this week

NEWS ONLINE

•  Gap in lifespan of rich and poor in UK grows for first time in 150 years

•  Research funds should be returned if findings can’t be reproduced, proposes Merck chief

•  US gets lower return on its cancer drug spending, study finds

Ministers in “denial” over NHS crisis

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The UK government is in “denial” over the financial crisis facing the NHS and must act immediately to ease the unprecedented pressure on doctors, the BMA’s chairman of council, Mark Porter, has said.

In a speech to a BMA special representatives meeting in London on Tuesday 3 May, specially convened to discuss the crisis facing the health service, Porter warned the government that its policies on and attitudes to healthcare were driving doctors away from the UK.

Although doctors were unflinching in their commitment to patients, the government’s funding cuts, diminishing morale among doctors, and ever growing demand from patients were placing intolerable pressure on the medical workforce, Porter said. “It is a health service with a revenue larger than the GDP of many countries but which would struggle to get a credit rating, which suffers from debt but is crippled by denial,” he said.

Porter described the efficiency savings demanded by the government for the NHS as “fantasy” and “unachievable.” He said, “The chancellor speaks of a ‘fully funded’ NHS but has come up with less than a third of the extra £30bn in England alone that he admits it needs.

“His claims are fantasy, but so too are his solutions. He says we just need to be more efficient. So much more efficient that £22bn worth of work that we do apparently won’t exist, or won’t cost anything, in four years’ time.

“We haven’t found anything remotely matching that. Instead, they’ve put the squeeze on hospitals. They receive less for every patient they treat. And every year their deficits grow. So the health service uses new money to pay off old debts.”

Also speaking at the meeting, Clare Gerada, a GP and former chair of the Royal College of General Practitioners, called for higher taxes to fund the health service, and Peter Holden, a GP and member of the BMA’s council, said, “We need to learn to say no and put barriers around our own workload.”

Sam Everington, a GP and chair of a clinical commissioning group, called for consultants to run hospitals, for a greater emphasis on “social prescribing,” and for the abolition of the regulator the Care Quality Commission, with the money saved reinvested in improvement of quality of services. Gareth Iacobucci, The BMJCite this as: BMJ 2016;353:i2507

Delegates at the BMA meeting heard that efficiency targets set for the NHS were “fantasy” and “unachievable”

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PAGE 212 Health checks not beneficial • PAGE 214 Women GPs outnumber men

SEVEN DAYS IN

General practiceReal time data confirm GP workload is unsustainableDemand for primary care in the past five years has far outstripped the cash available and the staff required, real time data showed in a King’s Fund report. Data collected over five years from 177 practices and a one week snapshot of 43 practices found that consultations grew by more than 15% from 2010-11 to 2014-15, while the GP workforce grew by only 4.75%. The work became more complex and more intense during that period, but funding fell by 0.4% in real terms (full story doi:10.1136/bmj.i2470).

BMJ Awards 2016“Hello, my name is” doctor is honouredKate Granger (below), the doctor behind the “Hello, my

name is” campaign to encourage medical staff to introduce themselves

to patients, won a Special Achievement award

at The BMJ Awards 2016, the first time the award

has been given. The

University Hospital of Wales won Cardiology Team of the Year for improving antenatal detection of congenital heart defects by better training of sonographers, and UK Research Paper of the Year went to Edinburgh University researchers for their work showing that infants with bronchiolitis treated to 90% oxygen saturation do better than those treated to 94% saturation (full story doi:10.1136/bmj.i2478).

MelanomaNICE recommends two drug combination for melanomaNICE recommended trametinib in combination with dabrafenib for NHS treatment of patients in England with advanced unresectable or metastatic BRAF V600 mutation positive melanoma. Evidence from two clinical trials showed that patients treated with the combination survived for an average of six months longer than those taking other drug treatment. Life expectancy in patients with advanced melanoma is currently less than two years. The NHS will pay a reduced price for the drug

combination (list price: £10 080 for 28 days), after a discount was agreed with the manufacturer.

College newsPaediatricians vote to stop funding from formula companiesSome 66 delegates at the Royal College of Paediatrics and Child Health’s annual general meeting voted in favour of a motion to “decline any commercial transactions or any other kind of funding or support” from companies that market breast milk substitutes; 53 delegates voted against. The motion is not binding. The college president, Neena Modi, said that the “implications of the vote” would be considered at the next council meeting in July (full story doi:10.1136/bmj.i2459).

VaccinesFlu vaccination in pregnancy protects newbornsInfants born to women reporting receiving influenza vaccine during pregnancy had a 61% reduction in flu-like illnesses in the first six

months of life when compared with infants whose mothers were not vaccinated, showed a US study published in Pediatrics. Infants with vaccinated mothers also had an 81%

reduction in hospitalisations associated with flu (full story

doi:10:1136/bmj.i2469).

Petition for $5 pneumonia vaccineMédecins Sans Frontières delivered a petition of almost 400 000 signatures to GlaxoSmithKline (GSK) in London and to Pfizer in New York, demanding that the companies reduce the price of their pneumonia vaccine in developing countries to $5 (£3.45) a child. The petition was delivered to GSK board members in an oversized syringe. Greg Elder, of the charity’s Access Campaign, said, “After

The NHS Health Check, the risk assessment offered every five years to patients aged 40-74 who have no known vascular disease, provides only marginal health benefits, a study funded by the Department of Health has found.1

The department commissioned researchers at Imperial College London to examine the electronic medical records of a random sample of 138 788 patients aged 40-74 registered with 462 English general practices from 2009 to 2013. Changes in outcomes among patients who attended a health check were compared with those who did not, over a median follow-up of two years.

The results, published in the Canadian Medical Association Journal, showed that just 21.4% of eligible patients attended a health check and that the 10 year risk of cardiovascular disease in those who did so was reduced by just 0.21% (95% confidence interval –0.24% to –0.19%). This is equivalent to one cardiovascular event, such as a stroke or heart attack, being avoided every year in every 4762 people.

In terms of the effect on individual risk factors, attendees experienced a 2.51 mm Hg fall in systolic blood pressure (–2.77 to –2.25), a 1.46 mm Hg fall in diastolic blood pressure (–1.62 to –1.29), a 0.15 mmol/L fall in total cholesterol (–0.18 to –0.13), and a drop in body mass index of 0.27 (–0.34 to –0.20).

Over 40s’ health check offers only modest benefits

Ingrid Torjesen, London JIM V

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SO, ARE WE TALKING GUARDIAN ANGELS, GUARDIANS OF THE GALAXY, OR MULTIPLE COPIES OF A LEFTIE NEWSPAPER? None of the above. “Guardians of safe working” are an entity created as part of the new contract for junior doctors in England.

IT’S RATHER A HIGHFALUTIN TITLE. WHO ARE THESE PEOPLE? NHS Employers said that the guardian would be a “senior person” who was otherwise independent from hospital management, so a consultant or senior manager. They would report to the trust and to a BMA representative.

RIGHT. SO WHAT ARE THEY ACTUALLY GOING TO DO? The idea is that guardians will act as the champion of “safe working hours” for doctors in training. It will be their job to ensure that rotas are safe. They will also be in charge of distributing money raised through fi nes incurred on trusts when junior doctors work too many hours. This money will be spent on improving the training and “service experience” of junior doctors.

ARE THE ROLES BEING ADVERTISED? Yes, hospital trusts are now advertising the roles. One such role is for 12 hours a week, with a full time salary of £75 249 to £101 451, paid pro rata. The successful applicant, the trust said, would have “facilitation, interpersonal, and negotiation skills in order to promote medical and dental education and challenge practice.” They must also be able to “deal with constraints.”

IS THE BMA HAPPY WITH THIS IDEA? In January the BMA warned that the

guardian role had been diluted and lacked teeth. It said that there

were still “serious and worrying omissions” regarding the role, which meant that the BMA’s concerns about the safety of patients and doctors remained.

ANYTHING ELSE I SHOULD KNOW?

Don’t c onfuse these guardians with “freedom to speak up guardians.” These have also been

appointed by trusts, but their job is to support staff who wish to raise

concerns.

SIXTY SECONDS ON . . . GUARDIANS

Abi Rimmer , BMJ Careers Cite this as: BMJ 2016;353:i2486

MEDICINE

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SELF HARMOnly

53.2% of people attending hospital after self harming (35 960 of 67 653) were followed up by specialist mental health staff as recommended by NICE

Apple juice may be more palatable than

rehydration fluids to children with gastroenteritis

combined sales of more than $30bn for the pneumonia vaccine alone, we think it’s pretty safe to say that GSK and Pfizer could find the money to lower the price, so that all developing countries can protect their children from this killer” (full story doi:2016;353:i2455).

Research news Infections in first six months of life are linked to type 1 diabetes Recurrent viral respiratory tract infections during the first six months of life are associated with developing type 1 diabetes, a study published in JAMA showed. Analysis of the medical records of 295 420 infants born from 2005 to 2007 in Bavaria, Germany, showed a 17% higher risk of type 1 diabetes in children who had a respiratory tract infection between birth and 2.9 months or at 3-6 months than in children who did not (full story doi: 10.1136/bmj.i2497 ).

Neuropsychiatric events increase during H pylori therapy

People taking Helicobacter pylori eradication treatments containing clarithromycin showed a short term increased risk of neuropsychiatric events over a 14 day course, data from Hong Kong showed. The authors reported in JAMA Internal Medicine that this risk was more than four times higher while taking H pylori treatment than two weeks before or after (full story doi: 10.1136/bmj.i2481 ).

IS THE BMA HAPPY WITH THIS IDEA? IS THE BMA HAPPY WITH THIS IDEA? IS THE BMA HAPPY WITH THIS IDEA? In January the BMA warned that the In January the BMA warned that the

guardian role had been diluted and guardian role had been diluted and lacked teeth. It said that there lacked teeth. It said that there

were still “serious and worrying were still “serious and worrying omissions” regarding the role, omissions” regarding the role, which meant that the BMA’s which meant that the BMA’s

KNOW? KNOW? KNOW? Don’t c onfuse these guardians Don’t c onfuse these guardians with “freedom to speak up with “freedom to speak up guardians.” These have also been guardians.” These have also been

appointed by trusts, but their job appointed by trusts, but their job is to support staff who wish to raise is to support staff who wish to raise

concerns. concerns.

Abi Rimmer , BMJ Careers Abi Rimmer , BMJ Careers Cite this as: Cite this as: Cite this as:

Diluted apple juice may work for gastroenteritis Diluted apple juice may be an alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration, a study in JAMA found. The trial of 647 children with gastroenteritis attending an emergency department showed that those given diluted apple juice experienced less treatment failure, including a need for intravenous rehydration or hospitalisation, than those given electrolyte maintenance solution (16.7% v 25%) (full story doi: 10.1136/bmj.i2479 ).

Obesity More women get bariatric surgery Of 6030 bariatric surgery procedures carried out in England in 2014-15 some 76% (4590) were performed on women, figures from the Health and Social Care Information Centre showed. Overall, 58% of women and 65% of men were overweight or obese, and the prevalence of obesity has increased from 15% in 1993 to 26% in 2014. Sunderland had the highest rate of hospital admissions with a primary diagnosis of obesity (135 per 100 000 population) and the highest rate of inpatient bariatric surgery procedures (64 per 100 000). Cite this as: BMJ 2016;353:i2493

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Court to hear challenges to junior doctor contract in JuneTwo High Court challenges to the lawfulness of the health secretary’s decision to go ahead with the new contract for junior doctors in England are expected to be heard in June, The BMJ has learnt.

The timing means that a court ruling on the contract’s lawfulness should be delivered before the health secretary, Jeremy Hunt, proceeds with his plan to introduce the contract as doctors move into new jobs from August.

The news came as it emerged that the United Kingdom’s watchdog on equal rights, the Equality and Human Rights Commission, had advised a United Nations committee that the proposed contract discriminated against female doctors and could breach the UK’s obligations under the

Over half of qualified GPs are now women, show figuresOver 50% of qualified GPs in England are now women, data from the Health and Social Care Information Centre have shown.

Provisional experimental figures showed that female GPs, excluding GP registrars, retainers, and locums, made up 51.9% of the workforce in 2015, up from 49.9% in 2014.

When salaried GPs, registrars, and retainers were included, women accounted for 54.4% of

the workforce in 2015, up from 52.4% in 2014.

For the first time, in 2015 the figures included GP locums. They showed that in total there were 41 877 headcount GPs working in general practices in 2015, with a full time equivalent (FTE) of 34 592 GPs. This was a decrease in the GP workforce from 2014. The figures showed that in 2015 there were, excluding locums, 34 055 FTE

GPs, an estimated decrease of 657 (1.9%) from 2014.

When GP registrars and retainers were excluded as well as locums, there were 29 271 FTE GPs in 2015, an estimated decrease of 980 (3.2%) from 2014, the HSCIC said.

Responding to the figures, Richard Vautrey, deputy chair of the BMA’s General Practitioners Committee, said that they exposed the crisis in general

practice, with GPs leaving because of unsustainable workload pressure. “It is deeply worrying that at a time of escalating patient demand, especially from an ageing population, there has been a decrease in the number of GPs and staff focused on delivering patient care,” he said.

Vautrey added, “The public is already seeing the impact of this in their local GP practice,

International Covenant on Economic, Social and Cultural Rights.

Imposition challengedThe BMA and a group of junior doctors, Justice for Health, are mounting two separate High Court challenges to the decision to introduce the contract, each arguing on a different basis that the decision is unlawful. Each is seeking permission from the court to bring a claim for judicial review of Hunt’s decision.

In most cases, permission is granted first and the full hearing takes place a few months later. But in some cases—usually urgent or complex ones—the court will grant a “rolled-up” hearing. In these hearings the permission stage and the full hearing happen at the same time, so

the case is resolved more quickly.The BMA already has its rolled-up

hearing listed for 8-9 June. Justice for Health is asking the court to let it go ahead with a rolled-up hearing just before or after the BMA’s. Its preference is to go first, on the basis that Justice for Health’s claim is a more fundamental challenge to the health secretary’s powers.

Legal basis questionedJustice for Health argues that the health secretary has no power in law to tell NHS foundation trusts, local councils, or general practices whom to employ and on what terms, since his powers were recast by the Health and Social Care Act 2012. While he may be able to instruct other NHS trusts, he can do so only after conducting a proper consultation, which he has not done, the group contends. It also argues that the decision to impose the contract was irrational and hasty.

The BMA’s challenge is based on Hunt’s failure to carry out an equality impact assessment to determine whether it would have a disproportionate impact on certain groups, such as women, before taking his decision. The Department of Health’s own assessment, carried out after Hunt announced that he would go ahead with the contract, conceded that the new pay structure would disadvantage part-timers, many of whom are working mothers. Clare Dyer, The BMJCite this as: BMJ 2016;353:i2472

Each group is seeking permission from the court to bring a claim for judicial review of Hunt’s decision

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“Any sense of vindication I have [from the inquiry which on 26 April found that supporters were unlawfully killed and that police and emergency services were negligent] is a completely joyless one, although I am delighted for the families. If those

at fault had had the courage, honesty, and integrity to admit their failings back in 1989 the families of the victims would have been allowed their right to grieve properly for their lost loved ones. They would not have been forced to spend the last 27 years giving up potentially normal lives to fight for truth and justice.”

Phillips had been at the FA Cup semifinal on 15 April 1989 as a spectator with his brother and two friends, when overcrowding on the terraces led to a crush among fans. Ninety six fans died and hundreds were injured. He performed cardiopulmonary resuscitation on a man he found in an unresponsive state.

DEFIBRILLATORS MISSING“My personal sense of vindication is also limited by the fact that these new coroner’s inquests have not been tasked with correcting the errors (in my view) relating to my evidence in the findings of the Taylor interim report [published in August 1989]. In that report Taylor disagreed with my criticisms of the emergency response. [I believed] that defibrillators should have been available and utilised.

IMMEDIATE IMPACT“In the immediate aftermath [of the disaster] I was very upset. I returned to work two days afterwards but quickly realised I was in no fit state to be seeing patients. I returned to Merseyside. By then accusations about the conduct of Liverpool fans were being made via various media outlets and I was involved in responding to these. I drove to Sheffield six days after and visited Hillsborough. A social worker guided me around the ground and listened to my account of the day. I remain very grateful for her kindness and sensitivity. I visited the Sheffield hospitals to try to find the young man I had resuscitated. I could not and assumed he had died. “The East Kilbride practice I was a partner in was very busy, so although still very upset I was compelled to go back [to work] nine days after the event. I had to detach myself from the event, and the

distance from Liverpool helped to some degree. I had nightmares and intrusive flashbacks about the disaster for about six months.

“In 1990 I assisted West Midlands Police in their investigation and as a result discovered that the young man I had resuscitated had survived, although with some permanent anoxic brain damage. His survival was a tremendous relief to me.”

Court to hear challenges to junior doctor contract in June

Gareth Iacobucci, The BMJ Cite this as: BMJ 2016;353:i2499

A far reaching clause in the new NHS contract for junior doctors in England allowing employers to vary the terms and conditions unilaterally is highly unusual and could well be successfully challenged if acted on, employment

law experts say.Under the clause, NHS employers “reserve the right from time to time 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.”

Although the BMA has said that there were no legal grounds to challenge the inclusion of the clause in the contract, legal experts said that it could be challenged in the courts if employers tried to rely on it to change junior doctors’ pay or conditions. One QC told The BMJ, “The effect of it is to destroy collective bargaining in the NHS.”

Robin Allen QC (below), a leading employment law specialist, said, “This clause strikes at the heart of the relationship hitherto between doctors and health authorities and is inconsistent with all normal principles of contract law. It’s all the more remarkable for being imposed by a monopoly employer.”

John Hendy QC (above), another leading barrister who specialises in employment law, said, “It’s completely unconscionable, and nobody who had a choice would sign a contract with a clause like that in it. It gives the employer complete freedom to halve the pay or double the hours. It’s a form of slavery.”

Lawyers said that the courts would be unlikely to uphold such a clause in the junior doctors’ case, where there was no collective agreement and no bargaining power because doctors who want to train in England have no choice but to accept the contract.Clare Dyer, The BMJ Cite this as: BMJ 2016;353:i2473

CLAUSE IN JUNIOR CONTRACT THAT ALLOWS TERMS TO VARY IS “A FORM OF SLAVERY,” SAYS BARRISTER

Over half of qualified GPs are now women, show figures with many struggling to provide enough appointments. A recent BMA survey showed that more than 300 GP practices believed they were facing closure because of their increasingly difficult financial situation.

Nigel Mathers, honorary secretary of the Royal College of General Practitioners, said it was disappointing that the GP workforce had not increased to match rising demand. Abi Rimmer, BMJ CareersCite this as: BMJ 2016;353:i2480

UP FROM 2014 Women accounted

for 54.4% of the GP workforce in 2015, up from

52.4% in 2014

FIVE MINUTES WITH . . .

Glyn Phillips The GP who helped football fans caught up in the Hillsborough disaster reflects on the past 27 years

the bmj | 7 May 2016 215

Glyn Phillips came to the aid

of spectators but was also

injured during the Hillsborough

disaster on 15 April 1989

Social media’s censorship of women’s nipples creates a problem for organisations trying to teach women how to examine their own breasts for early signs of cancer. Argentinian breast cancer support group MACMA (Movimiento Ayuda Cáncer de Mama) has cleverly worked around this problem. Its “TetasxTetas” (“TitsxTits”) YouTube video demonstrates correct self-examination technique using a man’s breasts in place of a woman’s, and has been viewed millions of times.Tom Moberly, The BMJ

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EDITORIAL

Prescribing sodium oxybate for narcolepsyDemanding that a patient’s need is “exceptional” is irrational and should be abandoned

Narcolepsy affects around 4 in 10 000 people. Its cardinal features are excessive daytime sleepiness causing

frequent, irresistible naps; cataplexy, leading to collapse, embarrassment, and sometimes injury; and marked disturbance of nocturnal sleep. It is usually due to a specific deficiency of the hypothalamic neurotransmitter hypocretin and most often starts in the teens, probably as the result of an autoimmune process. Narcolepsy is far more than an occasional dose of sleepiness: it is a lifelong, pervasive, and potentially disabling disorder with a similar effect on quality of life to treatment resistant epilepsy.2

While potentially disabling, it is also highly treatable.3 A combination of stimulants and antidepressants improves symptoms appreciably in most patients. But treatment response may be partial; contraindications or side effects can prevent their use; and none of these drugs deals with the symptom that is sometimes the most distressing—the fragmentation of nocturnal sleep.

Enter sodium oxybate (Xyrem) or γ-hydroxybutyrate (GHB), an agonist at GABAB (γ-aminobutyric acid type B) and GHB receptors.4 It has a chequered history, acquiring a louche reputation as a date rape and recreational drug. More recently a series of trials have shown its efficacy in treating narcolepsy: given at night in two doses, sodium oxybate consolidates nocturnal sleep, reduces excessive daytime sleepiness, and often abolishes cataplexy. Its potential to cause respiratory depression in overdose and substantial sedation at therapeutic doses, with attendant risks of falls in the night, enuresis, and new onset parasomnias, means that a careful approach to prescribing is needed. However, it is the only drug available for use in narcolepsy that simultaneously treats all three cardinal symptoms.

Since it was licensed in 2006, we, in common with sleep specialists around the world, have found it a remarkably effective treatment. Despite the need for gradual titration and the nuisance of taking the drug twice nightly, many patients find sodium oxybate life transforming, often enabling them to return to work or study.

Sodium oxybate is currently priced at around £13 000 a year at full dose, although many patients are optimally treated on lower doses. Prescribing policies around the UK are inconsistent. The Department of Health has agreed to underwrite its cost in selected vaccine related cases (a small narcolepsy epidemic followed the use of Pandemrix in 2009-10).5 Some clinical commissioning groups have agreed sensible prescribing arrangements with local hospitals.6 In most parts of the country, however, use of the drug requires the approval of an individual funding request, showing that a patient’s need is “exceptional.”7 8

Making an exceptionThis process is tortuous, primarily because of the unclear definition of exceptionality. Given the drug’s cost, together with variations in the severity of narcolepsy and response to standard treatments, prescribing policies that restrict its use to more severely affected patients who respond poorly to other treatment seem sensible. But under the opaque operation of the exceptionality rule, a patient will be allowed sodium oxybate only if his or her response to the drug is judged likely to be exceptional compared with that of a patient with a similar clinical need.

In our joint experience of around 30 applications, the increasingly rare agreements to fund the drug are emerging at random. Of 10 recent applications made by the authors in carefully selected patients, none has been successful. Reasons for refusal have included the explanation that “the patient belongs to a cohort of similar patients.” This logically necessary truth provides a convenient but empty justification for declining to fund valuable therapies.

Sodium oxybate should be prescribed with care. However, the individual funding request process is time wasting for doctors, frustrating for patients, and fundamentally irrational. It should be abandoned. We suggest that it should be replaced by agreements to fund the drug, under the care of specialists, for patients who meet predetermined criteria.

We note that NHS England has recently issued a draft proposal relating to the use of sodium oxybate in postpubertal children,9 We welcome this but can see no good reason for adopting different policies towards postpubertal children and adults. We hope that the recent decision to allow a judicial review of prescribing10 will lead to a more rational and equitable approach to the use of this expensive but valuable drug.Cite this as: BMJ 2016;353:i2367Find this at: http://dx.doi: 10.1136/bmj.i2367

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Adam Zeman, chair of cognitive and behavioural neurology, University of Exeter Medical School, Exeter EX1 2LU, UK a.zeman@ exeter.ac.ukZenobia Zaiwalla, consultant neurophysiologist and non-respiratory sleep disorder lead clinician, John Radcliffe Hospital, Oxford OX3 9DU, UK

It is the only drug available for use in narcolepsy that simultaneously treats all three cardinal symptoms

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EDITORIAL

Delivering universal health coverageA new initiative to focus on improving healthcare delivery systems

Universal health coverage—the notion that people should have access to healthcare services regardless of

their ability to pay—is a major focus for G7 policy makers and others around the globe. It is an important component of the sustainable development goals, leading many countries to increase their use of scarce public resources to ensure their citizens are covered. The motivation, of course, is compelling. People should not develop or die from preventable or treatable conditions because they are poor, and treatment should not bankrupt them.

Simply prioritising universal health coverage, however, will not be enough to achieve its main goals. Even if nations are able to identify the necessary resources, fundamental questions about achieving effective universal coverage remain unanswered. Without these answers, simply pushing for universal coverage may waste precious resources without achieving the important goals of improved health and wellbeing of citizens in a way that is efficient.

Making trade-offsAlthough the primary focus is coverage, success depends on the underlying healthcare delivery system. It also requires clarity about the trade-offs. Governments have limited resources but many important priorities. What will not be funded because governments focus on universal coverage? Even in Massachusetts, one of the wealthier US states, investments in achieving universal health coverage for its population coincided with substantial reductions in spending on public health, education, and infrastructure.1

If policy makers decide that universal health coverage is worth supporting, they will need better information on how to implement

it. How should investments be structured? Should it all be public funding or should governments fund private insurance and private providers? How should governments ensure that there is a legal and regulatory framework to manage the legal rights that such programmes might confer? And, of course, how is it possible to ensure that the coverage that is created is worth having? As Teerawattananon and colleagues have pointed out, setting priorities early helps nations make better decisions about how best to achieve these goals, especially when faced with scarce resources.2

Herein lies one of the largest challenges of universal health coverage. The safety, quality, and efficiency of most healthcare delivery systems are not as good as they could be. In many countries, the quality of the underlying healthcare delivery system is so poor that it is unclear whether increasing access to services will do more good or more harm.3-5

Ashish Jha, director, Harvard Global Health Institute, Cambridge, MA 02138, USA ajha@hsph.harvard.eduFiona Godlee, editor in chiefKamran Abbasi, international editor, The BMJ, London, UK

Of bangs and bucksWhile we strongly support the idea of universal health coverage, we do not know how to ensure we get the most for our investments. We do know, however, that given the millions of deaths that occur from poor quality care, one way to improve the value of that investment is to improve the quality of the underlying delivery system.

To this end, the Harvard Global Health Institute and The BMJ are partnering to launch a new initiative on effective universal coverage. We agree with the underlying goals, but there is a vast gap between the goals and our ability to deliver them. This is mainly due to deficiencies in knowledge about both optimal approaches to financing and effective models for healthcare delivery.

So little is known about how to do this well—partly because each nation is unique with a different set of needs and a different path to achieving true, effective universal health coverage. We also know little about how best to deliver what is known to work. But that doesn’t mean that there aren’t generalisable principles, and our hope is that The BMJ can be a vehicle for furthering our knowledge about how to do universal health coverage well. We welcome articles for consideration that help us further our knowledge and insights (see box).

We are at a critical juncture in global health. The world has increasingly come to realise that we are interdependent and that a poor performing health system in one place is a threat to us all. We must pull together to help nations develop their own healthcare systems and achieve effective universal coverage in ways that are consonant with their history, culture, and values. We can all learn from each other, and learn we must, because good intentions are a start but are not enough.Cite this as: BMJ 2016;353:i2216Find this at: http://dx.doi: 10.1136/bmj.i2216

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There is a vast gap between the goals and our ability to deliver them

HARVARD GLOBAL HEALTH INSTITUTE AND THE BMJ’S NEW INITIATIVE ON EFFECTIVE UNIVERSAL COVERAGEWe welcome original research papers, analyses, and opinion pieces on:• Efforts to improve effectiveness of health services in low and

middle income countries• Comparative analyses of financing schemes• Intended and unintended effects of policy level interventions• Scale-up and broader applicability of delivery strategies• Legal mechanisms that aim to improve accountability• Measurement strategies for complex delivery environments

Ask somebody, “What is the NHS?” and they’re likely to answer, “The people who work in it, the buildings they work in, and the tools they use to do their work.” But it clearly isn’t that. The people who work in the NHS come and go, and they weren’t working in the NHS when it began. Buildings also come and go, and the tools are constantly changing. The NHS is not a thing but a � ction, and it’s none the worse for that. Indeed, if we recognise the NHS as a � ction we’re more likely to be able to keep it alive.

So, if the NHS is � ction, what’s the story? For some the story may indeed be sta� , buildings, and tools, but that’s a dull, uninspiring story. For others it’s a public service—funded, owned, provided, and regulated by the state and infused with a “public sector ideology,” whatever that is exactly. This, too, is a rigid, in� exible story that, if adhered to with too much devotion, may mean the end of the NHS. It’s also an inaccurate story, in that many services, particularly primary

care and end of life services, are provided by the private sector.

The best � ction, I suggest, is that the NHS is simply three values: universal coverage of health services; provision by need rather than ability to pay; and equal quality care for all. Equal quality of care has never been achieved, but it remains an important aspiration. Universal coverage and provision by need rather than ability to pay have been eroding ever since 1948—think prescription charges, dentistry, and long term care.

This story is, however, a � exible one that provides greater resilience. The

values—the centre of the � ction—should stay, but we need to develop the subplots. To keep the NHS alive we need to move rapidly from a service dominated by hospitals, doctors, disease, death denial, and drugs and surgery to one more focused on community services, teams including patients, life enhancement,

and a wider range of interventions, including urban redesign, changes in food supply, and much more.

And should we move beyond health to include social care? In fact, health and social care are also � ctions. Health was the � ction we cared most about in 1948, because treatable disease killed many people prematurely and spending on services could bankrupt people, just as happens today in low and middle income countries. But now, in Britain, the need is di� erent: the provision doesn’t � t the need, and yet it must do so for the NHS or a national care service to survive—and not degenerate into a rump service for poor people. For many of the elderly people who cost the NHS the most, social care matters much more than healthcare.

Is there a story we can agree on? I fear not right now, but perhaps, as we come closer to the collapse of the NHS, we will.Richard Smith was the editor of The BMJ until 2004

220 7 May 2016 | the bmj

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The NHS is a fiction, but what’s the story?

The NHS is simply three values

the bmj | 7 May 2016 221

Countries should consider breaching their international obligations and move to regulate legal markets to reduce the harm associated with taking illicit

drugs, a high profile panel recently said. The former presidents of Mexico,

Colombia, and Switzerland, former UK deputy prime minister Nick Clegg, businessman Richard Branson, and others said that countries should “experiment” with their policies related to drugs like heroin, cocaine, and cannabis.

Representing the pressure group the Global Commission on Drug Policy, they made the call on 21 April 2016 to coincide with the conclusion of a special session of the United Nations general assembly (UNGASS) in New York City to discuss the “world drug problem.”

More humane and evidence based“Several countries and some US states are exploring regulation in a more humane and evidence-based manner,” the commissioners wrote in a statement. “These approaches should be encouraged despite the restrictive language of the UN drug conventions.”1

They also expressed their “profound disappointment” and condemned UNGASS’s outcomes document for failing to mention regulation or to acknowledge “the comprehensive failure of the current drug control regime to reduce drug supply and demand [and] the damaging effects of outdated policies on violence and corruption as well as on population health, human rights and wellbeing.”2

They wrote, “By reaffirming that the three international conventions are the ‘cornerstone of global drug policy,’ the document sustains an unacceptable and outdated legal status quo.”

Werner Sipp, president of the International Narcotics Control Board, the body that monitors UN member states’ compliance with the treaties, had the day before told delegates at the general assembly that the Portuguese model of decriminalisation of all drugs, with administrative sanctions replacing criminal sanctions for possession of small quantities, represented “best practice.”

Legalisation not permittedViolent criminals remain in control of supply in Portugal, however, and Sipp emphasised that legalisation and regulation of drug markets was not permitted within the treaties.

Three treaties require countries to prohibit all non-medical activity related to illicit drugs, including possession for personal use.3-5 Many states fulfil this obligation, including by criminalising and incarcerating non-violent drug users. People imprisoned for drug offences in the United States are estimated to have risen from about 40 000 in the 1970s to about 500 000 in four decades.6 But still the UN Office on Drugs and Crime estimates that prevalence of drug use rose from 4.6% of adults in 2008 to 5.2% in 2012—some 243 million people globally.7 And 1.7 million people worldwide who inject drugs have HIV infection.8

In the UN plenary meetings, representatives of governments, including Canada, Italy, Mexico, New Zealand, and Uruguay, urged radical reform to better protect health and human rights.

Widespread criticismMany UN bodies, including UNAIDS, the UN Development Programme, and the Office of the High Commissioner for Human Rights, as well as non-governmental organisations, have criticised current national drug policies for not putting health and human rights first.9 10

The World Health Organization’s director, Margaret Chan, told the conference, “Drug policies that focus almost exclusively on use of the criminal justice system need to be broadened by embracing a public health approach.

“WHO promotes a comprehensive package of interventions to achieve these objectives. The evidence shows they work.”

But the UN general assembly reaches decisions by consensus, and for political or other ideological reasons many countries are intransigent despite best evidence. Russia, for example, where treatment of drug dependency with opioid substitutes is outlawed despite high rates of HIV among drug users, vetoed use of the term “harm reduction” in the outcomes document.

Many delegates were disappointed that the assembly made only incremental progress in its formal outcomes but these seemed light years away from the last meeting on drugs, in 1998, which had the unrealistic aim of “a drug-free world.”11

The forum succeeded, however, in publicising the deep lack of consensus among member states and the many pleas for reform to better protect health and wellbeing, which is an overarching goal of the UN treaties.

“The UN is increasingly divorced from reality,” summed up Nick Clegg.Richard Hurley is features and debates editor, The BMJ rhurley@bmj.comCite this as: BMJ 2016;353:i2474Find this at: http://dx.doi.org/10.1136/bmj.i2474

ILLICIT DRUG POLICY

Legalise drugs despite UN treaties, says influential panelMany countries are already looking beyond the prohibitive stance of the “war on drugs,” which is widely seen as a harmful and costly failure. Richard Hurley reports from New York

Former presidents and others said that countries should “experiment” with their policies related to drugs like heroin, cocaine, and cannabis

222 7 May 2016 | the bmj

The United Kingdom’s involvement in the European Union is both deep and broad, and, let’s be frank, for many people, both deeply boring and highly

confusing. Yet the referendum result on 23 June will be important. A vote to leave will affect many aspects of UK life and business—including healthcare.

A recent “poll of polls” suggests the public remains almost evenly split between exiting and remaining—but with a sizeable minority of around 20% undecided.1 Over the longer term, and with more than just the in-out binary option, the public’s views are more nuanced. As fig 1 shows, crucially, the poll indicates that a much greater percentage (43%) would want to remain in the EU if its powers were reduced.2 And in particular, it seems there is popular support to restrict access to NHS treatment for people from other EU countries, curtail the ability of the EU to set maximum working hours, and to end the right of people from other EU countries to work in the UK.2

This free movement of labour is an important aspect of membership of the EU. Recent figures for the third quarter of 2015 suggest that out of a UK working population of around 30 million, about 7%—just over 2 million—were born elsewhere in the EU (fig 2).3 For the (broadly defined) health and social care sector, the figure is 228 000—around 6% of 3.8 million.3 For the NHS in particular, employment of non-UK qualified clinical staff has been a feature of the workforce for decades. However, while 34% of doctors working in the NHS qualified in non-UK countries, only 8% were from the European Economic Area

DATA BRIEFING

Brexit, Bremain . . .or Brundecided?The result of the EU referendum could have huge implications for doctors. John Appleby considers some of the key questions

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(28 EU countries plus Norway, Iceland, and Liechtenstein) and 26% from other countries (fig 3).4-6 How Brexit would affect staff employed by the NHS from EEA countries will depend on many factors, including the nature of any renegotiated immigration rules.

Trends in registrations with the Nursing and Midwifery Council have been different. The last peak in overseas registrations, just after the turn of the century, consisted mainly of nurses from non-EEA countries. Since then, people from EEA countries have made up an increasing proportion of initial registrations (fig 4).7

Are any of these facts and statistics helpful? Does the fact that the UK will pay around £10bn this year to belong to the EU (including

the bmj | 7 May 2016 223

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Fig 4 | Initial registrations of qualified nurses by country of birth, 1993-94 to 2014-15 7

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a substantial rebate (fi g 5) 8 ) move opinion one way or the other? What about the fact that the European Health Insurance Card (EHIC) scheme simplifi es EU citizens’ travel arrangements? 9 Is this countered by news that the Spanish government is currently claiming £222m from the UK for UK nationals’ use of Spanish healthcare versus the UK’s claim against Spain of £3.4m? 10 And what about the recent introduction of the European professional card for nurses, physiotherapists, and pharmacists (and, er, estate agents and mountain guides) to ease communication of professional qualifi cations between EU migrants and their new resident country? 11

The good, the bad, and the ugly? What about the fact that the eff ect of EU membership on healthcare is also felt indirectly? Limits on working hours through the working time directive have been, according to a Department of Health taskforce on the matter, both good and bad for the NHS. 12 EU rulings on competitive tendering in procurement of goods and services by the public sector were an important underlying context for the 2012 NHS reforms in England. But the eff ects of such directives (the latest incarnation is to be implemented this year 13 ) on NHS commissioning in practice is always open to broad interpretation based, ultimately, on what is good for patients. 14

Aft er 43 years of membership of the EU, unwinding agreements, obligations, and laws, and then renegotiating trade, security, legal, and other relationships with the EU is unlikely to be a snappy or straightforward process. The problem for referendum voters keen on evidence is that there is no comprehensive and reliable cost-benefi t analysis that weighs up the facts, the positives and negatives, over the short, medium, and long term and across diff erent groups in society of exiting or remaining in the EU. And like many decision problems there is a good deal of uncertainty, such that it is hard to impossible to predict future outcomes and consequences with suffi cient accuracy to be helpful. John Appleby, chief economist , King’s Fund, London, UK j.appleby@kingsfund.org.uk

Cite this as: BMJ 2016;353:i2328 Find this at: http://dx.doi.org/10.1136/bmj.i2328

� PERSONAL VIEW p 232

224 7 May 2016 | the bmj

MEDICINE AND THE MEDIA

Strike in the papersCoverage was as divided and intransigent as the two sides in dispute, writes Thomas Macaulay

“Interesting day, experiencing the job of a junior trainee. Lots of forms to fill and file. Good use of their time . . .” @dacrejane (Jane Dacre, president of the Royal College of Physicians)

“Lots of complex IT /bean counting challenges detracting from patient contact”@alistair5hall (Alistair Hall, professor of cardiovascular epidemiology and consultant in cardiology)

“Walk a mile in FY1’s shoes . . . I was H.O. [house officer] 16y ago. Now recall how hard it is!” @acmedr (Anu Mitra, consultant emergency physician)

“Put it this way—some of the excuses used for not getting ward jobs and tasks done will no longer wash!”@vinwad (Vineet Wadehra, consultant cardiologist)

FIVE INSIGHTS FROM THE SHOP FLOOR DURING THE STRIKEConsultants tweeted what they discovered when they covered for junior doctors during the all-out strike on 26 and 27 April

“Chaos caused by first all-out strike in NHS history,” screamed the Daily Mail last Tuesday, as the strike began.1 The cancellation of 12 711 operations and postponement of 112 856 outpatient appointments will have knock-on effects,2 but “most hospitals coped well and did not experience problems” on the day, said the Guardian, with emergency units quieter than normal.3

On the strike’s second day, the Sun warned of “heightened risk for patients,” echoing Jeremy Hunt. But their fears were unfounded, with ITV News reporting “low waiting times and no urgent calls for doctors to return from the picket lines.”4

The first day dominated the national newspapers, given top billing on the front pages of the Telegraph, i, Metro, Times, Daily Mirror, and New Day. But none repeated the move the next day. On Thursday, as media coverage of the strike declined, the Daily Mail continued to predict “chaos” on its front page.5

The papers’ coverage split predictably along political lines, with only the Mirror, New Day, and Guardian in support of juniors. The Independent provided lone impartiality, blaming both sides for “failure to compromise and a stubborn intransigence.”6

The broadcast media were

more nuanced. Cathy Newman on Channel 4 News and James O’Brien on BBC’s Newsnight grilled Jeremy Hunt over the claim that 500 junior doctors had signed up to the new contract and the attempted cover-up of junior doctors’ loss of earnings, respectively.

In The Guardian, Polly Toynbee and Owen Jones both looked for political parallels, calling the dispute the government’s “miners’ strike moment,”7 8 claiming the Conservatives sought a similar symbolic victory over public sector unions in 1984.

“Junior doctors are protecting patients by taking to the picket line,” said the Mirror.9 The claim was denied by the former BMA chief Russell Hopkins in the Daily Mail.10

“Beyond all the sentimental rhetoric about ‘patient safety,’” he argued, “the BMA is really motivated by its self-serving determination to retain lucrative weekend overtime payments.” The Independent agreed that “yes, the junior doctors’ strike really is about money” but with a crucial proviso: “how little government is willing to spend on our health.”11

The Telegraph’s James Kirkup was also on the attack, writing that many striking doctors “do not know what they are doing and do not understand the conflict they are now escalating . . . Many, engaged

The papers’ coverage split predictably along political lines, with only the Mirror, New Day, and Guardian in support of juniors

The Telegraph’s James Kirkup was on the attack, writing that many striking doctors “do not know what they are doing and do not understand the conflict they are now escalating”

the bmj | 7 May 2016 225

We fi rst noticed the diff erence early on 26 April. On Twitter, groups of patients were asking each other

what they thought about the strike, rather than stating a defi nite opinion. People discussed whether it was time to stop self censoring. Increasingly, they seemed to be turning to direct messaging or private emails to have these discussions.

The overwhelming feeling was that no patients in these groups wanted to go on record with their views. We wanted to get patients’ voices into The BMJ for its coverage of the junior doctors’ strike, and a request for views resulted in immediate volunteers among the enthusiastic pro-strike patients—but every conversation we had about featuring more diverse responses to the strike ended the same way. Long, detailed, passionate emails full of interesting thoughts, closing with something like, “. . . but I don’t want to put this into print.”

In short, anyone using mainstream or even social media to gauge public opinion on the strike is going to miss a lot. Don’t be fooled: a murmur is going on below the parapet. Some of the main themes coming up in these conversations are:

•  We are not comfortable with doctors and politicians discussing our health service without patients being involved.

•  We are not happy that “patient safety” and “patient harm” are being defi ned by doctors and politicians but not by those at risk of harm.

•  We are afraid that questioning anything in the debate will lead to a backlash.

•  We no longer know where to fi nd trustworthy information on this topic.

•  We are worried that our experiences will be taken out of context and used by one side to bash the other; we are concerned that the debate is now so polarised that any nuance will get shouted down; we are afraid of becoming political pawns.

•  We want to help, but we don’t know how. Calls for patients to mediate in this dispute or discuss what we mean by “safety” or “24/7 working” have been made very eloquently, for example by National Voices, and patients are talking about how we could resolve this. Nobody is taking us up on it. What is clear is that these closed

discussions are not saying, “My doctor, right or wrong,” but nor are they pro-government. One comment (reproduced by permission) on a closed Facebook page sums it up: “I support the junior doctors. I don’t support this strike. I really don’t support Hunt. How am I going to fi t all that on a banner?” Rosamund Snow is patient editor , The BMJ David Gilbert is patient panel member , The BMJ Cite this as: BMJ 2016;353:i2458

FIVE INSIGHTS FROM THE SHOP FLOOR DURING THE STRIKE

PERSONAL VIEW

Patients caught in the middle Rosamund Snow and David Gilbert detect a sea change in how the public have started talking about the junior doctors’ strike

“There are consultants everywhere. One of them suggested that we should all go to the doctors’ mess later. But none of us know the code.”@elinlowri (Elin Roddy, consultant physician)

in politics for the fi rst time, cannot understand why the government will not do exactly as they want.” 12

However, the newspaper did attempt to refl ect the other side through a live question and answer session and an interactive quiz. 13  14

Confl icting media coverage did little to aid public understanding: YouGov suggested that the public was increasingly blaming the government for the impasse, 15 with 52% holding the government primarily responsible for the contract dispute, up from 45% in February. But an Ipsos MORI poll suggested that those blaming the government had fallen to 54% from 64% in February. 16 Both polls found support dropped when juniors also refused to provide emergency care.

Although most of the public still side with the juniors, several pundits argued that further strikes risked alienating the supporters of the politically inexperienced protestors.

“Sympathy will ebb, and criticism will mount,” said Hugo Rifk ind in the Times . “When doctors go on strike we enter lands not of medicine, nor hospital management, nor even industrial relations. This, rather, is a place of politics . . . And here, my medical friends, you are no longer the experts.”

“Do we rate doctors more than politicians?” asked Michael White in the Guardian . “Of course we do, but doctors as politicians is a diff erent matter.” 17

“Time to calm down and talk,” he pleaded. But it was a struggle to hear his rare conciliatory voice above the fi ghting talk. 17 Thomas Macaulay , MA student in newspaper journalism , City University, London, UK Cite this as: BMJ 2016;353:i2506

“I support the junior doctors. I don’t support this strike. I really don’t support Hunt. How am I going to fit all that on a banner?”

226 7 May 2016 | the bmj

BMJ CONFIDENTIAL

Paul GibbsKidney donation altruist

Paul Gibbs, 47, is a specialist in kidney transplantation and director of the transplant programme at Queen Alexandra Hospital in Portsmouth. A strong supporter of altruistic kidney donation, he is a trustee of Give a Kidney, a charity set up in 2011 to promote donation. Numbers of donors have risen swiftly—surprising Gibbs, who initially expected only a few very enthusiastic individuals to be prepared to give up a kidney. He trained at Charing Cross and Westminster Medical School and did higher surgical training in the Wessex region. He sits on the council of the British Transplantation Society.

What was your earliest ambition? From an early age I was interested in the past and in understanding where we started. I wanted to go and dig up a T rex in Montana. Who has been your biggest inspiration? My uncle, John: a consultant anaesthetist who took me to his hospital when I was about 9. He showed me an operating theatre, and it was so exciting. That was where I wanted to be, and surgery was how I was going to do it. What was the worst mistake in your career? Leaving the operating theatre 10 minutes too soon when a colleague was taking out a live donor kidney. What was your best career move? Taking a “stand alone” renal transplant job (one that isn’t part of a rotation) in Cardiff, to be closer to a girlfriend. I’d never considered it before then. Bevan or Lansley? Who has been the best and the worst health secretary? After Bevan, it’s never been the same. We need someone to be honest. We can’t fund the NHS with an ageing population who have increasing expectations. Who is the person you would most like to thank, and why? Simon Darke, a retired vascular surgeon from Bournemouth. He wanted me to convince him that I had what it takes. He challenged me just when I needed it most. To whom would you most like to apologise? The patients and families who have had a bad outcome from surgery. I’m relieved to say that it hasn’t been many, but it’s still been more than I would’ve wished. If you were given £1m what would you spend it on? A bolthole in southern Spain and a Porsche GT3 to get me there. Where are or were you happiest? Outdoors with nature: hilltop hiking, mountain top skiing, or surfing. What single unheralded change has made the most difference in your field? The Human Tissue Act 2004. That act made it possible for people to donate a kidney to a stranger—what is called altruistic, or non-directed, donation. This year will see the 500th altruistic kidney donor: that’s 500 heroes, right there. Do you support doctor assisted suicide? Absolutely. I believe in alleviating suffering. What book should every doctor read? Anything by Atul Gawande. He has such a refreshing way of looking at the medical world we live and work in. What poem, song, or passage of prose would you like at your funeral? I’d have to follow my friend, “Always Look on the Bright Side of Life”! What is your pet hate? People who live in the past. Learn from it, and move on. Do you have any regrets about becoming a doctor? Sometimes I do, on those dark days. Fortunately, there aren’t too many of them. If you weren’t in your present position what would you be doing instead? Running a beach bar somewhere sunnier than Portsmouth. Cite this as: BMJ 2016;353:i2500

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