new contract, Saturday would be treated as a normal working day for pay purposes, although anyone who works one Saturday a month


Bitter dispute leads junior doctors to take unprecedented actionClare Dyer looks at the top issues worrying junior doctors about the new contract

Doctors are demoralised and suspicious that the contract will leave them worse off financially

THE STRIKE IN NUMBERS

PICKET LINES The first day of full strike action on Tuesday 26 April saw 147 official BMA supported picket lines across England. The number of acute care trusts, says the NHS Confederation, is 154 (including 101 foundation trusts), although several trusts have more than one hospital.

ELECTIVE OPERATIONS POSTPONED On the eve of the strike NHS trusts reported that they

expected to postpone 12 711 elective operations between 18 April and 2 May because of the strike,

including 4187 inpatient cases and 8524 day cases.

OUTPATIENT APPOINTMENTS POSTPONED NHS trusts anticipated that 112 856 outpatient appointments would be postponed over the two weeks between 18 April and 2 May as a result of the knock-on effects of the action taken by junior doctors.

112 85612 711147

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“The GP Forward View [which promised an extra £2.4bn for primary care by 2020-21] did very much reflect the issues

around workforce. It’s not just the increasing number of consultations GPs are facing but the increasing complexity and the shift [of treatment] from secondary to primary care. It was very clear to me from discussions with colleagues that what is getting to GPs is the relentless pressure, the people doing marathon surgeries, and the remorseless treadmill of 10 minute consultations. There is

a sense of perennially running behind, finishing the surgery, and facing a backlog of bureaucracy.

“In terms of seven day working, what works for rural Devon won’t work for central Birmingham. We want to avoid a ‘one size fits all’ approach. Some patients seem to think

that a seven day service means being able to see their own GP at 7 pm on a Sunday evening, when we know that’s not going to be the case. We need much more clarity on the issue.

“It doesn’t mean surgeries from 8 am till 8 pm. It needs to be about local flexibility, and what works in a rural area is different from what works in a city.

“The GP Forward View has a target of 1000 physician associates in general practice. We heard mixed views. Some GPs are very keen to have physician associates having a limited prescribing list, and some thought physician associates shouldn’t be prescribing at all. One of the key problems is registration: as a professional group they’re an unregistered workforce. The government needs to sort this out, because the level of responsibility they will have means that they should be registered.

“Being able to refer to a physiotherapist or a mental health therapist would be a good way of taking some of the pressure off GPs. Technology

is another area that needs to be addressed. GPs and consultants should be able to email each other, and we should think about online consultations. We need to

think very carefully about allowing patients to email their GPs. Having made the shift from GP to MP, the impact of my emails is huge. I regularly get 300 emails a day.”

FIVE MINUTES WITH . . .

Sarah Wollaston MP The health select committee chair talks about primary care

Bitter dispute leads junior doctors to take unprecedented actionClare Dyer looks at the top issues worrying junior doctors about the new contract

or more will get premium pay.Junior doctors contest Hunt’s

claim that pay for Saturday working is the only outstanding issue in the dispute, although it is one of the main concerns. Other worries include the removal of pay protection for those who change specialties, whose pay is protected under the current system. Under the new contract, a doctor who moves into a shortage specialty will get a premium, but those who move into other specialties will see their pay reduced.

Annual pay rises will be abolished under the new contract, and doctors in training will get pay increases only when they move to a higher level of responsibility. The Department of Health’s own equality assessment said that the new pay structure would disadvantage part time workers, many of whom are mothers. It insisted, however, that “any indirect adverse effect on women is a proportionate means of achieving a legitimate aim.”

Monitoring working hoursAnother area of concern is the new Guardian of Safe Working system that will replace the current routine monitoring of working hours which employers undertake at least twice a year. The current monitoring system allows for appeals to an independent panel, but the new guardian will be employed by the trust, which junior doctors say will create a conflict of interest. They say that the details are still to be fleshed out and are not sure if the system is workable. The current system of fining employers for breaches of working hours rules

works well, they say, but under the guardian system fines will be smaller and imposed in more limited circumstances.

On-call rotasChanges to the way non-residential on-call rotas are paid for—where doctors will be paid a small percentage of their normal hourly rate when on call at home—amount to “trying to put doctors on a zero hours contract,” one junior doctor has said. Doctors fear that the new system will encourage employers to put more doctors on call “just in case.”

Those who work while on call will be paid for the hours worked, which will be “calculated retrospectively across the rota cycle,” but how this will work is still unclear.

Right to change termsThe new contract also includes a term reserving the right of the employer “in our absolute discretion to review, revise, amend, or replace any term or condition of this contract and to introduce new policies and procedures, in order to reflect and respond to the changing needs or requirements of the organisation or the NHS.”

“It’s inconsistent with the concept of a contract that one party is bound by its terms and the other isn’t,” Robin Allen QC, a leading employment law specialist, told The BMJ. “It can certainly be challenged.”Clare Dyer, The BMJCite this as: BMJ 2016;353:i2404

blogs.bmj.com Follow The BMJ’s live blog on the junior doctors’ strike at blogs.bmj.com/bmj

Anne Gulland, LondonCite this as: BMJ 2016;353:i2360

THE STRIKE IN NUMBERS


What is getting to GPs is the relentless pressure, the people doing marathon surgeries, and the remorseless treadmill of 10 minute consultations

JUNIOR DOCTORS COMING TO WORK Just 40 of 249 doctors (16%) working for South London and Maudsley NHS Foundation Trust across four London boroughs (Croydon, Lambeth, Lewisham, and Southwark) came into work on 26 April. Outside the usual holiday periods and the royal college examination season, 80% would be expected.

PUBLIC SUPPORT An Ipsos MORI poll published on the eve of the strike showed that the general public’s support for junior doctors remained strong: 57% supported the industrial action taken, while 26% said that they did not. In January, when emergency cover was provided during the strikes, 66% supported the action and 15% did not.Cite this as: BMJ 2016;353:i2405

16% AT ONE TRUST 57%

VOICES F ROM THE PICKET LINE


“Escalating action is a significant move but unfortunately it’s the only possible one. The next action would be a longer period of strike action or a full walk out. Given the state of the contract I would support that. The negative impact of the contract in the long term is going to be significantly worse than any short term strike action we take now. It’s like ripping off a plaster. You either rip it off all at once, or you peel it off nastily and slowly.” Miles Gandolfi, year one specialty trainee in acute care, Royal Free Hospital, London

“I am supporting the junior doctors because the new contract carries safety risks for our patients, will affect the quality of care that can be delivered, and puts our doctors themselves at risk. I will be admitting and discharging patients and carrying out duties that would usually be performed by junior doctors. I have no concerns about patient safety over the strike period. There’s been overwhelming support from patients and the public. I think that they understand why junior doctors are striking.” Zoe Wyrko, consultant geriatrician and associate medical director, Queen Elizabeth Hospital, Birmingham

“I cannot understand why the government hasn’t already taken notice. I cannot fathom what their motivations are. They must think that the public will turn and that we’ll all just lie down. But as it goes on, people are just feeling more determined that this is the right thing to do. My friends and family are overwhelmingly in support of why we’re here. My neighbours are occupational therapists and they’ve said they absolutely support this. They know that it is going to be rolled out to the entire workforce.” Rebeka Jenkins, renal trainee, clinical research fellow, St George’s Hospital, London

“It was more difficult to come out on strike today but the government is really not listening to us. We have quite a lot of consultants and senior cover. I am confident about the service being provided.” Alechi Nduka, year one specialty trainee in plastic surgery, Chelsea and Westminster Hospital, London

“I fully support the junior doctors. I am aware that if I require NHS treatment today, senior consultants and GPs will see me. The resolution I hope for is that Jeremy Hunt will engage in meaningful dialogue and use leadership skills to listen and understand the implications of the contract for junior doctors, after all they are the experts in what their job entails.” Jay Virdee, patient with a chronic autoimmune disorder

“I am taking part in industrial action as I feel it is the only recourse left to defend against the threat posed by this government to my patients. My strike effort is being covered by my consultant senior colleagues who are 100% behind our action. The public is really supportive. Who are people going to trust—all their doctors or a Tory government?” Liam Rogerson, year one foundation programme trainee, York Teaching Hospital

Thomas Cassidy , Ingrid Torjesen, Thomas Macaulay , and Marina Soltan hear from doctors taking part in this week’s all-out strike and others a� ected by the action


“So far, I have received messages of support [from patients and the public] and been high fived by a member of the public. I think the public is struggling to understand the full meaning of the strike because of the amount of spin from the government. The message we need the public to understand is that we think that the new contract will worsen patient safety and cause doctors to leave the NHS. Stretching services from five days to seven without any extra investment or doctors is just unsafe.” Jamie Johnstone, year six specialty trainee in respiratory medicine, Queen Elizabeth Hospital, Birmingham

“I am hoping that this all-out strike will show how deep the feeling regarding this contract has gone and will show the public how important we think this imposition is to the welfare of their NHS. It is possible that previous strikes were underestimated as emergency care was still being provided. Now, with an all-out strike, I hope that the public can see that doctors are seriously concerned about the contract.”Dorreh Charlesworth, year six specialty trainee in obstetrics and gynaecology, Birmingham Women’s Hospital

“If we back down on things that compromise patient safety then other professionals in the hospitals will have to follow us—the consultants and nurses and so on. We’ve had really good consultant backing in this hospital, people falling over themselves to help us. Every time I’ve been on the picket line people have been overwhelmingly supportive. I’ve had a lot of patients come to me directly and say, ‘you’ve got to do it, we understand’.”Alison Berner, core medical trainee, Royal Free Hospital, London

“I don’t think we’ve been left with any other choice than to come out here. I went on my ward round yesterday and made sure each patient knew what was happening. I didn’t want them to worry so we let them know that the consultants would be looking after them. The public should feel free to come up to us and challenge us. There have been so many contradictory things said in the media that it must be very difficult for members of the public to know exactly what’s going on.”Elizabeth Gannon, junior clinical fellow in oncology, Royal Free Hospital, London

“We are showing people how to do basic cardiopulmonary resuscitation and how to put on a sling. But more importantly show the general public that as junior doctors we care for the public, we want to look after patients, we want to improve the quality of care for patients and safety. I think the public reaction continues to be positive but inquisitive—they want to know why are you doing this, what is the reason behind it?”Baljinder Singh, emergency medicine registrar, Chelsea and Westminster Hospital, London

“None of us here wants to strike but we feel that, in the interests of patient safety, patients would be better off if we did strike. There’s a lot of spin and different opinions that make it confusing and that’s why we’re out here today, to try to show patients why we’re doing it and the benefits of striking for them.”Henry Goodfellow, year one general practice specialty trainee, Royal Free Hospital, London

“We got to this point because Jeremy Hunt and the Department of Health refused to come back round the table with us and discuss fairly and like adults the contract for the benefit of the NHS. Their intransigence has essentially brought us to this point. A consultant will be doing the ward round and all the individual junior doctor jobs so, if anything, patients will probably be safer today than normally. ”Alex Chowbhury, core surgical trainee, Royal Free Hospital, London

“This is one of those situations of short term pain for long term gain, for the future safety of our patients and to make sure that people still want to be doctors. I hope the strikes will stop the imposition of the contract so we can get round the table to actually negotiate all those extra things that Jeremy said we could talk about.”Sofia Huddart, year seven specialty trainee in anaesthetics, Royal Free Hospital, London


EDITORIAL

Health anxiety: the silent, disabling epidemicTreatable with a range of highly effective interventions

We are glad to say, Mr Jones, that all your test results are normal and you have nothing

to fear. Mr Jones has received this message many times after being examined for many severe diseases, which over the years he has been convinced he must have.

Yet, this is the core of his problem—despite how much he would like to, he cannot do what the doctor says: stop worrying. He used to attend his general practitioner to be reassured that nothing was wrong with him, but the reassurance was only short lived and then the worrying started all over again.

Mr Jones is not alone. He joins many others with health anxiety. This diagnosis is a relatively recent one that will be unfamiliar to many readers of this journal. It overlaps with hypochondriasis and the new “illness anxiety disorder”1 in the American classification DSM-5, but it differs in several important respects. Illness anxiety disorder is narrowly defined; it includes only patients who do not display somatic symptoms, and this limits its use in clinical practice. The diagnosis of health anxiety is empirically based and defined by cognitive and emotional symptoms that allow it to coexist with other diseases. Both health anxiety and illness anxiety are primarily anxiety disorders and are unsatisfactorily lumped with somatic ones.2 3

Despite anxiety being the core component, people with health anxiety are rarely seen by psychiatrists; most attend primary care or secondary hospital clinics.4 Here, sadly, the pathology often goes unrecognised and is treated inappropriately by reassurance and investigations that invariably have negative results. Neither the patient nor the physician doubts that anxiety is present; what fails to be noticed is that, unlike people who want relief from somatic symptoms alone, people

with health anxiety do not ask for such relief, only freedom from worry about disease.

Health anxiety is remarkably common, persistent, and a generator of long term morbidity and increased sick leave.6 It is often found in conjunction with other disorders, including physical ones. Formerly, hypochondriasis could be diagnosed only in the absence of physical disease, but this can be present, and often is, in health anxiety. What is now clear is that people with health anxiety do not get better without the right intervention and experience great distress from their symptoms.7

Health anxiety is reaching epidemic proportions. In 2007 the Australian National survey found that 3.4% of people in the community met the diagnostic criteria.8 Much higher levels are found in secondary care.

In a study carried out in 2006, 12% of outpatients had excessive health anxiety,9 but four years later this had risen to 20%.4

CyberchondriaWhat is the explanation for this big rise? Methodological differences and change in diagnostic criteria may have a role. But a more likely explanation is the increased pathologisation of our society combined with internet browsing, appropriately called cyberchondria. Although the internet is of great value for those seeking the cause of medical symptoms, it is a menace for those with health anxiety. People with health anxiety pay selective attention to the most serious explanation of symptoms, even though these may be very uncommon.

Several highly effective psychological treatments are now available, ranging from traditional cognitive therapy10 to group based mindfulness11 and acceptance and commitment therapy.12 An additional bonus is that the benefit from these treatments tends to be long lasting.13 For people who recognise that they have health anxiety, treatment over the internet has also been found to be both cost effective and long lasting.15 16 Some of these treatments can be given by trained general nurses, whom patients may be more willing to accept as therapists than psychologists.17

So what is needed now? Physicians in primary and secondary care need to be more aware of this important diagnosis and not to regard their tasks as being restricted to excluding disease in their particular specialty. The diagnosis is in most cases easy to establish using research criteria, and, contrary to what many believe, it is well accepted by patients if explained respectfully.12 All patients with health anxiety should now be offered the many established, effective, evidence based treatments.Cite this as: BMJ 2016;353:i2250Find this at: http://dx.doi: 10.1136/bmj.i2250

Peter Tyrer, professor of community psychiatry, Helen Tyrer, senior clinical research fellow, Centre for Mental Health, Imperial College Trine Eilenberg, psychologist, Department of Occupational Medicine, Aarhus University Hospital, Denmark Per Fink, clinical professor, Department of Clinical Medicine, Aarhus University, Denmark Erik Hedman, associate professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden

Pathology often goes unrecognised and is treated inappropriately by reassurance and investigations that invariably have negative results


EDITORIAL

NHS England’s major boost for general practiceThe next step is to transform the rest of the healthcare system with the same vision

I n the words of Simon Stevens, chief executive of NHS England, in his introduction to the General Practice Forward View, “There is arguably no

more important job in modern Britain than that of the family doctor.” The plan recognises the mistake of expanding hospital funding at the expense of primary care over the past decade. Maureen Baker, president of the Royal College of General Practitioners, calls it “the most significant announcement for general practice since the 1960s.”2

The proposals are extensive—£2.4bn (€3bn; $3.5bn) extra funding to increase general practice’s share of the NHS budget in England from under 8.5% in 2014-15 to over 10% by 2020. There will be 5000 more general practitioners, 3000 new mental health therapists in primary care, 1500 pharmacists working in general practices, 1000 physician associates, £900m ($1.3bn) for new premises, reductions in bureaucracy, and a wide range of other proposals. The plans are largely in line with recommendations from the Primary Care Workforce Commission3 and the House of Commons Health Committee.4

Reduce bureaucracy nowSo what are the next steps? The proposals indicate a sea change in NHS England’s approach to primary care. However, the recommendations will take time to come to fruition, and the immediate priority is to see what can be done quickly to intervene in practices at risk of collapse. Some plans to reduce general practice workload can take immediate effect. For example, the proposals include stopping automatic discharge of patients who miss one hospital appointment, removing the requirement for specialists to refer back to the GP if another specialist’s

opinion is needed, and clear standards for communicating results to patients and GPs.

However, this needs to go much further. NHS England’s wider strategy for the NHS envisages a closer relationship between GPs and specialists.5 This requires a change in the way hospitals are funded. Activity based payment needs to be replaced with incentives to provide coordinated care, and clinical commissioning groups (CCGs) should take a lead in moving towards capitated population budgets. GPs already have a large role on CCG boards, and hospital doctors now need a much greater role in planning how hospitals can serve communities of patients.

We have estimated that outpatient attendance in some areas could be halved by specialists working in different ways, supporting clinicians working in the community, and making much greater use of information technology for communicating with GPs and patients.6 NHS England’s proposals for general practice should also be a spur to reduce the costs of regulation and inspection across the NHS, using

Sam Everington, chair, Tower Hamlets Clinical Commissioning Group, Mile End Hospital, London, UK Martin Roland, professor of health services research, Cambridge Centre for Health Services Research, University of Cambridge, Cambridge CB2 0SR, UK. [email protected]

the money instead for more effective quality improvement activities.

Universities and research funders have a role here as well. As new partnerships are developed between primary and secondary care in the NHS, this needs to be reflected in parity of esteem in teaching and research in universities. It is anomalous that in some medical schools 30% of graduates enter general practice training while in others it is only 7%,7 The House of Commons report is clear that “medical schools should recognise that they have a responsibility to educate and prepare half of all graduates for careers in general practice.”4

While the new proposals for general practice represent genuine progress, much of health and wellbeing has nothing to do with the NHS. Current NHS culture places the emphasis on patients’ rights, but many of the great improvements in health need to come from lifestyle changes. In supporting these changes, a key role for healthcare professionals will be navigating patients to motivational coaching in social prescribing projects9—such as exercise on prescription and use of employment advisers.

Last but by no means least is funding. While the NHS has a responsibility to maximise efficiency, few believe the £22bn “efficiency savings” required by the NHS Five Year Forward View can be achieved, especially if discretionary effort is reduced as a result of the workforce becoming alienated through disputes with the government. When will the public realise that spending 8.5% of our gross domestic product on healthcare isn’t expensive? There should be no pride in the fact that of 18 western European countries, only Ireland and Luxembourg spend less than the UK on healthcare.10

Cite this as: BMJ 2016;353:i2357Find this at: http://dx.doi: 10.1136/bmj.i2357

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The proposals indicate a sea change in NHS England’s approach to primary care

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Gillian P Christie, health innovation analyst at Vitality USA

“While Gilmore and Capewell argue that industry funds are only a fraction of overall research funding, public sector investment for prevention research has not kept pace . . . With growing budgets by the private sector into R&D, what is needed is greater funding by the public sector for basic and applied science to enhance our understanding of food and nutrition.”

Richard D Turner, retired director of public health

“Researchers whose salaries depend on the industry will of course be beholden to it whether payment goes to the institution which employs them . . . Given the extraordinary and expensive efforts so many in the industry have made in the past to produce misleading research . . . the strong safeguards Aveyard and Yach specify will only be credible if the funding of research is completely independent.”


THE DEBATE ONLINE AT THEBMJ.COM

Food industry funding of public health researchHealth policy researchers should support the food industry and accept research grants from it, argue Paul Aveyard, professor of behavioural medicine at the Nuffield Department of Primary Care Health Sciences and Derek Yach, executive director of the Vitality Institute (see pages 142-143).But Anna B Gilmore, professor of public health at the UK Centre for Tobacco and Alcohol Studies, and Simon Capewell, professor of public health and policy at the Department of Public Health and Policy, claim that such collaboration is inappropriate, and that food industry funding sways scientific findings.The debate, published online last week, provoked an energetic discussion via responses at thebmj.com and on Twitter via @bmj_latest.

Should the food industry fund health research?Yes 282No 265

Total votes cast: 547Yes

No

51%49%

THEBMJ.COM POLLS

Tjark Ebels @tjarkebels @pascalmeier74 @sareve @SimonCapewell99 @bmj_companyRisky business. It would have to be crystal clear what industry receives in return.

https://twitter.com/tjarkebels/status/724338464389500928

Sarah Kunkle @sareve @pascalmeier74 I think we should allow it if there are safeguards + transparency that allow for independent research (cc:@swimdaily)

https://twitter.com/sareve/status/724336536209248256


The BMJ recently held a discussion between experts in general practice, emergency medicine, and paediatrics about the state of out of hours care in the UK, and crucially, their vision for a better service. Are children a special case, can urgent care “hubs” be a silver bullet, is NHS 111 up to the job of triaging patients, are there enough clinicians involved in out of hours care, and are other countries doing a better job? Rebecca Coombes reports

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Out of hours care: which way now?

The state of out of hours care can best be described as “patchy.” Although some, even most, people receive

good and timely care, they have to access a confusing plethora of services—walk-in centres, urgent care centres, out of hours centres, telephone consultation, and, that most recognisable of all NHS brands, the emergency department (A&E). But the experts on The BMJ’s discussion panel also identified serious deficiencies, which they attributed to core problems. Around the table were Clifford Mann, president of the Royal College of Emergency Medicine and an emergency medicine consultant in Taunton, Somerset; Neena Modi, professor of neonatal medicine at Imperial College, London and president of Royal College of Paediatrics and Child Health; and Martin Roland, professor of health service research at the University of Cambridge, who has 35 years’ experience as a general practitioner.

“There are signs all over the country directing people to emergency departments,” says Clifford Mann. “Patients go where they know for certain they will see a clinician. What they actually aren’t demanding is to see an emergency

physician. They just want to see the right sort of person for them—maybe a pharmacist, or it could be a primary care practitioner such as a doctor or a nurse.” About a fifth of patients in emergency departments, says Mann, could be seen by other services. And it’s not patients’ fault for swamping hospital emergency departments; their behaviour “is entirely rational,” given the current restraints on the system.

How did the NHS get to this point? Neena Modi argues that the dismantling of the traditional out of hours family doctor service in 2004, and the introduction of algorithm-led gatekeepers to primary care—NHS 111—was a disservice to patients, especially children. “Why do we have to give up on the idea of a family doctor? If a child breaks a leg, you go off to A&E straightaway. But if it’s something more subtle and you think the child is not quite right, what should parents be doing? Pick up the phone. But who to? I would like parents to be able to phone somebody who knows them and who they trust.”

This kind of personal service just isn’t deliverable 365 days a year with today’s workforce, argues Martin Roland. “Almost certainly, most GPs don’t want to do much out of hours care and may be happy to do

none. And that is probably part of an increasing and a gradual trend among GPs to be working part time.” The heart of the problem is flawed commissioning, he says.

The current system where clinical commissioning groups tender local out of hours contracts has led to an uneven patchwork of care across England. “The present arrangements whereby out of hours care is provided by a third party that is linked neither to the hospital nor to general practice is a serious flaw,” Roland says. Under the current model, CCGs choose the most cost effective service but “with no discussion or consideration of impact on the rest of the system. If we were moving towards some form of capitated population budget, where actually, it matters to the commissioners if people go unnecessarily to A&E, it matters if they get unnecessarily admitted, then you don’t just go for the cheapest service which may have insufficient people available to answer the phone and then making the wrong decision.”

Before GPs gave up responsibility for out of hours care in 2004, practices were coming together into cooperatives to provide care, says Roland. “Doctors who wanted to do more out of hours work did and


NHS 111 calls in Cambridgeshire. “When the call handler told somebody to go to A&E, we had a GP on a phone reviewing that decision with the patient or the parent and they actually decided that they should do something else other than go to A&E in three quarters of the cases.”

So the idea that the more experienced person is more expensive is not necessarily the case if you’re looking at the whole system, argues Roland. He references Denmark, where in some regions GPs still take the initial out of hours call. “They recently published an evaluation of whether it would be more cost effective for nurses to take the calls instead, and the answer was, it wasn’t. And that’s partly because the GPs were able to deal with more things over the phone. The GPs were connected electronically to all pharmacies in Denmark, so they were able to say, “Yes, you need some more of your inhaler. I’ve just prescribed it. You can go and pick it up at your local pharmacy.” So the potential for doctors to do more actually is considerable.

Mann agrees: ‘The more direct clinician involvement in NHS 111, the more effective it is. In Peterborough, they’ve done a lot of work and they have an awful lot of GP input into the decision making of NHS 111. And they have far lower conversion rates to A&E attendance and ambulance dispatch, with pretty compelling evidence that, actually, the outcomes are as good or better. What is clear from that is that a system of telephone

increased their income as a result. Doctors who wanted to spend more time with their families were able to opt out of that at a cost to themselves. And if you gave responsibility for providing those services to federations of practices, we could get back towards that. They might commission those services from a third party provider, they might partly provide them themselves, but they wouldn’t want to provide services that they could see were costing the system more money or providing worse care for their patients.”

Are urgent care hubs one solution?For Clifford Mann, an urgent care hub that brings together out of hours primary care, emergency departments, and other services would be a pragmatic response to current patient confusion.

“We would have a hub in which the emergency department is just one part. It’s an important part and it would probably see over 50% of the patients that go there.

But a substantial proportion could be seen by community pharmacy—open at least 16 hours a day, 365 days a year—by primary care services, or by mental health teams.”

The great advantage of that hub model is that we’re not trying to re-educate a whole population, says Mann, or “change behaviours which are notoriously difficult to change.”

“A fairly quick triage and you can say well, you sound as though you’ve

got flu, frankly, so you can go to see the community pharmacist. There’s almost no queue there. You don’t ask people to get in a car and drive to another centre, two miles down the road. And we would be very keen that these hubs aren’t siloed—that they are effectively collaborating organisations where you can share staff, facilities, and expertise.”

How far is NHS 111 to blame for service failures?Since NHS 111 was created in 2013 there have been serious concerns—and persistent media criticism—that it is not fit for purpose. Recent deaths of patients let down by the service have given rise to reports on how companies running NHS 111 in different parts of the country are hiring people as young as 17 to handle calls, sometimes on very low pay and with little training.

“There’s a real paradox in the NHS at the moment, says Roland. “Hospitals have increasingly realised that you need somebody experienced at the front door. More and more hospitals have consultant physicians in A&E for large parts of the day and evening. In primary care, we’ve done precisely the reverse. So if you ring the out of hours service, in most cases, you get put through to NHS 111, a call centre staffed by very inexperienced people running off a computerised protocol which inevitably had to be very risk averse.”

He points to a recent analysis of

“There’s a real paradox in the NHS at the moment. Hospitals have increasingly realised that you need somebody experienced at the front door. In primary care, we’ve done precisely the reverse” Martin Roland

SHARED RECORDS: A QUESTION OF LIFE OR DEATH?The death of 12 month old William Mead (right) in 2014 from treatable septicaemia exposed serious failings in Cornwall’s NHS 111 service. The NHS England report flagged up how call handlers and out of hours GPs had no access to the baby’s primary care records. These records would have revealed how Mead had been seen by a GP six times in the month leading up to the call. Should access to medical records for everyone involved in out of hours care, including NHS 111, be the priority?

“It is quite extraordinary that we have not been able to crack this business of sharing records,” says Neena Modi. “In my specialty, a baby admitted to a neonatal unit will have health records that can be accessed instantly by any other neonatal

unit to which the baby is transferred.”Martin Roland says there is some hope

and cites the example of GPs in Liverpool. “You go into any general practice in Liverpool and at the press of a button you can see the community nurse records for that patient. And if you’re a community nurse you can press a button on your computer and see the GP records. The technology is there; it requires nothing very clever to develop.” But the larger step change is with secondary care. “It is a big additional step to link those to hospitals that don’t have electronic records that talk to each other. My local hospital has recently purchased an electronic medical system costing many tens of millions of pounds, and it’s been designed in a way that does not talk to local GP records, and

that seems to be a mistake in 2016.”Roland says technological change is

likely to happen by stealth.“Summary care records are already shared fairly widely, and there are plans within NHS England to produce enhanced summary care records that have more information in them. It looks as if they then could be pretty readily shared with other departments, hospitals, pharmacists, general practice, and out of hours.”

Mann is quick to point to Northern Ireland where, “every hospital can see the records of every other hospital and the mental health and social services records. They have a truly integrated system. So this can be done, and it is frustrating that it is done so badly throughout the rest of the system.”


HOW DOES NHS COMPARE WITH OTHER DEVELOPED COUNTRIES?England doesn’t rely as heavily on emergency departments for out of hours care as most other developed nations, says Clifford Mann. “England has the third lowest per capita use of emergency departments when measured by the Commonwealth Fund against 15 other developed countries. France, Austria, and Sweden all have higher rates of attendances.”

Instead, it is a shortage of doctors providing out of hours care that creates the pressure on the system. “The system is so stretched not because we have too many patients but we have too few clinicians, particularly in the out of hours part of the week. So we have fewer doctors per head of population than most other European countries,” adds Mann.

Cheap at the priceMartin Roland says that, considering the underfunding, the NHS out of hours service is actually good and timely for most patients: “We are now bubbling along at the bottom of comparable countries in terms of the percentage of GDP [gross domestic product] that we spend on healthcare. The rhetoric in the press is constantly how we provide a very, very expensive service and how can we save money on it. At some stage does it become politically acceptable to say, actually, it’s a very cheap service and that’s at the heart of some of its problems.”

“If you haven’t got a plan for what happens to your patient at 9 o’clock on a Friday evening, then really, you haven’t got a service, you’ve got a paid hobby.” Clifford Mann

At all stages there should be access, not necessarily immediate, to a competent clinician who’s able to make decisions about what care is needed.” Martin Roland

“From the perspective of the parents of a young child who they think is not quite right, what should they be doing? I would like them to be able to pick up the phone to somebody who knows them and who they trust.” Neena Modi

triage is always going to be enhanced by having a trained clinician on the end of the phone.”

Neena Modi is shocked at the lack of evaluation: “There are very legitimate concerns about whether or not it is effective in young children. We’re stumbling in the dark here. We don’t know how effective NHS 111 is. We don’t know how safe it is. And yet, it would not be impossible to tie in constant evaluation of the outcomes of patients who direct themselves to NHS 111. But we’re just not doing this.”

In defence of NHS 111, Mann says, “they can only send patients to services that are available. A&E is often all that is available.”

“One of the key graphs that we’ve demonstrated is the spike in the number of people who phone 111 and who are directed to an emergency department, which occurs every single Saturday, Sunday, and bank holiday. With NHS 111, the algorithm is linked to a directory of services and it will match you out with a service—assuming it’s available. They send so many people to A&E at weekends not because we are the most suitable service for this patient, but we’re the only available service.”

Could GPs do more?“We’ve got to move away from this idea that people can provide services for their patients Monday to Friday 8 am to 6 pm without a credible plan for what happens when those teams aren’t available,” says Mann.

“I’m not suggesting for a moment all services need to be 24/7, but if you haven’t got a plan for what happens to your patient at 9 o’clock on a Friday evening, then really, you haven’t got a service, you’ve got a paid hobby.”

Should GPs be obliged to do some out of hours work, as happens in the Netherlands? Roland thinks this isn’t achievable under the current workforce. “People would clearly want that as an alternative rather than an addition to in hours work. And already we have a problem with increasing number of GPs working part time and providing continuity of care in hours.”

So how about extending opening hours for conventional GP surgeries? Roland says the government has moved away from this position. “We are clearly not in the ideal situation to do that.” Modi adds: “You really don’t need absolutely everything 24/7. But what you do need is a jolly good safety net 24/7.”

But what does that safety net look like? Roland says: “At all stages there should be access, not necessarily immediate, to a competent clinician who’s able to make decisions about what care is needed.

“Compared to many of the other countries, we still have a pretty good system that most of the time meets the needs of the vast majority of patients.”Rebecca Coombes, head of features and investigations, The BMJ [email protected] this as: BMJ 2016;353:i2356Find this at: http://dx.doi.org/10.1136/bmj.i2356


BMJ CONFIDENTIAL

George AlbertiLaid back and iconoclastic What was your earliest ambition? To be a refuse collector. This changed at the age of 6, when I discovered that our GP seemed to have a nicer lifestyle. Who has been your biggest inspiration? Knud Lundbaek, a professor of medicine in Aarhus, Denmark. A larger than life polymath who taught me to question everything, particularly medical dogma. What was the worst mistake in your career? Never learning to say no. What was your best career move? Leaving Oxford to join the new medical school in Southampton. It was an exciting environment, where I was given the freedom to develop a new research group. Bevan or Lansley? Who has been the best and the worst health secretary? Bevan was best. I had a lot of time for Alan Milburn, who was full of ideas and galvanised change for the better in the NHS—although he was a bit antipathetic to doctors—and for Frank Dobson, who was totally committed to the NHS. Who is the person you would most like to thank, and why? Harry Keen, of Guy’s Hospital: a fine role model who involved me in work at the World Health Organization, which has continued for nearly 50 years. It’s often frustrating, but it’s generally worth while and always interesting. To whom would you most like to apologise? My colleagues in sub-Saharan Africa for not spending more time with them. They’ve achieved amazing standards of care, considering the lack of funding. If you were given £1m what would you spend it on? Half on diabetes care in Tanzania and Cameroon, and half on my wife’s diabetes research programme at King’s College Hospital . Where are or were you happiest? In the Lake District, regardless of climatic conditions. What single, unheralded change has made the most difference in your field? The introduction of nurse educators into diabetes practice. Together with self monitoring of blood glucose, this has totally revolutionised patient care. Do you support doctor assisted suicide? No. What book should every doctor read? The Shepherd’s Life: a Tale of the Lake District , by James Rebanks. An inspirational account of the life of triumph through total commitment, regardless of what is thrown at you. If you could be invisible for a day what would you do? Sit in a cabinet meeting to see whether they really are as banal as they sound. Summarise your personality in three words Laid back, iconoclastic, and irreverent. Where does alcohol fit into your life? It doesn’t. If you weren’t in your present position what would you be doing instead? Running a secondhand bookshop in a rural village in Cumbria. Cite this as: BMJ 2016;353:i2331

George Alberti has been a force in national health policy for nearly 20 years, � rst as president of the Royal College of Physicians and then as national clinical director for emergency access, where he championed the development of fewer but better resourced emergency units, backed up by local urgent care centres for less severe cases. The idea took time, but it is now accepted. A specialist in diabetes with a particular interest in sub-Saharan Africa, Alberti has held chairs in Southampton and Newcastle, where he was latterly dean of medicine. He was also chair at Diabetes UK, the International Diabetes Federation, and King’s College Hospital. He is currently senior research investigator at Imperial College and visiting professor at King’s College.

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