Friday, 14 April 2017

The BMJ talks a good talk.....


The BMJ does publish some very insightful work at times, I particularly enjoyed Iona Heath's recent piece on 'conflicts of interest within England's NHS':

"Although definitions and guidance about what to declare are useful, the real challenge facing individual clinicians and employers is to find a way to declare interests in a practical and meaningful way. "

I couldn't agree more and the BMJ has often written some very coherent stuff on conflicts of interest.  Therefore one would expect the BMJ to actually apply the same rules to itself and the studies it chooses to publish.  Sadly when applying the rules to the Freemantle 2015 study, the BMJ has been found to be sadly lacking.

Since the publication of the Freemantle 2015 study in the BMJ much evidence has emerged.  It is now apparent that the commissioning of the study came directly out of NHS England's 7 day service work and involved NHS England's senior leadership including Simon Stevens.  The private firm Deloitte were also involved.  None of this was declared by the authors, and the evidence demonstrates that Bruce Keogh was fully aware of this situation and the fact that the study had not simply come from just his request, but had involved the senior leadership of NHS England including Simon Stevens.  Notably the DH were also intimately involved in this process and kept very well up to date on the 'research' on which Jeremy Hunt later relied, labelling it 'independent'.

The BMJ has still not acted to prevent readers from being misled by the overt failure of the Freemantle authors to adequately declare who actually commissioned the study.  The full political context to the study's commissioning is vital in its interpretation.  This failure is a clear breach of the BMJ's guidance to authors, this being that of the ICMJE.  Whether issuing an adequate erratum or retracting the study, the BMJ should act and their failure to do so smacks of hypocrisy, they frequently hold others to such high standards but when dealing with the Freemantle authors they appear to be ignoring their own rules.

Monday, 13 March 2017

My thoughts on physician associates et al

I read the latest edition of JTO with interest and noted the comments from the Editor regarding 'physician associates', as well as the feature by Anandu Nanu.  Certainly it is possible that other allied healthcare professionals can be used to provide valuable service and this can potentially improve the training of junior doctors; perhaps medical support workers can be more cost effective and useful in this regard than physician associates, as much potential junior doctor training time is wasted doing many lowly skilled bureaucratic tasks.

The significant underlying barriers to improving training remain unaddressed by the introduction of more allied staff however.  The fundamental root problems include government enforced austerity, the resultant widespread NHS deficits, huge budget cuts to HEE and an unfunded service expansion being pushed amidst a drive for an utterly unachieved £22bn of 'efficiency savings'1-4.  Then combine this government ineptitude with a perfect storm in terms of an unpopular inadequate new junior doctor contract which is only catalysing a marked deterioration in junior doctor recruitment and retention5,6.  The overall result is an inevitable deterioration of the quality of surgical training. 

Training can only be improved with adequate government investment which may then both address the dire recruitment and retention of staff, as well as increasing staffing levels to absorb the less useful service provision currently performed by junior doctors.  In the current financial and political environment, the introduction of more allied health professionals can only be of benefit to training if they are in addition to the current workforce.  In the current environment it is far more likely that junior doctors will be replaced, rather than added to by these new staff; and this can potentially harm training further by increasing the burden on the remaining doctors.  Fundamentally without adequate funding, training quality is only going one way.


1.            CBS. Written evidence to the Public Accounts Committee by Cass Business School. February 18th 2016.
2.            PAC. Managing the supply of NHS clinical staff in England. Fortieth Report of Session 2015–16. 27th April 2016 2016.
3.            Dunn P MH, Murray R. Deficits in the NHS. The King's Fund. 2016;http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Deficits_in_the_NHS_Kings_Fund_July_2016_1.pdf.
4.            Campbell D. Secret documents reveal official concerns over 'seven-day NHS' plans. Guardian. 2016;https://www.theguardian.com/society/2016/aug/22/secret-documents-reveal-official-concerns-over-seven-day-nhs-plans.
5.            Campbell D. Almost half of junior doctors reject NHS career after foundation training. Guardian. 2015;http://www.theguardian.com/society/2015/dec/04/almost-half-of-junior-doctors-left-nhs-after-foundation-training.
6.            Dean b. The new junior doctors' contract will create a staffing crisis in the worst possible places. Telegraph. 2016 2016;http://www.telegraph.co.uk/news/2016/04/28/the-new-junior-doctors-contract-will-create-a-staffing-crisis-in/.