Saturday February 27, 2010
The voice of doctors
Survey reveals pressure on juniors BY FLAVIA MUNN
Six months after full implementation of the 48-hour working week we talk to doctors about how it has affected them PAGE 10 Professor Sir John Temple talks about his role in the review of healthcare training under the shortened working week
JUNIOR DOCTORS are missing out on training opportunities because they are working excess hours to plug gaps in services, a BMA survey reveals. As a major BMA conference on the impact of the European Working Time Directive on training was taking place this week, research shows more than half of juniors are still working more than 56 hours a week. And the survey, which was carried out for the BMA junior doctors committee, reveals that one in three junior doctors is working in excess of an average of 65 hours a week, six months after the 48hour week was introduced in August 2009.
There is also evidence that juniors are being pressured to come into work during their time off to fill long-term gaps in rotas. Almost half of those surveyed reported missing out on training since August 2009. Half of this group reported that this was because they were covering rota gaps. JDC chair Shree Datta said: ‘The government would have us believe that the 48hour week has been successfully implemented in UK hospitals. ‘Our survey suggests that compliance has only been achieved by pressurising junior doctors into working off the clock.’ Dr Datta said rota design must be addressed to ensure juniors got the training they
An SAS doctor bucks the trend by becoming chair of a hospital medical staff committee PAGE 3 To get online daily news from the BMA and to download BMA News as a PDF log in to
Rota gaps are increasing with 41.3 per cent of respondents reporting vacancies in 2009, compared to 29 per cent in 2008. Specialty training posts in years three to eight are most likely to be vacant and emergency medicine is the most affected specialty Three in five junior doctors reported having to come to work during their rostered time off More than half of the 1,567 respondents to the survey have been being asked to provide emergency cover at less than 48 hours notice and 12 per cent of these trainees have been asked to do so on more than ten occasions Of those who had missed out on training, three quarters reported missing lectures and training days and six in ten had missed supervision and opportunities to complete new procedures Two in five respondents have come into work in their free time to receive training.
THIS WEEK’S issue is guest edited by BMA junior doctors committee chair Shree Datta (above) and focuses on the European Working Time Directive. It includes:
Guest editorial, page 2 Off the record, page 6 News plus, page 6 BMA view, page 6 Doctors decide, page 9 Feature, page 10
Call to join march against privatisation BMA MEMBERS are urged to join a rally against the privatisation of the welfare state and cuts in services. The association’s Look After Our NHS campaign will join other public service unions at the march which takes place in London on April 10. BMA council chairman Hamish Meldrum will be among the speakers at the rally afterwards.
BMA steps in after students report job-allocation mistake 2
FROM THE CHAIR OFF THE RECORD
BMA News is a supplement of BMJ Vol: 340 No.7744
How training is sacrificed to fill rotas
doctors’ rotas due to annual leave, maternity, out-ofprogramme opportunities and the NHS is extremely adept at managing this to ensure patient safety at all times.’
THE ACHIEVEMENTS of 100 NHS scientists in England have been celebrated in a Department of Health-funded book called Extraordinary You — Healthcare Science. The stories and portraits of scientists who have made breakthroughs in areas ranging from artificial limbs to the human genome fill the book. Among them is Val Davison, head of the National Science School of Genetics and the regional genetics lab in the West Midlands (pictured). Her reorganisation of labs in Birmingham saved £1m that was invested in a new breast cancer genetic service. Health minister Ann Keen said the project was designed to recognise achievements and encourage young people to take up jobs in healthcare science. BMA medical academic staff committee co-chair Peter Dangerfield said it was good to recognise scientists but warned that proposals to raise tuition fees would put students off studying medicine and science at university.
Family doctors are warning that plans for community health reform could damage patient care PAGE 2
required while a safe level of patient care was maintained. She urged trusts to work with junior doctors on this. A DH spokesperson said: ‘There will always be gaps in
SEE ONE, DO ONE
STANDING UP FOR DOCTORS
THE BMA has taken action to ensure foundation programme applicants are not disadvantaged by problems with the allocation of jobs. On February 19 the BMA began to receive reports of potential problems with the allocation of jobs for foundation house officer 1s. There was a particular difficulty with posts organised through the NETFS (North East Thames Founda-
tion School) and mainly involving students from Barts and the London Queen Mary’s School of Medicine and Dentistry. A small number of students at two other medical schools have also reported problems. The BMA medical students committee is still finding out exactly what has happened but it appears that mistakes were made in
calculating or reporting the academic quartile scores of 34 students at Barts. This meant that some medical students did not gain places at their first choice of foundation school, while others did not receive their preferred jobs. The BMA contacted the UKFPO (UK Foundation Programme Office) as soon as students began reporting the problems. It has also spoken
to the NETFS. The association is continuing to monitor the situation at other schools. In a statement, MSC cochairs Tom Foley and Nicholas Deakin said: ‘In all cases we have applied significant pressure on these bodies and told them that the situation is unacceptable.’ Students are being advised to keep an eye on the UKFPO website, contact their medical school directly
if they have concerns and email the MSC with any information. A joint UKFPO/NETFS statement said six students missed out on their first choice foundation schools. It added that the NETFS would work with other schools to ensure those students were placed in the school to which they had been allocated as vacancies arose as a result of withdrawals and finals fails.
2 NEWS FROM THE CHAIR TIME IS running out. By now, you should be aware of the announcement by HMRC (HM Revenue & Customs) about its intention to look closely at doctors’ income tax returns. There is a brief opportunity — until the end of March — for those who believe they may have underpaid, to own up and pay up, in exchange for a much lower penalty than normal. After this HMRC will use information it claims to have to target certain doctors. Those found to have underpaid tax will have to pay a penalty of up to 100 per cent of tax owing and interest on the outstanding debt. They could also face criminal charges, which could obviously have repercussions for those concerned in terms of the GMC. The BMA’s role in this is clear. It wishes to inform the profession of the HMRC’s plans but it will not support tax evasion, nor is it able to offer individual advice to members. If you are in any doubt, consult your financial adviser — soon.
Hamish Meldrum, BMA council chairman To contact a BMA adviser Tel: 0300 123 1233 8.30am to 6pm Monday to Friday, not UKwide bank holidays BMA Counselling & Doctors for Doctors Service For help, counselling and personal support, you can call 24 hours a day. Tel: 08459 200 169 Doctors Support Line Confidential peer support line staffed by trained volunteer doctors. Tel: 0844 395 3010 Www. dsn.org. UK BMA Charities Financial assistance to doctors and their dependants, whether BMA members or not. Tel: (020) 7383 6142 Email: Info. bmacharities@ boa.org. UK Doctors Support Network Self-help group for doctors with mental illnesses. Tel: 0871 245 8376 Www. dsn.org. UK The Cameron Fund Help and support for GPs and their dependants Tel: 020 7388 0796 Email: janeiro@ cameronfund.org.UK www.cameronfund.org.UK The British Doctors & Dentists Group Support for doctors recovering from alcohol or drug dependency. Tel: (020) 7487 4445 The Sick Doctors Trust Confidential intervention and treatment for doctors addicted to alcohol or other drugs. Tel: 0370 444 5163 www.sick-doctors-trust.co.UK Samaritans Tel: 08457 90 90 90 Email: email@example.com www.samaritans.org.UK
Doctors for Doctors
08459 200 169 and ask to speak to a doctor-adviser
An enhancement of the BMA Counselling Service giving doctors in distress or difficulty the choice of speaking in confidence to another doctor Doctor-advisers who work with the Doctors for Doctors Unit have agreed to provide their services on a voluntary basis and are not employees or agents of the BOA. Accordingly, the BMA cannot be held responsible for any acts or omissions by any of those doctor-advisers. Although the Unit works to ensure that the contact details of doctor-advisers are kept up to date, it cannot accept any responsibility should a doctor adviser not be available.
GPs warn community health plans will harm patient care
Figures reveal £16m bill for out-of-hours GP services
BY MIKE FOSTER
THE TRUE costs of OOH (out-of-hours) GP provision in Northern Ireland have been revealed. Health minister Michael McGimpsey’s written response to a question from Fermanagh and South Tyrone Social Democratic and Labour Party MLA Tommy Gallagher, reveals that OOH services cost almost £16m in 2007/08. Mr Gallagher asked Mr McGimpsey for a breakdown of the operational costs of each GP OOH service in each trust during the 12-month period. According to the figures, the Western Health and Social Care Trust paid the most for the services — £5.4m. The Southern Health and Social Care Trust paid the least for OOH at just under £3.2m. BMA Northern Ireland GPs committee chair Brian Dunn said: ‘For a long time the government estimated the OOH service was worth about £6,000 per GP.’ He added: ‘GPs were telling them the cost was much more than that, but government didn’t believe them and it has proved correct [GPs have been vindicated] in recent years since the implementation of the new GP contract.’
PLANS FOR the future of community health services are being pushed through too quickly and will damage patient care, GP leaders have warned. BMA GPs committee chair Laurence Buckman said PCTs across England had accelerated plans to make district nurses, health visitors, physiotherapists and other community health staff work in new structures, such as social enterprises, private companies or hospital trusts. Dr Buckman said financial pressures meant the TCS (Transforming Community
Services) plans were being pushed through ‘very, very fast’, with no input from GPs or local medical committees. He said: ‘Because of the economic situation there has been enormous pressure on PCTs to get on with it very quickly.’ The changes will be implemented in March 2011 but the plans have to be finalised next month. The GPC has released a statement calling for NHS organisations to keep control of community services, such as care for older people, child protection and terminal care. The committee’s statement says: ‘Moving community
health services to organisations outside the NHS risks the fragmentation of services, goals no longer being shared, and instability in vital services.’ The statement adds: ‘The government has recently stated that the NHS is the preferred provider. Social enterprise organisations may be “not for profit” but are outside the NHS.’ The Department of Health launched the TCS programme in January 2009. NHS chief executive David Nicholson gave PCTs a more flexible timetable for the reorganisation in July 2009, but The Operating
Framework for the NHS in England 2010/11 says that future forms of PCT-provided community services have to be agreed by strategic health authorities by the end of March. A DH spokesperson said: ‘Ultimately what matters to patients is whether they receive safe, high-quality care and treatment, not whether it is provided by a PCT, social enterprise or NHS trust.’ The spokesperson added: ‘Social enterprises have a long, successful history of providing responsive, personalised services, often to some of the most vulnerable people and communities.’
Scotland urged to join fair trade push THE BMA has called on the Scottish government to follow England and draw up guidance on ethical procurement in the NHS. The association has warned that many supplies used in the NHS, such as surgical instruments, are produced in dangerous working conditions, sometimes using child labour. But while the BMA is working with the NHS in England to produce guidance on ethical purchasing, to be
published shortly, the NHS in Scotland has yet to follow suit. At the start of Fairtrade Fortnight, which runs until March 7, BMA medical fair and ethical trade group adviser Mahmood Bhutta said: ‘There is evidence to suggest that many supplies used in the NHS are produced in unhealthy, unsafe and unfair working conditions. ‘It seems perverse that labourers around the world are risking their lives to
HARSH CONDITIONS: making surgical instruments in Sialkot, Pakistan
supply us with equipment to save British lives.’ He said that many surgical instruments were made in Pakistan, where people worked 12 hours a day, seven
days a week, with some suffering injuries due to poor health and safety standards. ‘We want to work with the NHS and the industry to make positive changes,’ he added.
BMA NEWS GUEST EDITORIAL ‘Any incoming government must work with employers to ensure hospitals are fully prepared’ WE ARE are now six months into full implementation of the EWTD (European Working Time Directive), so it seemed an appropriate theme to take when I came to guest edit BMA News. The directive has been a key concern for doctors at all levels for quite some time, and it is crucial to review the initial impact it has made — both on junior doctors and those working with them. The EWTD is vital health and safety legislation but the implications for good-quality training and service provision are only beginning to reveal themselves. Junior doctors have valid concerns about the continuity and quality of their training — an issue that is essential not only for juniors but also for the patients we care for. The directive has provided an opportunity to review the delivery of junior doctors’ education and to find realistic solutions to concerns about training across all specialties. High standards can be maintained and training improved by focusing on training provision more efficiently, and we hope that this is considered in more depth at the BMA EWTD and Training Conference, which takes place this week.
bma news Saturday February 27, 2010
Despite having almost 11 years to prepare, we have seen derogations from the regulations, which have been an unfortunate necessity for some underprepared services. Any incoming government must work with employers to ensure hospitals are fully prepared and compliant when the derogation period comes to an end. Redesigning junior doctors’ rotas in order to accommodate the need for training, service provision and the working hours stipulated by the EWTD remains a key factor in achieving these goals. It is essential to involve juniors in the redesign. The BMA junior doctors committee has run a campaign to highlight the benefits of the current junior doctors contract, which aims to support those undergoing changes in their rotas or pay banding, and a further campaign is planned for later this year. One of the possible solutions the JDC has considered, given the changes that the EWTD has brought, is negotiating a new contract. The merits of this in the current financial climate need to be considered very carefully, bearing in mind that the
changes are likely to be implemented in the very distant future. I have no doubt that in the next few months junior doctors will experience more challenges as the full effect of the EWTD becomes clear. However, I hope that we can make the most of this opportunity to reflect and improve the quality of our training — which will have a real impact on patient care. Find out more at www. bma.org.uk/ contractcampaign The BMA News EWTD and Training Conference Forum is at www.bma.org.uk/ ewtdtrainingconference
Shree Datta is BMA junior doctors committee chair
BMA on guard for private-sector sweeteners THE BMA will be watching to see whether private firms are offered sweeteners to take over a debt-laden hospital. Hinchingbrooke Hospital in Cambridgeshire, which has debts of around £40m, is set to become the first UK hospital to be run entirely by a private company after the only remaining NHS bidder for its contract dropped out.
IT meltdown plans alert DOCTORS HAVE called on NHS trusts to ensure they have emergency plans in place for major IT problems. The call came after BMA News learnt that the IT systems at West Middlesex University Hospital were infected with a virus on February 11. Consultant work was disrupted as a result. Consultant member of the BMA NHS IT working party Paul Flynn said: ‘Trusts must plan for these worst-case scenarios so that clinical care is not compromised.’ A hospital spokesperson said: ‘Shutting our network caused some operational problems, but we implemented our business continuity plans and operated manual systems as part of our standard contingency plan.’
Warning over obesity legacy THE BMA has warned of the danger of raising generations of people with chronic conditions if tough action is not taken to tackle obesity. Doctors leaders made the call as the Scottish government published its obesity strategy, and ahead of a Scottish Parliament debate on the issue this week. BMA Scottish GPs committee chair Dean Marshall said: ‘The BMA has been lobbying the government for some time to take action on this issue in order to achieve a real improvement in the future health of our children.’ The Scottish government strategy, Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight, outlines cross-government and agency plans to make healthy choices easier. See www. scotland.gov.uk/publications
CUH (Cambridge University Hospitals NHS Foundation Trust) pulled out last week, saying the time and money taken up by the bidding process risked affecting its other services. Five private companies are now vying to run the hospital
on a contract lasting seven to ten years. BMA central consultants and specialists committee chair Mark Porter said he was convinced the private bidders would not have to shoulder the same debt burden that would have been expected of a public sector body, and that the bidding process was loaded against NHS bidders.
He said: ‘The reason why CUH walked away from taking on Hinchingbrooke is the debts it comes laden with. ‘I would be very surprised if the private bidders will be faced with the same conditions … We will be looking carefully at the contract.’ He added that care could suffer because of corporate obligations to shareholders.
Hospital staff choose SAS doctor as leader BY ANITA WILKINSON THE ELECTION of an associate specialist to represent permanent medical staff at a hospital has been hailed as ‘an outstanding achievement’ by doctors leaders. Laurie Baxter is one of the first staff and associate specialist doctors to be chosen as chair of a hospital MSC (medical staff committee) — a post traditionally held by a consultant. The ENT doctor takes up the post at Derriford Hospital in Plymouth in September. She is currently deputy chair of the committee. Dr Baxter said she felt honoured to be elected by the consultants and SAS doctors at the hospital. She told BMA News: ‘I look forward to continuing many of the new projects that the chair, secretary and myself started to revitalise the hospital MSC.’ BMA south-west regional SAS committee chair
BAXTER: ‘has advanced the role of women in medicine’
Jonathan Alper congratulated Dr Baxter on her election. ‘This is an outstanding achievement for an SAS colleague, and speaks volumes for Laurie’s qualities,’ he said. ‘Laurie has made significant contributions to the development of SAS doctors and the specialty of ENT. She has advanced the role of women in medicine.’ BMA industrial relations officer Richard Griffiths
also welcomed Dr Baxter’s election. He said: ‘There are MSCs out there that don’t allow SAS doctors in their meetings, let alone elect them to the chair.’ Plymouth Hospitals NHS Trust chief executive Paul Roberts said: ‘To be appointed chair of the hospital MSC is a fantastic achievement and is testament to Laurie’s commitment to healthcare in the South West, particularly at Plymouth Hospitals.’ Dr Baxter was previously BMA south-west regional SASC chair and was a key organiser of the inaugural joint royal college conference for SAS doctors last month. She is also chair of the SAS group of ENT UK, the representative body of head and neck doctors, and she sits on the equivalence committee for article-14 applications to the Royal College of Obstetrics and Gynaecology.
Call for eating disorder media code Psychiatrists have called for an editorial code to stop eating disorders being ‘glamorised’ by the media. To coincide with Eating Disorders Awareness Week, which runs until February 28, the Royal College of Psychiatrists Eating Disorders Section has called for the use of more diverse body shapes in programmes and publications. The college said the government should establish a forum, with media, advertising, health and political representatives, to tackle the issue.
Book now for consultant seminars Free seminars offering consultants advice on everything from pensions to revalidation are being run by the BMA. The Met Hotel in Leeds will host the first event on March 31. It will be a one-day programme offering sessions that will include job planning and clinical excellence award workshops. The second event, with the same programme, will take place at BMA House, London, on April 21. To make reservations or request more information, email firstname.lastname@example.org. See www.bma.org.uk/employmentcourses for more details.
Hospital infection strategy updated A new strategy and action plan to reduce and control the spread of healthcare-associated infections has been launched. Northern Ireland’s Department of Health, Social Services and Public Safety has updated its 2006 strategy Changing the Culture in an attempt to drive down levels of infections in the country’s healthcare facilities further. The updated strategy complements the Northern Ireland health trusts’ action plans on healthcareassociated infections, which aim to implement all the recommendations of Northern Ireland’s Regulation and Quality Improvement Authority’s review of the C difficile outbreak that took place at Northern Health and Social Care Trust between June 2007 and August 2008.
MPs urge end to homeopathy cash The NHS should stop funding homeopathy because there is no evidence the treatment works, MPs said this week. The Commons science and technology select committee report Evidence Check 2: Homeopathy says the Medicines and Healthcare products Regulatory Agency should not license homeopathic products because they are not medicines. The government accepts there is no evidence of homeopathy’s efficacy but continues to fund the treatment because of its placebo effect. In 2008, the BMA called on the National Institute for Health and Clinical Excellence to examine the cost-effectiveness of homeopathy and to decide whether it should continue to be funded by the NHS. See www.parliament.uk/parliamentary_committees/science_ technology/s_t_homeopathy_inquiry.cfm
BMA News BMA House Tavistock Square London WC1H 9JP Editorial Tel: (020) 7383 6122 Fax: (020) 7383 6566 Advertising Tel: (020) 7383 6181 Fax: (020) 7383 6556 Call a BMA adviser: 0300 123 123 3 Email: email@example.com Editors Carol Harris/Caroline Winter-Jones Deputy editor Neil Hallows News editor Lisa Pritchard Senior writers Edward Davie, Mike Foster, Flavia Munn, Anita Wilkinson Feature writer Polly Newton NI correspondent Lisa Smyth 07766 527604 Scotland correspondent Jennifer Trueland 01877 384337 Wales correspondent Felicity Waters 07762 167553 Chief subeditors Emma Small/Rebecca Thomas Deputy chief sub-editor Ben Skelton Sub-editor Chris Patterson Art editor/production manager Fiona Edwards Advertisement production Sean Johnson Marketing and Editorial officer Wendy Barford
HELPING HANDS: Cornwall GP Jane Nash (pictured centre) helps to unload shelter kits for Haitian earthquake survivors in advance of expected spring rains. The kits from charity ShelterBox contain tents (pictured inset), stoves and blankets. Dr Nash, who has just returned from Port au Prince, said the importance of the tents could not be overestimated. She said: ‘The look on one woman’s face when I gave her a tent was like it was the best thing she had ever had.’ See www.shelterbox.org/ and www.bma.org.uk/international/haitiemergency.jsp
BMA News is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £97 (UK), €131 (Eurozone), $189 (USA) per year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise, without the written permission of the editor. Printed by Precision Colour Printing Limited. All advertisements in BMA News are subject to the standard conditions of acceptance of advertisement orders printed on the rate card. A copy may be obtained from the publishers on written request.
bma news Saturday February 27, 2010
4 NEWS •
BMA WELSH LMCs ANNUAL CONFERENCE
Surgeries urged to abolish half days All surgeries, except single-handed and small practices, should not close for a half day during the week, the BMA Welsh LMCs annual conference has heard. GPs in Wales said ending the traditional half-day closure would ensure patients had reasonable access to GMS (general medical services). The conference agreed that practices should have a ‘doors open’ policy for almost all of the GMS-contracted hours of 8am to 6.30pm, Monday to Friday. Morgannwg LMC secretary Ian Millington said doctors needed to be ‘realistic’ about access. Guidance published by the BMA Welsh GPs committee in January encourages practices, except single-handed ones, to open all week and states that patients should have telephone access throughout the day.
Call to up mental healthcare access GPs in Wales have condemned wide variations in access to mental health services and demanded better direct access to therapeutic services for their patients. ‘GPs only have access to CBT [cognitive behavioural therapy] and other treatments through psychiatrists,’ said Morgannwg GP Steve Rix. ‘The National Institute for Health and Clinical Excellence is telling us to access therapies [such as] CBT but we have no way of accessing them, and then we are criticised for over-prescribing medication. Waiting times to see psychologists in Swansea are well over 12 months. The service isn’t there.’ Doctors also called for better information from secondary care colleagues who discharge patients with incomplete information.
Delay in help for medics ‘scandalous’ Continuing delays in setting up a full occupational health service for GPs in Wales were described as ‘scandalous’. Doctors praised the work of the PCSS (Primary Care Support Service), which supports Welsh doctors, but said a full-time service offering comprehensive provision, such as counselling and workplace risk assessments, was now urgently needed. Pontypool GP David Grant said: ‘Enough is enough. The PCSS deserves applause but scrimping and saving cannot and must not continue.’ BMA Welsh GPs committee chair David Bailey said plans were under way for the PCSS to be taken under the wing of Public Health Wales by the end of the year and he welcomed the prospect of future funding for a full service.
BMA WELSH LMCs ANNUAL CONFERENCE
BMA WELSH LMCs ANNUAL CONFERENCE
Doctors accuse health boards of withholding service funds Felicity Waters reports from the BMA Welsh local medical committees annual conference in Llandudno
GP PRACTICES across Wales are losing out on thousands of pounds for enhanced services because LHBs (local health boards) are not passing on funding from the Welsh Assembly government. Doctors gathered at the BMA Welsh local medical committees annual conference in Llandudno last week called for an investigation by the assembly into how the money was being spent. They also demanded that the assembly issue a directive to health boards to stop the funding of ‘quasi’ enhanced services, such as patient transport, and to identify how much money
had been diverted from primary care to other areas. Carmarthenshire GP Heather Evans said enhanced services money in her health board area had been spent on other things including specimen transport and out-ofhours services. Dr Evans said patients were being deprived of services. ‘We have repeatedly pointed out to the health board that they can’t do it,’ she told representatives. ‘They agreed that they wouldn’t use enhanced services money, but a year later we found that they were. ‘The time has come for the [BMA Welsh] GPs committee to approach the Welsh
BAILEY: LHBs are misusing funds
Assembly government to investigate how LHBs have been using enhanced services money. We must have some sort of accountability.’ The assembly government agreed in 2008 to fund a £6.4m pot for directed enhanced services — services GPs could use according to the needs of their own community. These include diabetes care, work in nursing
homes, extended hours and support for the homeless and asylum seekers. However, doctors are angry that much of this funding is not reaching many surgeries for the purposes it was intended. Welsh GPC chair David Bailey said: ‘LHBs are not doing what they have been asked to do by the minister. LHBs have ridden coach and horses through the principle of the basket and are refusing to use the money for which it was allocated.’ A Welsh Assembly government spokesperson said: ‘The agreement with GPC Wales on enhanced services was not reached until half way through the financial year 2008/09. That made it difficult for LHBs to spend their full allocations.’
GPs demand patients take priority in drive to reduce waiting-time targets DOCTORS HAVE criticised the ‘gaming’ involved in meeting RTT (referral-totreatment) waiting-time targets in Wales. GPs called on the Welsh Assembly government to ensure that LHBs (local health boards) had safeguards in place to ensure that no patients were ‘lost to the system’ in the quest to meet waiting time targets. GPs also demanded that
if patients were removed from waiting list figures or had their appointments cancelled that both they and their doctors would be told the reasons why. Morgannwg GP Sean Young said: ‘I support the principles of RTT but games are being played and the systems employed are becoming more difficult for patients to navigate. Patients don’t know where they stand; not know-
ing they’ve been off-listed and for no apparent reason.’ Dr Young said he was also concerned that chasing targets was having a knock-on effect on other services, such as follow-up clinics being cancelled in order to meet first appointment targets. ‘Patients are now being advised to get referrals rather than sticking with getting a follow-up appointment,’ he added.
Doctors agreed GPs should be encouraged to submit a significant event report to their LHBs if any patients were exposed to unacceptable risks or came to harm. They also called on LHBs to ensure that RTT targets did not affect appointments for patients with chronic conditions needing long-term follow-up.
OFF THE RECORD ... WALES
‘Goodwill is the only thing sustaining many hospital services’
ON PAPER Wales is compliant with the EWTD (European Working Time Directive). A maximum 48-hour working week for all junior doctors is being enforced in hospitals in Wales but, with the continuing shortage of doctors, many are asking: at what cost to those on the frontline? It is six months since new legislation was introduced to restrict the working week of junior doctors. However, behind the scenes, the daily struggle to staff wards continues. Somehow rotas get filled, usually by colleagues not wanting to let each other down, but sometimes, by less polite means, this is resulting in study leave being sacrificed and little or no time for trade union activities. The Welsh Assembly government insists that all rotas in NHS Wales are compliant with the EWTD but they say they are aware that
bma news Saturday February 27, 2010
vacancies in some specialties are making it difficult for local health boards to maintain that compliance. They are in the process of monitoring those rotas. BMA Welsh junior doctors committee chair Dai Samuel says members are reporting the same concerns as six months ago when the EWTD came into force — gaps in rotas and constant pressure to fill them. ‘We have already seen services closed or reduced in hospitals and have to be moved where there are staff,’ he says. ‘People are going to have to go further for their treatment.’ BMA Welsh staff and associate specialists committee chair Ram Kumar says the problem is not the EWTD per se but the chronic shortages of staff, particularly SAS grades. He also says the problem is worse now than it was last August.
Rotas may be compliant, he says, but continuity of care is suffering because of the number of locum doctors being used to fill them. He insists that the only solution is to give doctors more incentives to work in Wales. ‘We have got to find new ways of encouraging more doctors to come to work in Wales making it the destination of choice rather than elsewhere,’ Mr Kumar says. The assembly government is working with the BMA and the Wales Deanery to recruit more doctors to Wales in the long term but the chronic short-term shortages of junior and SAS grades is impacting heavily on morale. Doctors on the frontline in Wales say that goodwill is the only thing sustaining many hospital services. This, they say, cannot be taken for granted for much longer. Felicity Waters
Regulator seeks feedback on fitness-to-practise proposals BY FLAVIA MUNN A MAJOR CONSULTATION will be launched next week into the working details for plans to ensure doctors are up to date and fit to practise. On March 1 the GMC will launch a three-month consultation to gauge the views of the profession, employers and patients on revalidation. In the first step towards revalidation, more than 218,000 doctors were given licences to practise in November. Last year, it became law for all UK doctors who wished to practise to be registered with the GMC and to have licences. Now the GMC wants to hear what the profession
and the public think of revalidation before the process is introduced nationwide in phases starting next year. The BMA intends to respond to the consultation. Launching the consultation document Revalidation: The Way Ahead, GMC chair Peter Rubin said: ‘It’s [doctors’] opportunity to say “this looks OK” or “it looks too bureaucratic”. ‘We are very conscious that revalidation must work at the frontline with doctors, which is why we have been keen to make it as devoid of red tape as we possibly can.’ The consultation will focus on four main themes: How revalidation will work: the process by which final recommendations about
doctors will be made to the GMC by designated responsible officers What doctors and employers will need to do. The consultation will consider aspects of appraisal and assessment, specialty standards developed by the medical royal colleges, the role of continuing professional development in revalidation, and multisource feedback The role of patients: how their feedback on the performance of doctors will be included in the revalidation process How and when revalidation will be introduced. The Department of Health-funded revalidation support team is running
‘pathfinder pilots’ in ten locations in England this year. They will test the key components of revalidation among more than 3,000 doctors in a variety of specialties. One pilot in the West Midlands will focus exclusively on the role of the responsible officer; the other nine will test the responsible officer role as well as proposals for a strengthened appraisal system, and the function of the medical royal colleges and faculties in revalidation. Similar pilots are planned for the devolved nations. Separately, Wales is currently trialling an appraisal system for hospital doctors based on the existing computer-based GP model.
Doctors back scan firm’s advert ban RADIOLOGISTS HAVE welcomed an advertising watchdog’s decision to uphold complaints against a television commercial advertising unnecessary CT scans. The Advertising Standards Authority effectively banned the ad, after two consultant radiologists complained that it made no mention of the risks of scans. CCSC radiology subcommittee chair Tom Kane said: ‘We are very pleased that the ASA accepted the Committee on Medical Aspects of Radiation in the Environment assessment that the adverts did not warn of the dangers of exposure to radiation … We have long campaigned for better regulation of private companies subjecting the “worried well” to unnecessary scans.’ Dr Kane said that the ruling would inform Health Protection Agency recommendations for a new legal framework for CT scans. Lifescan chief executive Claire Barlow said: ‘We are very disappointed that the ASA has adjudicated in this way … Our service is strictly monitored [and] performed according to internationally recognised clinical protocols.’ www.bma.org.uk/bmanews
Aid-funding deadline imminent The deadline is approaching for applications for funding to support doctors’ humanitarian work. The Humanitarian Fund, which is administered and largely funded by the BMA, has £25,000 to assist healthcare projects set up by NHS staff in developing countries. The deadline is 5pm on March 5. See www.bma.org.uk/developingworld and email firstname.lastname@example.org.
Swine-flu infections remain low New cases of swine flu are at their lowest level since the H1N1 virus first emerged in the UK, according to statistics released last week. In his bulletin on the illness, CMO (chief medical officer) for England Professor Sir Liam Donaldson says the Health Protection Agency estimated that the number of cases in the week ending February 14 was below 5,000, in keeping with the previous eight weeks. The number of people receiving antiviral drugs within the same period was 667. Sir Liam added: ‘Vaccination is the best way to protect against the risk of serious complications from the pandemic flu virus that is expected back in this country later this year.’ Read the CMO’s bulletin at www.dh.gov.uk/en/News/Recentstories/DH_112794
Chief of adjudication office named The first chief executive of the body that will oversee fitness-to-practise cases has been appointed. Former prisons ombudsman Stephen Shaw (pictured) will take the helm at the OHPA (Office of the Health Professions Adjudicator) in May. From 2011, the OHPA will adjudicate on fitness-to-practise cases involving doctors, opticians and optometrists. The GMC and the General Optical Council will continue with their other regulatory roles. Mr Shaw said: ‘The establishment of the OHPA represents a great opportunity both to enhance public confidence in the health professions and to deliver a lean and consistent adjudicatory process in fitness-to-practise cases.’
TV ad targets armchair sports fans
LIFE SUPPORT: celebrities from BME (black and minority ethnic) backgrounds are backing a campaign to enlist organ donors of South Asian and African-Caribbean origin. Pictured, from left, are television presenter Ama K Abebrese, pop stars Jaya and Jay Sean, and broadcaster Sonia Deol. Britons with South Asian and African-Caribbean backgrounds are three times more likely to need kidney transplants than the rest of the population, yet only 1.2 per cent of people from South Asian backgrounds and 0.4 per cent of people from African-Caribbean communities are on the NHS Organ Donor Register.
A TV advertising campaign has been launched to encourage people to lose weight. It is part of the Department of Health’s Change4Life initiative, and will urge adults to make simple diet and lifestyle changes. Using the slogan ‘Swap it, don’t stop it’, it will encourage people to change their behaviour by, for example, taking part in sports they like to watch and eating brown rice instead of white. See www.nhs.uk/Change4life
JUNIOR DOCTORS: is the EWTD affecting your training?
Students told ‘don’t forget your roots’ WELSH STUDENTS who leave the country to study medicine are being encouraged to return to train as doctors, as part of a major BMA campaign to entice talent back to Wales. The We’ll Keep a Welcome (Pleidiol Wyf I’m Gwlad) campaign will be launched on March 1, St David’s Day, and aims to encourage Welsh undergraduates at English, Scottish and Irish medical schools to return to Wales for training and work after graduation. BMA Cymru Wales plans to contact all schools in
Wales in a bid to reach out to prospective medical students before they go to university. Students will receive packs, which will include letters from the BMA and from Welsh postgraduate dean Derek Gallen, as well as information about training in Wales, and posters to put up in medical schools. There are severe shortages of junior, staff-grade and associate specialist doctors in Wales, and the campaign is part of a major drive to retain talent and boost numbers. A letter to students by BMA Welsh secretary
Richard Lewis, who studied in Leeds before working as a GP in Bridgend, says: ‘Enjoy what your medical school has to offer; enjoy new cultures; make the most of your student days. But don’t forget your roots. When the time comes to decide on your placements, we at BMA Cymru Wales and the Welsh Deanery would be delighted to offer any advice and help.’ The campaign has a virtual group on the social networking website Facebook. See www.facebook.com/home.php?#!/group. php?gid=438985125108
Have your say on our web forum, with topics including: Training challenges within surgery
Learning from flexible training
Rota design and training
Ways of assessing when training is good
These topics tie in with workshops at the EWTD and Training conference being held by the BMA on February 26 and your comments will be an important contribution to what is discussed on the day. Go to: www.bma.org.uk/bmanews To register with the BMA website go to www.bma.org.uk/register
bma news Saturday February 27, 2010
Man on a mission The impact of a 48-hour working week has led to claim and counterclaim about damage done to junior doctors’ training and NHS services. Flavia Munn reports on one man’s intention to find out if the effect has been negative or positive
TEMPLE: seeking to present a ‘snapshot’ of the effect of the EWTD on training
Qualified for the job AS SPECIAL adviser to the chief medical officer for England, Sir John Temple was responsible for introducing the Calman reforms to higher specialist training from 1995. He was also the Conference of Postgraduate Medical Deans chair and chaired the Medical Workforce Review for Scotland, which was commissioned by the Scottish Executive and led to the publication of Future Practice in 2002 and Securing Future Practice in 2004. Sir John was knighted in 2003 for services to medicine and medical education and holds honorary fellowships, or the equivalent, of 14 colleges and associations in ten countries.
ROFESSOR SIR John Temple describes his role in leading an independent review of healthcare training under a shorter working week as one of an ‘honest broker’. He will be listening to and not provoking debate while searching for a balanced view on delivering training for doctors and other healthcare professionals within a 48-hour working week. The past president of the Royal College of Surgeons of Edinburgh was appointed to chair the review by NHS: MEE (Medical Education England) last October and will hear opinions on the effect of the EWTD (European Working Time Directive) on training from a number of organisations, including the BMA. NHS: MEE is the independent body that advises ministers on medical education, training and workforce matters and on which the BMA is represented. Sir John says he will not be asking leading questions of those who come to share their thoughts on the EWTD. ‘I am not challenging them; I am not debating with them. It’s for them to come and talk to us about what they think about it,’ he says.
Four key questions The review was commissioned by former health secretary Alan Johnson in response to concerns raised by trainees and trainers about the impact on the quality of training of last August’s move to a 48-hour week. It will look at the training experiences of four groups of healthcare professionals — doctors, dentists, healthcare scientists
and pharmacists, and it will seek to answer four key questions: How should high-quality training be defined? What has the impact of the introduction of the EWTD been on the quality of training? How has the healthcare system responded since the introduction of the EWTD, with regard to the provision of training? What can be learnt from national and international experience? Evidence will be taken from dozens of different organisations from the four professions to inform the recommendations for action. Among those will be the Royal College of Surgeons of England, which welcomes the review and has been vociferous about what it sees as the detrimental impact of the EWTD on surgical training. Workforce issues are central to the debate raging around the EWTD, particularly how the move to a 48-hour week has exacerbated rota gaps. But Sir John’s review will cover neither service issues nor the implementation of the directive. He says: ‘The question is: what is the impact of the EWTD regulations on the training of doctors, dentists, pharmacists and healthcare scientists? ‘It’s a snapshot; it’s not a longitudinal study. It’s to find, in particular, what has happened since August 2009 when working hours were reduced from 56 to 48 hours.’ Sir John has appointed a small team —
the EWTD Expert Group — from within NHS: MEE to provide expert assistance, and a team from management consultancy company PA Consulting to help with the administration of the review. ‘I have put around me a very small group of experts from various walks of life, from medicine, dentistry and so on. They may hold official positions, but when they sit around my table they leave their flags outside the door,’ he says. ‘They include a postgraduate dean, a trust chief executive and a senior human resources director, two doctors in training — one from the BMA and one from the Academy of Medical Royal Colleges — one [person] representing pharmacy, dentistry and healthcare scientists. They are advisory and we are meeting regularly with them.’
of medicine or the training requirements within the legal maximum working week. There are many rota gaps, including in my own department, which leads to a continuous search for and dependence on locum doctors. This is hugely expensive, and locums who fill shortterm service gaps merely keep a service barely running, have poor training opportunities, and are far from an ideal means of operating a high-quality service. The thorny issue of post-EWTD rationalisation and reconfiguration of hospital services has not been tackled or managed properly within the NHS. Failure to manage the change will inevitably lead to service collapse in some geographical areas. It is essential that the BMA continues to warn that
doctors are not responsible for this; it’s the impact of a law designed to lead to a better quality of service for patients. To offer the highest quality service for patients and to provide the best training opportunities for doctors, we need to have a major realignment of services. It is all too easy to be parochial about acute hospital services, but we need to remind ourselves that we are the patients of the future, and we expect and deserve the best-quality treatment. There is more to healthcare than bricks and mortar. The vast majority of doctors are highly professional and dedicated: in spite of the EWTD, they do not clock on and off the minute shifts begin and end. What the BMA must ensure is that doctors are appropriately paid for the actual hours that they work, and are well
Airing opinions Earlier this year, Sir John sought the views of around 48 organisations connected to the NHS in the four professional areas including, from medicine; the medical royal colleges, the BMA, the GMC, NHS Employers, the Association of Surgeons in Training and the British Orthopaedic Trainees Association. The organisations were then invited to air their opinions in one-hour sessions, which took place throughout January and February. An extensive literature review of national and international publications has also been carried out for the review, by PA Consulting and health charity the King’s Fund. More than 40 articles relating to the impact of the EWTD on
By BMA council European Working Time Directive working party chair Peter Maguire
‘Post-EWTD reconfiguration of services has not been tackled properly within the NHS’
bma news Saturday February 27, 2010
FOR MANY years I have been an advocate and BMA leader on the issue of the EWTD (European Working Time Directive). The directive is health and safety legislation aimed at protecting doctors and their patients. The lead-in time for full implementation of the directive was more than 11 years, and I despair every day when I note that there has been inadequate planning and preparation for its legislative provisions. The NHS and its managers have talked plenty about the EWTD but not actually got to grips with how it is going to permanently change healthcare delivery throughout the UK and the EU. Training remains patchy since implementation of the directive, and insufficient measures have been taken in the NHS to protect the apprenticeship
‘All we are hearing about the EWTD are the downsides and we are not hearing the upsides’ the quality of training, found through searches of academic journals, books and reports, have been analysed. This work provided an initial evidence base for the review’s gathering of oral and written evidence. A draft report is due to be completed by the beginning of March. Sir John says: ‘We will then see what the issues are and use that draft to start formulating solutions. Then we will test those by inviting back the individuals or organisations to talk to us further. ‘If there are issues that need resolving there would be no point if we did this and did not come up with solutions.’ The report will be finalised and agreed by the EWTD Expert Group, with the aim of submitting it by the end of April to NHS: MEE, which will then consider Sir John’s recommendations at its meeting in May. NHS: MEE board members will decide what advice and recommendations to make to the health secretary. ‘We want to hear about their positive as well as negative experiences,’ Sir John says. ‘All we are hearing about the working time directive are the downsides and we are not hearing the upsides — there must be some positives about this. ‘When you change a system it cannot all be bad. We are looking for a principally balanced view.’ Doctors decide, page 9 Feature, page 10
FRONTLINE MEDICINE TALESTALES FROMFROM THE THE EMERGENCY DEPARTMENT EMERGENCY DEPARTMENT
WHY DO people write to newspapers to complain? Is it some form of revenge — getting their own back for a real or imagined slight? Do they want to ridicule or embarrass someone publicly? A trust decided, in response to a press enquiry, that it was right to acknowledge that emergency department staff were doing a good job and were working hard to achieve their access target. This had occurred miraculously and possibly with a little of what has elsewhere been described as creative accounting. If you are trying to imagine what a creative accountant looks like, he’s a man with a calculator, red-framed spectacles and a black T-shirt. Whatever the mechanism — and irrespective of whether it was achieved by installing some patients in empty cupboards in the nurses’ home and older ones on the children’s ward because they had shrunken enough to fit in cots with the sides up — the trust’s announcement had the effect of keeping the inspectorate at bay and the operations manager in a job for more than the usual six months. So, it sounded as if this could only be positive and the paper duly reported with the headline, ‘Trust achieving four-hour target’. The following issue carried a letter from a local councillor who thought it was a
out the night before, somebody with a baseball cap on backwards will kick it over’
Charles Lamb is a consultant in emergency medicine
SEE ONE, DO ONE
WORKING AND SURVIVING AS A JUNIOR DOCTOR
‘When all the clinical features do not just whisper towards death, but beckon it, there is no honour in fighting
trained to be the best possible doctors of tomorrow. It is very likely that the European Commission will open negotiations to revise the EWTD during 2010, but it will be some years before any new agreement (if one is ever reached) will be enacted into UK law. For now, we must make do with the situation that we have.
‘If I leave [my bin]
disgrace that 98 per cent of people had been treated in four hours — why weren’t we treating them immediately? The councillor, an elected representative who has just lost about 30 votes, doesn’t understand what he is talking about as he is normally responsible only for bin collections (and possibly street lights and social workers). I have to wait two weeks to get my bin collected, which can occur anytime from 6am onwards on a Thursday. If I haven’t left my bin out in time, I will have to wait for two more weeks for a second chance by which time it will be so full that the lid won’t close, and they won’t empty it. On the other hand, if I leave it out the night before, somebody with a baseball cap on backwards will kick it over and it won’t be collected because it would be against the council’s rules for one of its employees to stoop down to pick anything up. I will have to sweep up the mess and refill my bin after getting home from spending the day treating people with baseball caps on backwards, and I will have to wait for two weeks for another opportunity to have a ‘refuse technician’ tell me my bin is too full for him or her to empty. You will observe that this is considerably in excess of four hours. I see no alternative but to write to the local newspaper to complain about this ridiculous situation.
GENERAL MEDICAL wards always seem to host a number of patients who are dying. Some of the moribund are swiftly placed on the LCP (Liverpool Care Pathway) and die peacefully a few days later. Others, however, meet with resistance from the medical team; intravenous fluids may be slowed but blood tests and antibiotics continue during what will be their last weekend on earth. Being so new to this phenomenon, I often wonder where the hesitance comes from. Is it because we believe that by trying our hardest to save everyone, regardless of their predicament, we will rescue a few patients from the jaws of death? I am not aware of a quality adjusted life year analysis of those harmed versus those healed in these situations, but the law of diminishing returns is at play. Of course it must be an individual-by-individual decision-making process; sometimes playing against the odds is the right thing to do, an acumen that I have yet to acquire. But when all the clinical features do not just whisper towards death, but beckon it, there is no honour in fighting the irresistible. Perhaps, if we are honest, it is because the profession does not like to be embarrassed. I recently put a very sick, comatose woman in her mid-90s on the LCP in the morning, fearing that the raging infection that was not responding to
treatment would be her last, only to find her sitting up in bed later that afternoon eating cake and chatting. When the drugs that were poisoning her were stopped, she got better. Blush as I did when I heard the good news, it was obviously not a failure from the patient’s perspective, but a success. That same lady walked out of hospital to her own home a week later and, with parting thanks, offered me an open invitation to tea. It is unsettling and reassuring to know that this is not a rare event. Because the LCP does not harm patients and can be stopped as easily as it is started, doctors must risk being wrong; it is not just our pride that is at stake, but their lives. I am convinced that we live in an important era for end-of-life care. The LCP is bringing high-quality terminal care out of the hospice and into hospitals, nursing homes and the community: it is righting one of the key health inequalities of our times. The message is spreading that the LCP is a flexible way of ensuring that our most vulnerable patients get the care they need. Work is being done to facilitate the process, but perhaps doctors should aspire to what I am still painfully learning; when it comes to life and death, we must have the courage to be wrong. Robert Brodrick is a foundation house officer 1 in general medicine in East Sussex
See One, Do One is a 450-word column about life as a junior doctor. If you would like to submit an article for this column, use the details in ‘Write to us’ (see left). Payment is made for those published.
bma news Saturday February 27, 2010
I would like to congratulate the NHS on its bare-below-the-elbows policy, which has obviously had a dramatic effect on handwashing and infection control. But there appears to be a flaw in the system. I learnt about a ‘pets for therapy’ service. This involves man’s best but unclean friend wearing a short-sleeved yellow jacket and mingling with patients on the wards. I am all for this idea if it improves patients’ motivation and mental wellbeing. I just wonder how the infectioncontrol nurses will deal with this. Perhaps they will gamma-irradiate the dogs. If not, they could always have them exterminated, just like any junior doctor who dares to wear a long-sleeved shirt to work.
Recruitment reform overdue The comments in the recent BMA junior doctors committee Q&A about the recruitment responsibilities of deaneries may need taking further (BMA Q&A, February 13, 2010, page 6). When I was chair of the Association of Course Organisers/UK Association of Programme Directors, I called for an application form similar to that used by the university application service UCAS. I still believe that would be fairest for trainees. Whatever solution the deaneries come up with, however, it is unlikely to be enough. If trainees are not allowed to apply to individual schemes, they will not be treated in the same way as university applicants. The obvious way for a form to be completed would be to allow, say, four scheme choices and then an ‘order of deanery’ as a safety net.
PRIZE LE T TER
Who let the dogs in?
Roger Burns MB BS FRCGP Haverfordwest, Pembrokeshire
Peter Kenyon MB ChB MRCS(Ed) Liverpool
The chief executive of my medical defence organisation recently circulated a letter referring to the importance of strong relationships between doctors and patients in order to minimise investigations into medics’ practice. The doctor-patient relationship is evolving from a paternalistic model to one that is more patient-led. Despite this, the likelihood of doctors being investigated by the GMC has steadily increased. Does this mean we should return to paternalism? I don’t think so, but the strong relationship that is necessary between doctors and patients is typified by the confident doctor who offers clear guidance. Rebecca Thomson-Glover MB ChB MRCP Liverpool
Consultancy costs excessive The telephone directory of the hospital at which I work lists about 180 consultants and more than 200 managers. Not long ago, an initiative to investigate potential cost-savings within the trust led to the recruitment of more managers. In contrast, a large, local private hospital employs seven managers. It makes a profit, and has a good record for patient satisfaction. On a recent radio programme about the NHS, two human resources employees phoned in to talk about management consultants on the payrolls of their employers. One team of three had been charging £10,000 a day for
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bma news Saturday February 27, 2010
four years. Another individual had been charging £5,000 a day for three years. Does anybody who works with patients in the health service have any doubt that excessive management should be addressed? Enormous cost savings could be made without detrimental effect to patients. That would release a large amount of money that could be spent on recruitment and training of staff who would have direct patient contact. Name and address supplied
Managers not all bad Nikhil Kaushik’s pessimistic rant about management (Opinion, February 13, 2010, page 8) lacks insight. To imply that clinical agendas are universally superior yet always subservient to managerial and political ones is naive and simplistic. He is also wrong to suggest that clinicians working in management have nothing useful to contribute to patient care. No group has a monopoly on good or bad works. Clinical agendas might, for example, include jobs for the boys and the continuation of ineffective or unpopular services. Managerial agendas in such scenarios might rightly include redirecting resources to individuals and services more focused on improving patient outcomes. It is time to recognise that many players, not just frontline clinicians, contribute towards improved patient care. Marko Kerac MB BS MRCPCH London
Contractual chaos In order to know your contract, as the BMA junior doctors committee recommends, it is necessary to receive it before starting your post. That is something that all human resources people who I have had experience of as a junior doctor have found unreasonable. I worked in business before retraining in medicine as a graduate, and I have been constantly flabbergasted by the lack of opportunity for doctors to check contracts, rights and responsibilities before they start jobs. In the business world, employees and employers would regard that as wholly unacceptable. Employment information (contractual and informal) is often available (and unchanged) year on year. But efficient preparation is rare, and sensible timelines are almost unheard of — hence the
seemingly age-old practice of giving rotas out within days of jobs beginning. Making sure an effective process is in place before the start of each rotation would put junior doctors well on the way to a much more informed and settled working environment. It would also avoid many morale problems, and it would go a long way to allowing doctors to focus attention on clinical responsibilities and training right from the start of jobs. Sarah Thoday MB BS London
False drugs economy
I am very concerned about the use of substitute generic drugs. For patients on anti-epileptics and lithium this could be dangerous as the therapeutic window is narrow. The possibility of dangerous side-effects or relapse could cost individuals and society a lot. Also, there is a significant minority of patients whose conditions can only be controlled by specific brand drugs. This may be placebo effect, but it is real for the patient. Spending money on generics that do not work for them is a waste of money. Jennifer Ellis MB BS Birmingham
Praise for whistleblower Whistleblowing is no game. Medicine is not a football match. I cannot begin to imagine what consultant urologist Ramon Niekrash must have endured in carrying out his duty and during his unjust suspension (‘Whistleblower doctor wins tribunal case’, February 13, 2010, page 3). His moral stance in the face of perverse incentives is an inspiration to us all. Sandra Pearson MB ChB MRCPsych Torquay, Devon
Offensive accusations As the chair of the BMA GPs committee at the time of the new GP contract negotiations, I would refute Hackney North and Stoke Newington Labour MP Diane Abbott’s suggestion that my If you have read something you would like to comment on, reply to or share with other readers, please write to: The Editor, BMA News, BMA House, Tavistock Square, London WC1H 9JP. Fax: (020) 7383 6566 Dictate: (020) 7383 6122 Email: email@example.com
negotiating team outmanoeuvred the government in securing the contract and its changes to responsibility for OOH (out-of-hours) care — particularly if that suggestion implies that our behaviour was underhand or manipulative. The agreement on the transfer of responsibility was hard won as part of contractual changes that were intended to be good for general practice and patients, and acceptable to all the negotiating parties. Negotiation is about reaching agreements that achieve mutual gain. The wise agreement meets the legitimate interests of both sides to the fullest extent possible. All three parties involved in the negotiations on the new contract — the GPC, the NHS Confederation and the government — recognised that 24-hour responsibility was deterring many young doctors from pursuing careers in general practice. I am saddened that in many parts of the country OOH services have worsened in terms of their accessibility, responsiveness and quality. Those problems must be addressed. But the contractual changes to OOH responsibility were made with good intentions. Additionally, GP leaders have long expressed concern about the way that EU regulations are predicated on the free movement of labour rather than on quality of care and patient safety. European law gives doctors from European Economic Area countries the right to practise anywhere in the EU, but it is essential that employers make sure that all staff have the necessary experience and language and communication skills. I realise I am recalling past negotiations and old issues because of my personal involvement, but I am offended by the accusation of outmanoeuvring. If that is the perception, other parties might seek revenge in subsequent negotiations. John Chisholm CBE MB BChir FRCGP London WE NEED: Your full name and postal address. Your medical qualiﬁcation and most recent membership/ fellowship of any medical royal college. Letters should be kept as brief as possible. They may be edited for length and clarity. The writer of the Prize Letter in each issue will win £50 of Random House books.
WRITE TO US
Trust us, we are doctors
DOCTORS DECIDE 9
Not enough hours in the week Has the EWTD had a positive effect on your NHS work?
Yes 17% No 70% Your views: No: ‘Continuity of care for patients is non-existent below consultant level. A consultant colleague of mine complained about having to present patients to his trainees on a ward round instead of the other way round. How stupid is that? The EWTD [European Working Time Directive] has meant frequent handovers with all the problems that they entail.’ Kent locum consultant general surgeon Mohamed Mohamed
No: ‘The EWTD has been used as an excuse by some trusts to restrict payment to 12 programmed activities — even though people regularly work in excess of the 48-hour limit.’ Staffordshire consultant chemical pathologist Timothy Reynolds
No: ‘As an FHO1 [foundation house officer 1] I feel that my duties consist of writing notes on the ward round and chasing scans. While this is all necessary and part of my duties, I believe it would also be beneficial for me to occasionally attend a clinic or theatre. As it stands, this is only possible if I stay late to finish the jobs that have accumulated through the day.’ West Midlands FHO1 Arun Ahluwalia
No: ‘The EWTD for surgeons is a disaster. My operative experience is down 60 per cent and I am now deployed doing work normally done by juniors and emergency departments because of a lack of juniors. What a waste of a senior trainee’s time and expertise as well as a disruption of my training. Senior trainees continue to ignore the EWTD limits as this is the only way to gain surgical experience and provide continuity of care and safe patient care. Handovers and shift working are a direct threat to patient safety and excellent clinical care. Each day, I, and many other colleagues, encounter instances where the EWTD has harmed patient care. Do trusts or the National Patient Safety Agency care? No.’ West Sussex SpR in trauma and orthopaedic surgery Andrew O’Brien
No: ‘I miss the old team spirit. It means that I run more things past my SpR than I would have previously. In the past I might have asked my fellow SHO before calling the SpR, but, on my own, I do not have that choice.
However, I do think I have more time to spend with friends and family and that is important to me.’
Junior doctors’ training, NHS service delivery and, some say, patient safety have suffered thanks to the European Working Time Directive, according to doctors in our survey. Flavia Munn presents their views
London ST1 in paediatrics Margaret Rhoads
Has your NHS organisation experienced problems with service delivery as a result of the move to a 48-hour week?
Yes 73% No 13% Your views: Yes: ‘Departments are struggling to fill their on-call rotas and, as a result, there are lots of internal locum shifts going so junior staff are signing disclaimers and picking up locum shifts in their own departments. There are so many compensatory days off — teams never really have the chance to work together and seniors never know which junior is looking after their team that day. It feels disjointed at times.’ Newcastle FHO2 Jillian Davis
Yes: ‘There are just not enough FHO-level doctors to cover all of the commitments with the current rotas and the 48-hour week. I do sometimes feel that patient care may be compromised as a result. Many of us work more hours than we ought to because we have the best interests of the patients at heart.’ Nottingham FHO2 Joannes Hermans
Yes: ‘The EWTD mitigates against providing excellent continuity of care for patients because the ethic of personal responsibility for a patient is eroded. Personal responsibility for a patient is immensely valuable for doctors in training, providing experience and giving job satisfaction as well as being greatly appreciated by patients.’ Cambridge consultant ophthalmologist Nicholas Sarkies
No: ‘Radiology is traditionally a 9pm to 5pm specialty with non-resident on call, so becoming EWTD compliant is not a major problem. If anything, it is good because it focuses consultants’ attention on the need to leave the hospital at a sensible time.’ London ST2 in radiology Daniel West
Has the EWTD had a negative effect on the ability of the NHS to deliver high-quality training?
Yes 76% No 10% Your views: Yes: ‘Handovers, competency-based training and work-based assessments are all fig leaves to disguise the fact that we have debunked “see one, do one, teach one”. We are all the poorer for it.’ Yorkshire consultant in endocrinology and diabetes Mo Aye
Yes: ‘It may seem odd but it is hard to get the trainees together as a group for specific training. Once compensatory time off after nights and leave is factored in, the exposure for any individual trainee can be limited.’ Yorkshire consultant paediatrician Douglas Gillies
Yes: ‘Despite the NHS having been aware for a decade of the implementation of the EWTD, most trusts only appear to have started looking at solutions in the past two years or less. This means that while rotas may on paper be compliant, the reality is that training has suffered considerably. Unfortunately, we are unlikely to see the development of a long-term solution to this problem until it is too late.’ Birmingham SpR in ENT Ram Moorthy
Yes: ‘The problem now is that the reduced working week, combined with a reduction in overall training (it took me 13 years to get a consultant ENT surgeon post, it now takes ten), means that the new batch of EWTD-trained doctors will have around half the experience I had by the time they are expected to go solo as consultants in their own right. I would fear for my own safety if I were one of their emergency patients.’ Merseyside consultant in ENT Christopher Webb
Yes: ‘In my opinion, the EWTD has reduced surgical training, in particular practical operative training. Furthermore, it has been detrimental for continuity of care for patients, particularly at FHO1 or FHO2 level where the team structure has been broken up and effective patient care has been reduced. Surgical training is opportunistic and requires flexibility to take on training opportunities as they arise.’
No: ‘My first job was compliant but meant I worked 90 hours a week with zero hour days (not annual leave but not expected to come in to work). This was against the point of the EWTD as I was tired when working. I also think the EWTD has had a negative impact on shift patterns as we are expected to work unusual times in order to cover days or evenings, which means we cross cover shifts and can have up to three or four handovers.’
Tyne and Wear SpR in general surgery David Borowski
Aberdeenshire FHO1 Rosalyn Shearer
Would you like to join the Doctors Decide panel and give us your views on topical issues? Questions are sent to panellists by email and you have about a week to respond. Every time you respond you will be entered in a draw with a chance to win a £50 Marks & Spencer voucher. To join the panel, email your name, specialty and grade — with Doctors Decide Panel in the subject line — to firstname.lastname@example.org. The winner of this month’s prize draw is Hampshire foundation year 2 Patrick Wilkinson. To air your views visit the EWTD and Training Conference Forum at www.bma.org.uk/ewtdtrainingconference
bma news Saturday February 27, 2010
10 FEATURE Six months on from full implementation of the 48-hour working week, Flavia Munn talks to junior and senior doctors and BMA representatives about the effects on training, work-life balance and morale, and about proposals for improving the situation
A timely solution? ‘F
ORTY-EIGHT HOURS? But isn’t that a weekend?’ That was the response of a consultant when BMA junior doctors committee chair Shree Datta explained the concept of a 48-hour week for doctors in training. Six months after the EWTD (European Working Time Directive) was implemented in full in August, the impact of a 48-hour working week is being considered very closely. An independent review into the effect of the EWTD commissioned by the training and education regulator NHS:MEE (NHS: Medical Education England) is under way, and this week the JDC hosted the first major conference to gauge doctors’ views on working time regulations and training at BMA House in London. The JDC hoped that the conference would highlight key problems with the directive, possible solutions and good practice. Dr Datta says: ‘Training opportunities clearly remain an issue for junior doctors. But that’s not the only aspect to worry them. We are hearing more frequently from juniors that a limit of 48 hours a week has resulted in more antisocial working and less continuity of care. ‘The implementation of the EWTD signifies a need to reassess the exposure junior doctors have to training at work, with a real emphasis on smart training to maximise the opportunities that are available during working hours. However, to do that, not only do we need motivated juniors; we also need motivated trainers — with allocated time to train juniors.’
Antisocial working The EWTD became law in the UK in October 1998, but the government was granted an extension of up to 12 years to prepare for full implementation of the directive with doctors in training. The juniors’ working week reduced to 56 hours in August 2003, although this was under the new deal measures introduced to protect working conditions prior to full EWTD implementation in 2009. The gradual squeeze on hours has given rise to concerns about the EWTD’s impact on training opportunities. A number of possible solutions have been suggested. At the same time, the JDC has been hearing anecdotally that some trainees are ‘quietly’ extending their hours. Dr Datta says this is unsustainable in the long-term. She says: ‘In some areas, this is primarily for service provision. In others it is to meet training needs. As the consequences of the EWTD become clearer, antisocial working hours have become more apparent, with little bma news Saturday February 27, 2010
positive impact on work-life balance and morale. ‘Shift working has distanced trainees from the firm structure that traditionally supported them. Continuity of patient care may also be affected. ‘There is an urgent need to provide juniors with the tools needed to input into rota design and for employers to support training. Motivated trainees are known to have a positive impact on the treatment and care patients receive, and this must continue in a 48-hour working week.’
National variations Compliance with the EWTD varies across the UK. In Scotland 99 per cent of rotas, including those hospital rotas that have derogated from the directive to run rotas of up to 52 hours, meet the legal requirement. In Northern Ireland between 66 per cent and 85 per cent of trusts are compliant. Compliance in Wales is now 100 per cent. In England, 88.3 per cent of junior doctors are working up to and including 48 hours a week according to new deal compliance figures for September 2009. NIJDC chair David Farren says the implementation of the EWTD has had a marked effect on junior doctor training and service provision in Northern Ireland. ‘In the past, Northern Ireland had a large percentage of international medical graduates in training posts,’ he says. ‘It has been struggling with rota gaps since the changes to immigration laws in recent years. ‘Despite several recruitment drives, there are still many posts unfilled, and there has been a heavy dependence on locum doctors to make sure service requirements are met.’ WJDC chair Dai Samuel says: ‘The EWTD has undoubtedly made service provision in Wales a greater challenge for specialties currently suffering from underrecruitment. We have also seen some hospitals withdrawing services at times. No doubt, rota gaps are made all the worse with limitations on hours.’ In Scotland, there have been relatively few derogations compared with the rest of the UK. However, SJDC chair Gordon Lehany says: ‘Many rotas appear compliant on paper, but we are concerned that the persistent problem of rota gaps means the actual hours of many junior doctors remain higher than EWTD limits. ‘As trainee numbers reduce — with core training 1 intakes down by approximately 10 per cent in many specialties this year — the prospect of widespread non-compliance in the longer term remains a real concern. www.bma.org.uk/bmanews
‘As the consequences of the EWTD become clearer, antisocial working hours have become more apparent’ ‘The issue of training detriment resulting from EWTD limits is a concern for some specialties.’ There have been particular concerns about the training opportunities for junior doctors working in craft specialties, such as surgery. Royal College of Surgeons of England president John Black believes the reason acute services in the NHS survive is that the EWTD has been implemented only on paper. He says: ‘The latest survey in the acute specialties showed that only 9 per cent of trainee surgeons in England are actually working 48 hours. They put in the rest for the sake of their patients and to try to get some training. ‘All the dangers from thin layers of cover and multiple handovers persist, with consultants papering over the cracks. Shift working — and over a third of surgical trainees work shifts — has produced some of the most exhausted doctors the NHS has ever seen. ‘Complex rotas have destroyed the firm structure, which has destroyed working relationships between trainer and trainee. Scarce hours are used for service, not training — particularly with early-years trainees. Nothing can replace trainer-trainee contact and experience. ‘Hospital reconfiguration is touted as a solution, but we have to be realistic about the chances of this happening in the politically charged environment of the NHS. I passionately believe that hospitals should be situated where they are needed, not sited to meet European rules.’
Increasingly disenfranchised Mr Black also believes one key solution lies in rota design. ‘Sensible rota working will also restore junior doctors’ lifestyle,’ he says. The BMA has produced a number of documents on maximising training opportunities under the EWTD. Dr Datta says: ‘The differential impact of the EWTD is only now becoming evident, but junior doctors are becoming increasingly disenfranchised as the directive beds in. ‘It’s very clear that service cannot be divorced from training, but there is a need for some joined-up thinking to make sure that every training opportunity is used.’ East Sussex consultant orthopaedic surgeon and director of medical education Scarlett McNally says it is perfectly possible to train surgeons within the context of a 48-hour week. ‘Training needs to be improved at every level, so that time spent doing activities that do not contribute to training are minimised,’ she says. ‘In many units the training is not good enough. ‘Surgical trainees are putting in extra hours, which motivated trainees have always done (through studying, skills courses, visiting other units, writing up audits, etc). But the important thing is that there is choice about when these activities are done, to fit around childcare, for example. It is important that medical students and junior doctors see surgery with 48-hour training as a career choice on a level with other specialties. The numbers of women applying is still sadly low.’ BMA central consultants and specialists committee joint deputy chair Ian Wilson is chair of the MMC (Modernising Medical Careers) ‘task and finish’ group on quality. In that role he has written a report about maintaining the quality of training within a reduced working week. Published last year, Maintaining Quality of Training in a Reduced Training Opportunity Environment says training should only be lengthened if there is evidence that junior doctors are typically not obtaining the necessary skills and competencies over the duration of their training programme. It adds that such extensions should be used only as a last resort. The report adds that the emphasis should be on improving the quality of and access to training opportunities. A number of ideas on maintaining the content and www.bma.org.uk/bmanews
quality of training in a 48-hour week are also included in a report led by Dr Datta’s predecessor as JDC chair, Andy Thornley. Maintaining the Quality of Training in the Craft Specialties: Managing EWTD Implementation (see www.bma.org.uk/ewtd) proposes solutions that include dedicated training lists to meet juniors’ training needs, making the trainee the first operator rather than the assistant to ensure they learn procedures, and ‘dry labs’ in which trainees can practise techniques using surgical simulation tools. The JDC report adds that failing training posts should be identified, and time must be found in job plans so consultants who do want to train juniors can do so. Dr Datta adds: ‘Training “smart”, with efficient and effective handovers rather than Chinese whispers, is paramount under such tight conditions. ‘Motivated trainers with the time and resources to train are also key to ensuring trainees receive the support and guidance needed to progress in training. Solutions such as dedicated training lists, rota design and tailored trainers must be considered and evaluated.’
Continued BMA vigilance The BMA continues to work with NHS:MEE, which has four BMA representatives, and the governments in the UK nations to try to resolve issues arising as a result of the EWTD. Dr Samuel says: ‘We continue to work with the Welsh Assembly and deanery to address the issue of poor recruitment, and we are carrying out an ongoing monitoring scheme regarding rota gaps and unfilled posts in Wales. ‘The EWTD has offered exciting opportunities in Wales to introduce Hospital at Night on a greater scale, and several health boards will launch their service in the coming months. ‘The BMA in Wales remains concerned that the more rural hospitals — where, traditionally, it is harder to recruit — may suffer from the EWTD more than larger centres. But we are visiting trusts, and rota gaps and training within the context of the EWTD are priorities for us.’ In Northern Ireland, Dr Farren says: ‘There have been a number of service reconfigurations that have been expedited as a result of the full implementation of the EWTD. ‘There has been some impact on training in these areas. For example, some foundation year 1 trainees have lost exposure to surgery in their first year of training. ‘But, by working closely with the Northern Ireland Medical and Dental Training Agency, we have been able to ensure that junior doctors are not disadvantaged by this. ‘The NIJDC continues to represent junior doctors in Northern Ireland during this difficult time and inform our members of their rights.’ As for Scotland, Dr Lehany says: ‘There are many difficulties facing junior doctors in the present climate, but the challenges presented by the EWTD remain among the key priorities that the SJDC is working to address.’ And summarising the situation for the UK as a whole, Dr Datta concludes: ‘Training within a weekend’s worth of hours clearly remains a challenge. Rota design and training opportunities for junior doctors must be one of the NHS’s priorities, to ensure that tomorrow’s patients benefit from the same standards of care they receive today.’
The experience of change IN AUGUST 2002 I returned to the UK after spending a year in Perth, Western Australia, after completing my house jobs. I had spent the year at a children’s hospital and thoroughly enjoyed my clinical experiences there. The 80-hour fortnights also allowed me to take advantage of the sun, sea and surf. I returned to a tertiary neonatal unit in the East Midlands. My disappointment was compounded by the fact that I knew I had to start getting my paediatric membership. The fact that the job was pay ‘band three’ didn’t really mean much to me at the time, except I knew it would help clear my substantial travelling debts. In practice, ‘band three’ meant a four-and-a-half week run of shifts with only four days off. I look back at that period with mixed feelings. Without a doubt, I went from a neonatal novice to being able to make middlegrade decisions within six months. The confidence I felt by the end of the job certainly outweighed the utter panic of a firstnight shift spent peering through Perspex glass wondering how I would get a cannula into the minute bag of skin and bones in front of me. To say I enjoyed the experience would be looking back with rose-tinted spectacles. During the runs of long days and evenings, I resented every little bleep or request for fluids. The maternity theatre bleep was particularly cunning, never going off when you were being grilled on a ward round, but waiting until your hurried lunch break. The shifts were exhausting, whether you did them for ten, 40 or 60 hours a week. However, having to do them for 50-plus hours meant you were never truly on top of your game. I count myself lucky to have experienced both sides of the EWTD (European Working Time Directive) coin. I know which regime I prefer. It is clear that one size does not fit all, but in paediatrics a suitably staffed rota does provide sufficient learning opportunities within the 48-hour framework. It is unfortunate, however, that many paediatric rotas are not suitably staffed. My experiences with the EWTD have been favourable, as I have always been rostered to allow exposure to elements in my training that are not just about deciding whether a feverish child is ill or not. Others have not been so lucky. Also, outpatient clinics, case conferences or governance meetings — which all count as training — are easily sacrificed if there is no one available to clerk the next patient on the assessment unit. Without these missed training opportunities the disadvantages of longer shifts, increased fatigue and less ability to unwind are irrelevant. I want to be given the opportunity to train, and I want the system to be flexible enough to allow me to take these opportunities. Ultimately, though, when I get frustrated about system failures I remember my neonatal job and am glad I don’t have to do it again. As time progresses, however, my memories will fade but the need to be trained effectively will remain. For paediatrics it is not the 48 hours that is the problem; it is the delivery of training within it. Damian Roland is a Leicester SpR in emergency medicine
bma news Saturday February 27, 2010
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ABBREVIATED PRESCRIBING INFORMATION. PROSTAP* SR/ PROSTAP* 3 Leuprorelin Acetate-Depot Injection 3.75mg/11.25mg Presentation: Prolonged release powder for suspension for injection after reconstitution with the Sterile Vehicle. Prostap SR Powder: contains 3.75mg of leuprorelin acetate, equivalent to 3.57mg base. Prostap 3 Powder: contains 11.25mg of leuprorelin acetate, equivalent to 10.72mg base. Indications: Prostap SR/Prostap 3:As an adjuvant treatment to radical prostatectomy in patients with locally advanced prostate cancer at high risk of disease progression; As an adjuvant treatment to radiotherapy in patients with high-risk localized or locally advanced prostate cancer; Locally advanced prostate cancer, as an alternative to surgical castration; Metastatic prostate cancer; Management of endometriosis including pain relief and reduction of endometriotic lesions. Prostap SR is also indicated for endometrial preparation prior to intrauterine surgery; preoperative management of uterine fibroids to reduce their size and associated bleeding. Dosage and Administration: Prostate Cancer: Prostap SR: 3.75mg administered every month as a single subcutaneous or intramuscular injection. Prostap 3: 11.25mg every 3 months as a single subcutaneous injection. Do not discontinue when remission or improvement occurs. Therapy should be monitored clinically. If response appears to be sub-optimal, it should be confirmed that serum testosterone is at castrate level. Endometriosis: Prostap SR: 3.75mg administered as a single subcutaneous or intramuscular injection every month. Prostap 3: 11.25
as a single intramuscular injection every 3 months. Treatment should be for a period of 6 months only and initiated during the first 5 days of the menstrual cycle. If appropriate, hormone replacement therapy (HRT - an oestrogen and progestogen) should be co-administered with Prostap to reduce bone mineral density loss and vasomotor symptoms. Endometrial Preparation Prior to Intrauterine Surgery: Prostap SR: 3.75mg as a single subcutaneous or intramuscular injection 5-6 weeks prior to surgery. Therapy should be initiated during days 3 to 5 of the menstrual cycle. Preoperative management of uterine fibroids: Prostap SR: 3.75mg as a single subcutaneous or intramuscular injection every month, usually for 3-4 months but for a maximum of six months. Elderly: As for adults. Children (under 18 years): Not recommended - safety and efficacy in children have not been established. For chronic administration, the injection site should be varied periodically. Contraindications: Hypersensitivity to any of the ingredients or to synthetic GnRH or GnRH derivatives. Women:Lactation, pregnancy, undiagnosed abnormal vaginal bleeding. Precautions and Warnings: General: Development or aggravation of diabetes may occur; therefore diabetic patients may require more frequent monitoring of blood glucose. Hepatic dysfunction and jaundice with elevated liver enzyme levels have been reported. Therefore, close observation should be made and appropriate measures taken if necessary. The ability to drive may be impaired due to visual disturbances and dizziness. Men: A transient rise in levels of testosterone may occur initially. This may be associated with tumour flare,
sometimes manifesting as systemic or neurological symptoms. These symptoms usually subside on continuation of therapy. An anti-androgen may be administered to reduce the risk of flare (see SmPC, section 4.4). Patients at risk of ureteric obstructions or spinal cord compression should be closely supervised in the first few weeks of treatment. These patients should be considered for prophylactic treatment with anti-androgens. Should urological/neurological complications occur, these should be treated appropriately. Women:Whilst ovulation is usually inhibited during therapy, contraception is not ensured. Patients should therefore use nonhormonal methods of contraception. During the early phase of therapy, sex steroids temporarily rise, possibly leading to an increase in symptoms, which dissipate with continued therapy. Menstruation should stop with effective doses of Prostap, therefore the patient should notify her physician if regular menstruation persists. The induced hypo-oestrogenic state may result in a small loss in bone mineral density over the course of treatment, some of which may not be reversible. However, during one six-month treatment period, this bone loss should not be important. For patients with major risk factors for decreased bone mineral content Prostap may pose an additional risk. Before treating these patients for fibroids, their bone density should be measured, and where results are below the normal range, Prostap therapy should not be started. In women receiving GnRH analogues for the treatment of endometriosis, the addition of HRT (an oestrogen and progestogen) has been shown to reduce bone mineral density loss and vasomotor symptoms.
Prostap may cause an increase in uterine cervical resistance. This may result in some difficulty in dilating the cervix for intrauterine surgical procedures. Diagnosis of fibroids must be confirmed prior to treatment by laparoscopy, ultrasonography or other investigative technique. In women with submucous fibroids there have been reports of severe bleeding following administration of Prostap as a consequence of acute submucous fibroid degeneration. Patients should be warned of the possibility of abnormal bleeding or pain in case earlier surgical intervention is required. Side Effects: General: Adverse events which have been reported infrequently include peripheral oedema, pulmonary embolism, hypertension, hypotension, palpitations, fatigue, muscle weakness, diarrhoea, nausea, vomiting, anorexia, fever/chills, headache (occasionally severe), hot flushes, arthralgia, myalgia, dizziness, insomnia, depression, paraesthesia, visual disturbances, weight changes, jaundice, increases in liver function test values, and irritation at the injection site. Changes in blood lipids and alteration of glucose tolerance have been reported. Thrombocytopenia, leucopenia and infarction of pre-existing pituitary adenoma have been reported rarely. Hypersensitivity reactions including rash, pruritus, urticaria, and, rarely, wheezing or interstitial pneumonitis have also been reported. Bone mass reduction may occur. Anaphylactic reactions are rare. Spinal fractures, paralysis and worsening of depression have been reported. Men: If tumour flare occurs, symptoms and signs due to disease e.g. bone pain or urinary obstruction may also occur. Other side
effects include impotence, decreased libido, hot flushes and sweating. Gynaecomastia has been reported occasionally. Women: Side effects reported are mainly those related to hypo-oestrogenism e.g. hot flushes, mood swings including depression (occasionally severe), and vaginal dryness. Breast tenderness or a change in breast size, and hair loss, may occur occasionally. A small loss in bone density may also occur, some of which may not be reversible (see Precautions and Warnings). Vaginal haemorrhage may occur due to acute degeneration of submucous fibroids. Legal Category: POM. Package Quantities: Prostap SR: Single injection pack. One vial containing 3.75mg leuprorelin acetate as microcapsule powder, one prefilled syringe containing 1ml sterile vehicle, three syringe needles (two 23 and one 21 gauge); Prostap 3: Single injection pack. One vial containing 11.25mg leuprorelin acetate as microcapsule powder, one prefilled syringe containing 2ml Sterile Vehicle, two 23 gauge needles. Basic NHS Cost: Prostap SR £75.24; Prostap 3 £225.72. Marketing Authorisation Numbers: Prostap SR: PL 16189/0008; Prostap 3: PL 16189/0009; Sterile Vehicle: PL 16189/0010. For full prescribing information and details of other side effects see Summary of Product Characteristics. Full prescribing information is available on request from: Takeda UK Limited, Takeda House, Mercury Park, Wooburn Green, High Wycombe, Bucks. HP10 0HH, UK. Telephone: 01628 537900; Fax: 01628 526617. Date of Prescribing Information: 01/07/2009 *Registered Trademark of Takeda.
Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Takeda UK Ltd on 01628537900 References: 1. Jocham D. Urol Int 1998; 60: 18–24. 2. Kienle E & Lübben G. Urol Int 1996; 56: 23–30. 3. Persad R. Int J Clin Pract 2002; 56: 389–96. 4. MIMS February 2010. PS100101y Date of preparation: February 2010