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NEWS ONLINE

• New bowel cancer screening test is recommended for England

• Speeding up access to new drugs threatens evidence based medicine, says health economist

• NHS plans sugar tax on food and drink sold in hospitals by 2020

High BP blamed for cancelled surgery

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GPs should include information on a patient’s blood pressure (BP) in referral letters for elective surgery and should refer only those with BP lower than 160/100 mm Hg over the previous 12 months, say new guidelines that aim to reduce surgery cancellations because of high BP.

Nearly 1% of planned surgery in the NHS is currently cancelled at the last minute, and hypertension is a common reason.

“Across the UK this equates to approximately 100 concerned and inconvenienced patients each day, with associated costs to the NHS and the national economy,” said the co-chair of the guideline working party, Andrew Hartle, who is a consultant anaesthetist at St Mary’s Hospital in London and president of the Association of Anaesthetists of Great Britain and Ireland.

The guidelines, developed jointly by the association and the British Hypertension Society, give national recommendations for the measurement, diagnosis, and management of raised BP in adults before planned surgery.

“There has previously been no consistency in what people do in deciding whether or not to go ahead with elective

surgery on the basis of a patient’s blood pressure,” Hartle told The BMJ. “Patients arrive for surgery, are rushed through, have their blood pressure measured, and, if it’s high, some would be measured again—and some would have their surgery cancelled and be sent back to their GP.”

Terry McCormack, guideline party co-chair, who is a GP in Whitby and secretary of the British Hypertension Society, added, “Cut-offs for BP levels at which surgery was postponed varied between different areas of the country, different hospitals, and even different departments within hospitals.”

Secondary care teams should accept patients for elective surgery if they have documented evidence in GP referral letters that the patient’s mean BP has been lower than 160 mm Hg systolic and 100 mm Hg diastolic over the previous 12 months, the guidance recommends. Patients who do not have documented primary care BP measurements can undergo elective surgery if readings taken in preoperative assessment clinics are below 180/110 mm Hg, but they should be referred back to their GP for diagnosis and management of hypertension.Susan Mayor, LondonCite this as: BMJ 2016;352:i296

Checking blood pressure as the patient is wheeled into surgery is far too late

the bmj | 23 January 2016 85

86 23 January 2016 | the bmj

SEVEN DAYS IN

Saturday 16thNew case of Ebola in Sierra Leone The World Health Organization confirmed a new case of Ebola virus disease in Sierra Leone, barely 24 hours after it had declared the end of transmission of the virus in west Africa. The new case, in the northern district of Tonkolili, was the 11th “flare-up” of the disease—that is, a case not epidemiologically linked to the original outbreak and most likely caused by the virus remaining in survivors after recovery. Contacts

were being traced and control measures put in place, said WHO. (See The BMJ’s full story at doi:10.1136/bmj.i298.)

Sunday 17thHunt’s use of stroke statistic is criticised In a letter to the Sunday Times doctors criticised England’s health secretary, Jeremy Hunt, for saying that people are 20% more likely to die from a stroke if admitted to hospital at the weekend: they claimed that the statistic was outdated and preceded rapid improvements in stroke care. Only 5.1% of patients

Hunt referred to were cared for on new acute stroke units, they argued, compared with 82% in the 2015 national data. “Misrepresentation of statistics on stroke care to justify the junior doctor contract proposals is inappropriate,” the doctors said.

Female doctors hit back at claims that they avoid antisocial hours Doctors criticised Dominic Lawson (below), the journalist who wrote in the Sunday Times that increasing numbers of female doctors was a key but unspoken factor in the disagreement over changes to antisocial hours in the new junior doctors’ contract. He also argued that an increase in female GPs who did not want to work unsocial hours had resulted in “an increasing pile-up in the emergency wards of our hospitals.” Johann Malawana, chair of the BMA’s Junior Doctors Committee, tweeted, “Middle of serious crisis in medical staffing and recruitment. What should we do? Put out sexist articles blaming it on women.” (Full BMJ story doi:10.1136/bmj.i323.)

Monday 18thDementia care requires greater scrutiny The Alzheimer’s Society called for all hospitals to publish an annual statement of dementia care to help raise standards of care across the country. In an investigation the charity found that care for people with dementia was highly variable. Last year 28% of over 65s who had a fall in hospital had dementia, but this was as high as 71% at the worst performing hospital trust.

Surgeon faces rare criminal charges of wounding patients Ian Paterson, the breast surgeon accused of carrying out unnecessary or inappropriate operations on hundreds of women, appeared at Birmingham Magistrates’ Court charged with

wounding with intent to do grievous bodily harm. The 21 charges, to which he entered

no pleas, concern 11 patients and cover the period from

1997 to 2011. He is due to appear before Birmingham Crown Court on 15 February. (Full BMJ story doi:10.1136/ bmj.i343.)

Tuesday 19thNICE issues standards on preventing obesity Adults should be able to get healthy food and drinks from vending machines in local authorities and NHS facilities, said a quality standard from the National Institute for Health and Care Excellence on ways to prevent adults from becoming overweight. They should also be able to see nutritional details on menus in these facilities, it added, and overweight or obese adults with comorbidities should be offered referral to a lifestyle weight management programme.

Acupuncture does not reduce hot flushes Acupuncture is no better at reducing menopausal hot flushes than “sham” acupuncture in which needles do not penetrate the skin, a study found. Eight weeks after 10 treatment sessions, women in both groups reported an approximate 40% decrease in hot flushes that was sustained for six months. (Full BMJ story doi:10.1136/bmj.i315.)

Junior doctors have welcomed the BMA’s decision to suspend their industrial action on Tuesday 26 January.

The association announced on Tuesday 19 January that it had suspended the action, so as to continue talks with the government on the new contract for junior doctors, facilitated by Acas (the Advisory, Conciliation and Arbitration Service).

Rhiannon Harries, president of the Association of Surgeons in Training, said that the move was a positive step. “Ultimately all junior doctors do not want to unnecessarily inconvenience patients, but we simply cannot allow a contract that is unsafe for patients, doctors, or the NHS,” she said.

Kitty Mohan, former co-chair of the BMA’s Junior Doctors Committee, said that the decision demonstrated the BMA’s willingness to negotiate in good faith with the government.

“The UK government must now show similar willingness by removing the overhanging threat of contract imposition and negotiating fairly with the BMA, listening and acting on the concerns voiced by over 50 000 junior doctors,” she said.

Junior doctors welcome strike suspension

Abi Rimmer, BMJ Careers Cite this as: BMJ 2016;352:i358

The thalidomide scandal stands as one of the worst ever medical disasters. The sedative, created in 1953 and marketed as a powerful antiemetic to pregnant women,

led to 2000 deaths and to 10 000 children with birth defects, principally in Europe, Australasia, and Canada. In the United Kingdom alone 2000 “thalidomide babies” were born limbless, and many had other effects such as deafness and blindness, in the three years after the drugs was licensed for use in 1958. There were no cases in the United States because of stricter drug safety laws.

In 1961 the Australian doctor William McBride wrote to the Lancet after noticing an increase in the number of babies with birth defects at his hospital. All the mothers had taken thalidomide. The drug, made by the giant German pharmaceutical company Chemie Grünenthal, was withdrawn the same year and banned in the UK in 1962. And yet still many of the families had no idea of the cause of their babies’ malformations.

Journalistic persistenceThe story of these thalidomide patients would have probably remained in the shadows if not for the newspaper editor Harold Evans, whose 10 year investigation and campaign for justice made it a national talking point. It is held up as one of the great achievements of 20th century journalism. A new film, Attacking the Devil, chronicles this investigation, with testimony from journalists, patients and their families, and Evans himself, at age 87 editor at large at Reuters.

As the young editor of the Northern Echo in the early 1960s, Evans asked how a drug this destructive ended up on the market and why, given the obvious damage it had caused, no compensation was forthcoming. The press took the side of the drug company, that according to “standard medical knowledge” the company could not have known that the drug crossed the placenta.Evans, who also led a campaign resulting in a national programme for the detection of cervical cancer in the UK, was rather more unflinching. He published pictures of thalidomide children, despite the obvious distaste of readers. He recalled, “They didn’t want to see these pictures, and said, ‘Why are you putting these monsters in front of us?’”

In the mid-1960s 62 families did sue Distillers, the drug’s UK distributor, for compensation. Then journalists were unable to report on the facts of an active civil case, and this gag kept cases away from the public eye.

Evans, who by 1967 was editor of the Sunday Times, was in a frustrating bind. A whistleblower from Chemie Grünenthal had leaked thousands of company documents, now translated and stacked floor to ceiling in his newspaper office, showing that the company had deliberately marketed the drug to pregnant women, without testing.

Risk of imprisonmentEvans risked sentencing for contempt of court if he published the real story of drug company negligence. His investigations team wrote article after article, all remaining on ice. He urged his lawyer to find him a way round the law—a “safe way up the Eiger.” And he did, by launching a moral campaign, which left aside the question of negligence. The Sunday Times published a huge splash, “A case for national shame,” and despite Distillers’ annual £60 000 advertising spend at the title.

Disgusted, the public began to boycott Distillers’ products; in just nine days their shares lost £35m.

Finally, in 1972 Jack Ashley MP spoke out in parliament in a famously powerful speech: “Adolescence is a time for living and laughing, for learning and loving. But what kind of adolescence will a 10 year old boy have when he has no arms, no legs, one eye, no pelvic girdle, and is only 2 feet tall?”

By 1973 Distillers was forced to increase its compensation offer to £28m, shared among 370 children. This was a far cry from its original paltry offer, including £3000 per arm.

“How very important” the media are, Evans told a BMJ investigative journalism conference in New York last year (http://bit.ly/1PnVMs5). “[They are] in the doghouse, quite rightly, considering phone hacking and intrusions into privacy. But the only force that could do any good in the thalidomide case was the free press. And this is so often the case.”Rebecca Coombes is head of features and investigations, The BMJ [email protected] this as: BMJ 2016;352:i353

Attacking the devil: the thalidomide storyA new film chronicles editor Harold Evans’s campaign for the rights of the children affected by the drug. Rebecca Coombes reports

Kevin Donnelly, a social worker who was disabled by thalidomide, and whose family received fair compensation following the successful Sunday Times campaign

• Attacking the Devil is on UK general release from Friday 22 January.


Dementia diagnoses increase The proportion of people in England who had a diagnosis of dementia in their GP record rose from 643 per 100 000 people in April 2014 to 755 people per 100 000 in December 2015—a total of 423 000 diagnoses—showed a report from the Health and Social Care Information Centre. However, half of patients with dementia who were admitted to hospital had no recorded diagnosis on admission, despite previously having had such a record.

Wednesday 20thNo link between anaesthesia and impaired cognition A study found no association between receiving anaesthesia for surgery after age 40 and developing mild cognitive impairment in later life. Researchers evaluated nearly 2000 people aged 70-89 every year and found that 31% developed mild cognitive impairment during the five year

follow-up, but no difference was found between those who had received anaesthesia and those who had not. (Full BMJ story doi:10.1136/bmj.i311.)

England has nearly twice as many hospital deaths as US The United States has the lowest

proportion of cancer patients over 65 dying in acute hospitals, showed a study comparing end of life practices in seven developed countries. Only 22% of US over 65s with cancer died in hospital, compared with 42% in England and 52% in Canada. Healthcare spending in the last six months of life was highest in Canada and lowest in England. (Full BMJ story doi:10.1136/bmj.i295.)

Thursday 21stComputer algorithm could help GPs predict dementia risk Researchers published details of a computer algorithm using routinely collected health data that could help GPs predict the risk of patients developing dementia. The algorithm, which used records of depression, stroke, high alcohol consumption, diabetes, atrial fibrillation, aspirin use, smoking, decreasing weight, and untreated blood pressure, worked well in people aged 60 to 79. It needs to be further evaluated but may help to rule out patients at very low risk for conditions such as Alzheimer’s disease and identify those who need further tests, said the researchers. (Full BMJ story doi:10.1136/bmj.i313.)Cite this as: BMJ 2016;352:i328

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SO JUNIOR DOCTORS IN ENGLAND WENT ON STRIKE, APPARENTLY. DID ANY ACTUALLY TURN OUT?Quite a few, it seems. NHS England said that around 52.6% of the 26 000 junior doctors due to be working on 12 January didn’t go to work, so 13 670 juniors were on strike.

THAT’S A VERY PRECISE FIGUREYes, suspiciously so, some might say. But the BMA isn’t disputing the numbers.

NHS ENGLAND SHOWED REMARKABLE EXPEDIENCYSure did. The first figures appeared at around 2 30 pm on the Tuesday, six and half hours into a 24 hour strike. NHS England puts it down to being prepared. It got head counts from all hospital trusts on the day and updated the figures when the night shift started.

I THOUGHT ALMOST ALL OF THE 38 000 JUNIOR DOCTORS WHO WERE BALLOTED SAID THAT THEY WOULD STRIKE?Yes, but only 26 000 were due to work between 8 am on 12 January and 8 am on 13 January. The 47.4% of junior doctors who did report for duty included those who were rostered for urgent and emergency care, which was allowed as part of the action.

WILL DOCTORS LOSE MONEY FOR TAKING PART?Yes, their pay will be docked if they were striking instead of working.

DO DOCTORS HAVE TO TELL THEIR EMPLOYER IF THEY PLAN TO STRIKE?No, but the BMA encourages them to.

WHAT EFFECT DID THE ACTION HAVE?Only time will tell. The NHS did not collapse on 12 January. NHS England said that 1279 inpatient and 2175 day case elective procedures were cancelled.

AND IN TERMS OF NEGOTIATIONS?The strike was described as a “punch” to the health secretary for England, Jeremy Hunt. He retaliated by threatening again to impose the new contract if talks fail.

SIXTY SECONDS ON . . . JUNIOR DOCTORS’ STRIKE

MEDICINE

GOING UP755 people per 100 000 were diagnosed with dementia in December 2015,

up from 643 per 100 000 people in April 2014

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Adrian O’Dowd, LondonCite this as: BMJ 2016;352:i314


“The only force that could do any good in the thalidomide case was

the free press”—Harold Evans


“The website www.clinicalstudy datarequest.com was originally set up by GlaxoSmithKline in May 2013 as a portal to access trial data. It has grown, and

there are now 13 companies who provide data and others wanting to join.

“The Wellcome Trust got involved because it believes strongly in the value of open data, and

we took over the secretariat last year. There are some other, single company sites, but we wanted to avoid fragmentation of the landscape and silos appearing.

“Because it’s multi-sponsor it makes it easier for researchers to access data from more than one company

with the same research proposal. There are 2800 studies listed on the site now, and so far we’ve had 179 proposals from researchers seeking data. But we think there could be much more use of it, and we are keen to increase awareness.

“The panel’s job is to do a high level review of the robustness of the research proposals, to give confidence that the data are being used to ask a valid research question in the best possible way. The site always had an independent panel, and there’s no doubt in my mind they were independent, but the fact they are now appointed by us gives an extra level of distance to allow people to fully trust the system.

“We’re delighted with the quality of the panel, which is chaired by Professor Jeffrey P Koplan of Emory University and includes the medical statistician Doug Altman from Oxford. Unlike some single company sites we don’t say that lawyers can’t access data. There’s nothing to stop them setting up a collaboration with an academic anyway, so we don’t think that restriction is helpful.

“People may think that access will be used to check original trial results, but of the first 100 proposals we had only two wanted to do that—the rest were completely novel analyses. A fifth were looking at new statistical methods, a fifth were for systematic reviews, which isn’t surprising, and more than half were trying to look for predictive factors.”Nigel Hawkes, London Cite this as: BMJ 2016;352:i278

FIVE MINUTES WITH . . .

Nicola Perrin The BMJ asked the Wellcome Trust’s head of policy how a new panel will review requests to access industry sponsored trial data

Austerity cuts are eroding benefits of Sure Start children’s centres

was not selected for the trial said that participants were to be paid €1900 (£1455) for a two week stay at the Rennes centre, which involved daily oral administration of the product and a series of tests on blood, urine, and vital signs. The trial began on 7 January.

Three days later one of the volunteers fell ill and was admitted to hospital with symptoms that doctors first attributed to a stroke. Five others followed in subsequent days. Pierre Gilles Edan, head of the neurology department at the University Hospital in Rennes, where the five surviving volunteers, all men, are being treated, said that three had brain damage including

bleeding and necrosis that “could be irreversible.” A fourth had neurological problems but of lesser severity, and a fifth man had experienced no adverse effects but was being monitored.

All six had been in the same trial group, which according to BIAL was the group given the highest dose in the third phase of the trial, when multiple doses were being given. The compound had been tested in the normal way, including in chimpanzees, said the French health minister, Marisol Touraine, although UK experts have questioned this claim.

French press reports said that the man who died was 49, the oldest of the six. Trial records from Biotrial were seized by the gendarmerie over the weekend, and leaks to French media indicate that investigators have focused on contamination as a reason for the effects.

Touraine has said that she expects a preliminary report from the three investigations by the end of the month.Nigel Hawkes, LondonCite this as: BMJ 2016;352:i319


“Investment in early child development is a rare example where efficiency (saving money) and equity (reducing inequality) come together”

Details of French trial must be released urgently

improved. Mothers using the centres showed improved mental health, and children exhibited greater social skills. These positive effects were greater in centres that didn’t experience cuts to staff and services.

The report concluded that the children’s centres “have the potential to promote better outcomes for families and to a lesser extent, for children and mothers” and seem to be targeting high need families successfully.

“In addition, centres that experienced budget increases and service expansion in 2011-2014 showed better effects on outcomes than those that experienced cuts and restructuring. This is an important message given the context in

which children’s centres were operating when this evaluation took place.”

Michael Marmot, director of University College London’s Institute of Health Equity, who led a government commissioned review of health inequalities in 2010, said, “Sure Start children’s centres can improve parenting and have a favourable impact on parent-child interactions. The better resourced the centre, the more favourable the impact. Closing these centres, or reducing their funding, is a false economy. Investment in early child development is a rare example where efficiency (saving money) and equity (reducing inequality) come together.”Ingrid Torjesen, LondonCite this as: BMJ 2016;352:i335

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Austerity cuts are eroding benefits of Sure Start children’s centres

British specialists have called for further information to be made available urgently about a drug trial in France that has claimed one life and left another five volunteers in hospital, three with serious brain damage.

Three separate inquiries have been launched into the disaster, by the French social affairs inspectorate, the national medical safety agency, and the gendarmerie, but details about the product under test and the trial’s protocol and dosing regimen have not been disclosed. Given that 90 people are reported to have been given the experimental treatment in various doses and that drugs with a similar mode of action have been tested by other manufacturers, Carl Heneghan of Oxford University said that an urgent need for transparency transcended any prosecution.

Munir Pirmohamed of the University of Liverpool said that it was possible that the adverse reactions were an off-target effect, in which the drug was interacting with

Investigators have focused on contamination as a reason for the effects

Details of French trial must be released urgentlya receptor other than that intended, but that without further information it was impossible to be sure. “It is therefore vitally important that as much information as possible is made available to the scientific community as soon as possible by the manufacturer,” he said.

Sheila Bird, a statistician and expert in trial design who retired recently from the UK Medical Research Council’s Biostatistics Unit in Cambridge, has appealed directly to the French licensing authorities, the National Agency for the Safety of Medicine and Medical Products, asking for the study design and protocol to be made available. Like the TGN1412 trial at Northwick Park Hospital in north London in 2006,1 these details have potential implications for the design of phase I studies internationally, she said.

What is known is that the product, BIA 10-2474, belonged to a class known as fatty acid amide hydrolase (FAAH) inhibitors. It was developed

by the Portuguese company BIAL and was being tested in a “first in man” trial in Rennes by the company Biotrial when the adverse effects emerged.

The target of the product was one or both of the enzymes that break down the fatty acid amides that act as transmitters to brain receptors such as those targeted by cannabinoids. This mode of action is intended to increase the activity of these receptors, achieving the pain killing effects of cannabis based drugs without the side effects (such as memory loss). At least five FAAH inhibitors have been developed by drug companies, including Pfizer, Sanofi-Aventis, and Merck, without so far producing a successful treatment.

The trial involved 90 healthy volunteers aged between 18 and 55 who were given the drugs in different doses and another 28 who were given a placebo. An email provided to the online news site Breizh-info.com by a man who had volunteered but who

A study commissioned by the UK government has concluded that children’s centres set up to support parents of young children can improve the mental health of mothers and functioning of families but that these benefits are being eroded by cuts.

Findings from the study were quietly published with a mass of other documents just before Christmas by the Department for Education.

The children’s centres were introduced under the last Labour government’s Sure Start programme to provide a range of services for parents and young children in deprived areas.

However, ringfenced funding was removed by the coalition government’s austerity budget in 2010, so some centres have been closed, and others have seen their services cut by cash strapped local authorities.

Researchers at the University of Oxford analysed annual interviews conducted with 2608 families registered with 117 Sure Start centres between 2012 and 2014 to assess the effect of cuts at some of the centres. They found that use of the centres was associated with positive effects on family functioning and home learning environments, that families experienced a less chaotic home life, and that relationships between parents and children

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Gordon Brown set up the Sure Start programme in 2009 when he was chancellor


EDITORIAL

Newer antiplatelet agents in acute coronary syndromeDoes prescribing outpace evidence?

Sticky patch

Dual antiplatelet therapy comprising aspirin and a purinergic P2Y12 receptor inhibitor has long been the standard

of care in patients with acute coronary syndrome (ACS). Clopidogrel is the most commonly used P2Y12 inhibitor,1 but its usefulness has been questioned, with 25-30% of patients achieving <25% inhibition of platelet activity. Moreover, onset (4-6 hours, even after a loading dose) and offset (5-7 days) of its activity are relatively slow. This slow offset may assume importance in patients with bleeding complications or in those requiring urgent surgical intervention. Slow onset is disadvantageous in patients with ACS, owing to the potential for propagation of thrombus in the interval until P2Y12 inhibition occurs.

More predictable pharmacokineticsThe newer P2Y12 antagonists prasugrel and ticagrelor have more predictable pharmacokinetics and pharmacodynamics than clopidogrel; additionally, both have faster onset of action, and ticagrelor has a much faster offset than clopidogrel.2 Consequently, many cardiologists use these two agents over clopidogrel, which is reflected in some3 4—but not all5 6—guidelines.

However, the perceived clinical superiority of prasugrel and ticagrelor in ACS is based on limited evidence, with only one trial for each drug showing improved clinical outcomes over clopidogrel. Moreover, both trials raise a number of fundamental questions that have yet to be tackled.

The Trial to Assess Improvement in Therapeutic Outcomes by Optimising Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38 showed superior cardiovascular outcomes for prasugrel compared with clopidogrel, on top of usual care, in patients

scheduled for percutaneous coronary intervention.7 However, the prasugrel arm had more major (including fatal) bleeding complications, and there was no difference in cardiovascular or all cause mortality. Prasugrel was not superior to clopidogrel in patients aged 75 or older or in those who weighed <60 kg and gave rise to worse outcomes in those with a history of stroke or transient ischaemic attack. In the Targeted Platelet Inhibition to Clarify the Optimal Strategy (TRILOGY)-ACS trial of patients managed medically, prasugrel gave no better outcomes than clopidogrel.8

In the Platelet Inhibition and Patient Outcomes (PLATO) trial 18 624 patients with ACS, scheduled to undergo either invasive or medical management, were randomised to receive ticagrelor or clopidogrel, on top of usual care.9 Better cardiovascular outcomes and lower all cause mortality were demonstrated for ticagrelor. Although no significant difference in the rate of major bleeding was found between groups, ticagrelor was associated with a higher rate of major bleeding not related to coronary artery bypass grafting, including more cases of fatal intracranial bleeding but fewer of fatal bleeding of other types. However, the subgroup outcomes in this trial are difficult to interpret. The outcomes for ticagrelor and clopidogrel were not different in North America, which led to a considerable delay before the Food and Drug Administration approved the use of ticagrelor in patients with ACS.10

Dyspnoea was experienced by 14% of patients on ticagrelor and did not improve with time in one third of these patients. This symptom led to a rate of discontinuation that was nine times higher for ticagrelor than clopidogrel. The high incidence of dyspnoea and the resulting discontinuations of ticagrelor were

confirmed in the Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin (PEGASUS)-TIMI 54 study.11

Some buried subgroups at risk?Although ticagrelor was shown to have a favourable effect on sudden death and ventricular arrhythmias in PLATO, it was associated with more atrial arrhythmias and ventricular pauses than clopidogrel. A previous trial—Dose Confirmation Study Assessing Antiplatelet Effects of AZD6140 Versus Clopidogrel in Non-ST Segment Elevation Myocardial Infarction (DISPERSE)-2—also showed more ventricular pauses with ticagrelor than with clopidogrel.12 In patients with a history of liver disease at baseline, the mortality rate was more than three times higher with ticagrelor than with clopidogrel, and ticagrelor was associated with more major bleeds. Patients with a low glomerular filtration rate were at higher risk of major bleeding complications, death, and renal failure.13 Thus, in a number of subgroups buried in the PLATO population, ticagrelor has the potential to cause more harm than clopidogrel.

Clearly there is not a “one size fits all” P2Y12 inhibitor—some patients may benefit from the newer drugs while others may experience no net benefit, and yet others may experience net harm. We need more trials to better inform clinical practice about which drug is the best fit for which patient. Cite this as: BMJ 2016;352:h7025Find this at: http://dx.doi.org/10.1136/bmj.h7025

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Albert Ferro, professor of cardiovascular clinical pharmacology, Cardiovascular Division, King’s College London, UK albert.ferro@ kcl.ac.uk

The perceived clinical superiority of prasugrel and ticagrelor in ACS is based on limited evidence


ONLINE HIGHLIGHTS FROM THEBMJ.COM

Jonathan Bilmen @BillersJ @bmj_latest I tried your brain cake recipe

OVERHEARD ON TWITTER

James Mackenzie writes that the trying life of soldiers, exposed to many and varied vicissitudes, should put a strain upon the heart has long been recognised. Physicians’ accounts published after the American Civil War gave the condition the name “soldier’s heart” or the “irritable heart of soldiers.” The chief complaint is an absence of the feeling of being well. Breathlessness on moderate exertion is frequent, and a sense of fatigue is common. The heart’s rate, however, is often not increased. Mentally, depression and irritability are features, and patients are often content to lie in bed and brood over their woes.

Citethisas:BMJ 1916;1:117

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EDITORIAL

Clinical academics’ postdoctoral careers Could be helped by mentoring, improving the work environment, and better access to funding

In 2005, the UK government established an integrated academic training pathway to generate a “pipeline” of world class future clinical

academics. This pathway, overseen by the National Institute for Health Research, encourages junior doctors with an interest in research to advance from an academic clinical fellowship, and after completion of a PhD, to clinical lectureship.3 Each step along this path is competitively awarded and provides a formal structure in which trainees receive protected research time alongside their clinical training. However, whether this pathway boosts our supply of clinical academics has yet to be assessed.

Heading for the exitRecent exit data for clinical PhD graduates from two of the largest funding bodies in the UK, the Wellcome Trust and Cancer Research UK, suggest that about a third progressed to a formal academic post, such as a clinical lectureship or clinician scientist fellowship (Cancer Research UK, personal communication, 2015).4 Additionally, the British Heart Foundation conducted an internet search of its PhD graduates and found that only 40% of clinicians who had completed their PhD since 2000 were subsequently active in research (British Heart Foundation, personal communication, 2015). These data should motivate us to

ensure that early career clinical academics are provided with a training environment that is as supportive as possible.

A new UK review of career paths and progression for clinical academics early in their careers has identified some of the barriers and enablers.5 North American research suggests four factors influence postdoctoral career progression within academic medicine: mentorship, work environment, access to funding, and intrinsic motivation. Doctors who experience supportive mentorship and positive role models tend to report greater career satisfaction and confidence.6 Supportive mentors are those who protect and encourage their trainees’ personal and career development and, consequentially, promote both greater independence of thought within research and a desire to remain within clinical academia.7 8

Veronica Ranieri, research associate Helen Barratt, clinical senior research associate, Department of Applied Health Research, University College London, London, UK Naomi Fulop, professor of health care organisation and management, Department of Applied Health Research, University College London, London, UK Geraint Rees, director, Academic Careers Office, School of Life and Medical Sciences, University College London, London WC1E 6BT, UK [email protected]

Inclusive, respectful, attentive Allied to mentoring, junior clinical academics express a desire to work in an environment that is inclusive, respectful, and attentive to their needs in an institution that is committed to their career progression.9 10 Access to such an environment may, however, depend on attaining research funding and financial stability. Indeed, difficulties in acquiring research grants feature strongly in early career researchers’ accounts. Those who experience financial pressure, such as debt, and are unable to obtain research funding may be unable to advance their academic careers.11

Nevertheless, trainees’ internal motivation and reasoning for becoming a researcher may influence their career path. Intrinsically motivated junior clinical academics who perceive research to be highly valuable pursue it even if career success is uncertain.12 13 These junior academics find their role intellectually stimulating and discovery exciting.14 When inevitably met with rejection from academic journals or sources of funding, they persevere in their careers and develop resilience.15

More substantive data are needed on the experiences of UK trainees, but the above evidence suggests three key actions that will create a more supportive environment. Firstly, research institutions should implement measures to help trainees feel welcome and supported. Secondly, UK universities and funding bodies should routinely collect data relating to trainees’ career pathways and ensure their accessibility. Finally, including trainees in a collaborative dialogue with research institutions and funding bodies could generate creative and inclusive approaches to supporting postdoctoral career progression.Cite this as: BMJ 2015;351:h6945Find this at: http://dx.doi.org/10.1136/bmj.h6945JO

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Clinical academics need a training environment that is as supportive as possible


Millions of pounds have been stripped from frontline public health services in England

as a result of the government’s cuts, The BMJ can reveal. According to the findings of our investigation, councils are disinvesting in areas such as prevention, addiction services, sexual health, and weight management after a 6% government cut in the public health grant for this financial year. More cuts are planned for 2016-17.

Examples include a £1m cut to weight management services in Camden (including £400 000 from a programme to manage child obesity); a £100 000 cut to programmes to reduce levels of infant mortality and low birth weight in Calderdale, West Yorkshire; a £300 000 saving made by delaying a mental health project in Essex; and a £50 000 cut to falls prevention services in Cambridgeshire.

Nearly a third (30%) of local authorities that replied to a freedom of information request made cuts to frontline services in 2015-16. Some have cut staff and management costs to make savings, while others have used cash reserves to plug gaps rather than cut services.

Public health—the frontline cuts beginThe BMJ’s investigations show how budget constraints are affecting public health services.

Gareth Iacobucci reports

Directors of public health told The BMJ they were trying to minimise the impact by focusing on efficiencies and areas of limited effectiveness. But they warned it would be hard to shield important services such as drug and alcohol recovery and sexual health from cuts given demanded reductions of 3.9% per year on average over the next five years that will be applied from this April.1

Andrew Furber, president of the Association of Directors of Public Health, said the scale of the proposed cuts would make it increasingly difficult to make savings without affecting the public’s health.

“Most directors of public health are saying that there is very likely to be some impact on services, and in due course that will cause deteriorations in public health outcomes,” Furber warned.

In response to a freedom of information request The BMJ sent to all 152 local authorities in England, 40 councils (out of 132 that replied) said they had applied cuts to frontline services in 2015-16. Eight also have concrete proposals for further service cuts from April onwards.

“In due course [cuts] will cause deteriorations in public health outcomes” Andrew Furber

CASE STUDY Cambridgeshire County CouncilThe council made £1.6m in savings to public health in 2015-16, including3:Smoking cessation—medication and payments to GPsSaving: £245 000 (26.8% budget cut)Action: Stopped taking proactive steps to increase uptake of local smoking cessation services. Stopped implementing a “harm reduction” approach to support longer term smokers to quit more gradually than the standard NHS smoking cessation programmePotential effect: Higher rates of death and disability from smoking related cancer, heart disease, and lung diseaseLong acting reversible contraceptives (LARCs) delivered by general practicesSaving: £100 000 from a predicted underspend (8.5% budget cut)Action: Underspend is due to reduced activity in delivering LARCs due to retirement of GPs trained in their use. Underspend will continue without if new GPs aren’t trainedPotential effect: LARCs are particularly useful for vulnerable women with chaotic lifestyles and have been shown to be effective in reducing teenage pregnancy

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and £1.3m from children’s public health services (fi gure).

More to come The investigation also identifi ed a further £26m of proposed service cuts from 2016-17, including an additional £3.3m on sexual health. But most councils said they had not yet produced their savings plans for 2016-17 and beyond, meaning these fi gures are likely to be the tip of the iceberg.

Alison Barnett, director of public health at Medway council, which had to make savings of £1m in 2015-16 (box), said one vulnerable area was chlamydia screening.

“We’d still test people who came forward but we perhaps wouldn’t seek them down. We do look at the impact of the cuts and try to direct them to those services where the impact is as

concern about the scale of service cuts, which in some cases, its members had reported, amounted to 50%. 2

When money is tight, prevention oft en takes a hit, adds Billington. “Nowhere near enough is spent on [this],” he admits. “But the danger is that under fi nancial strain, acute care becomes the place you have to spend, because that’s the bit that gets noticed.”

Sexual health is an area of public health that can ill aff ord further cuts. There are already clear challenges in curbing teenage pregnancies and reducing STIs, for example. And there is clear evidence that preventive services work. According to the Department of Health, every £1 spent on contraception and related services saves the public purse £11 in the longer term. 3 Sexual health charity, the FPA, recently calculated that a 10% cut in spending could end up costing an extra £8.65bn between

now and 2020 in unwanted pregnancies and STIs. 4

Reducing teen pregnancies was a key goal of the Department of Health’s 2013 framework for improving sexual health. 3 The UK birth rate among 15-19 year olds fell by almost 28% between 2004 and 2012. But that still left the UK ranked fourth worst among European Union countries, behind Bulgaria, Romania, and Slovakia. 5

Around 440 000 STIs were diagnosed in England in 2014. Although overall this is a slight fall from 2013, some infections increased, particularly syphilis (up 33%) and gonorrhoea (up 19%), a drug resistant strain of which emerged in the north of England last year. 6

No clear accountablity The squeeze on funding isn’t the only factor sparking anxiety. In its report published in July the all party parliamentary group deplored the lack of clear lines of accountability between local authorities, clinical commissioning groups, and NHS England following the reorganisation of services in 2013.

Public Health England oversees the public health outcomes framework, which includes sexual health, but there has been no national monitoring of whether the goals set out in the Department of Health framework are being met.

That’s partly down to data streams, suggests Wilkinson. “There are several streams of data that relate to the ambitions of the framework, but they are all in diff erent places and need pulling together, but it’s a huge job.”

He adds: “We used to have a system with much more accountability, right down to service provision.”

“It’s not as if everything was rosy when sexual health was the sole responsibility of the NHS. The system was fragmented then, just like now,” suggests Billington.

Amid the fi nancial gloom, there are many examples of innovative and collaborative practice and signs that a more integrated and holistic approach to sexual health is beginning to

emerge. Some in public health are optimistic about the future.

Andrew Furber, president of the Association of Directors of Public Health, still thinks that sexual health is better off now. “We now have the opportunity to develop integrated services, and include education and prevention rather than just focusing on the clinical.”

Whether the funds are available to realise and sustain this potential remains to be seen. Caroline White is a freelance journalist, London, UK [email protected] Cite this as: BMJ 2016;352:i309 Find this at: http://dx.doi.org/10.1136/bmj.i309

“We need an expansion in training numbers [in sexual and reproductive health]”

“It’s short sighted to allow cuts in preventive work”—John Ashton

little as it can be. It’s really diffi cult to prioritise as they’re all really important programmes for improving the public health.”

The UK Faculty of Public Health estimates that 40-50% of public health funding is spent on services delivered by NHS providers. 2 The faculty’s president, John Ashton, said members were particularly concerned about cuts to sexual health services.

Ashton said, “There has been quite a sharp increase over the last couple of years in gonorrhoea and syphilis and also it looks as though chlamydia has plateaued. That’s an example of how it’s short sighted to allow cuts in preventive work.”

A director of public health in one local authority, who wished to remain anonymous, told The BMJ that the huge cuts to wider council budgets had forced her to ask the

NHS to commission some treatment services to protect them from being axed.

She said, “Where the savings are not being seen to generate a “local government benefi t,” it’s really hard to protect them. So things like cardiac rehabilitation and diabetes prevention might have been funded by the public health grant before, but actually we are now going back to the clinical commissioning group (CCG) and saying that you are going to have to pick that up.”

“Where CCGs are forward thinking, they will fund it. But where they are struggling to balance the books, I think you’ll see those services decline for a signifi cant number of years.” Gareth Iacobucci, news reporter, The BMJ [email protected] Cite this as: BMJ 2016;352:i272 Find this at: http://dx.doi.org/10.1136/bmj.i272

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General prevention (includinglifestyle services and health checks)

Sta�ng and management

Substance and alcohol misuse

Sexual health

Children’s public health

Smoking and tobacco

Weight management

2015-16 2016-17 onwards

Sexual health services: divided and unprotectedHow are sexual health services coping in their new local authority home? Caroline White reports

Since 2013, local authorities in England have overseen the lion’s share of commissioning sexual

health services. The rest is left to the NHS: most contraceptive services, for example, are provided by general practitioners and commissioned by NHS England. So how are the country’s sexual health services faring under this new system, especially as painful government cuts begin to bite?

The BMJ sent freedom of information requests to all 152 local authorities in England to uncover what proportion of public health funds they spent on sexual health and to find out how protected services are from cuts. The results (99% response rate) show that the priority given to sexual health varies widely across councils, with spending varying from less than 10% of their public health budget (seven councils) up to 45% (24 councils).

The freedom of information data that The BMJ obtained (before in-year cuts of 6% were announced last autumn) show that so far only 10 local authorities have cut or restricted access to sexual health services over the past two years, but a further 37 (25% of respondents) indicated that reviews were planned.

Sexual health has been protected partly because many councils are tied into expensive hospital contracts in order to fulfil their statutory duty to provide comprehensive open access contraception and sexually transmitted infection (STI) services. STI testing and treatment services have historically been provided in hospitals, and HIV services are mostly hospital based. However, when contracts expire, local authorities are taking the opportunity to cut costs.

“It’s virtually impossible to see how to make any in-year cuts, because by far the greatest chunk of the budget is spent on hospital

services. These are open access, and NHS trusts are already under enormous financial pressure,” comments Andrew Billington, lead commissioner for sexual health and HIV for the London boroughs of Lambeth, Southwark, and Lewisham.

Soft targetsEvidence submitted to the recent inquiry by the All-Party Parliamentary Group on Sexual and Reproductive Health in the UK indicates that retendered services have changed clinic sites and opening times to cut overheads.1 One area that is being hit is specialist training places in sexual and reproductive health. Local authorities are not responsible for specialist training, but they do commission services that provide it. Expensive training places are a soft target for cuts when health providers are drawing up tenders to attract local authorities with increasingly limited budgets.

“We’ve had cases where the number of trainees has been reduced to make the tender more competitive, but in order to meet our requirements in sexual and reproductive healthcare, we need an expansion in training numbers,” argues Chris Wilkinson, president of the Faculty of Sexual and Reproductive Healthcare (FSRH).

In a survey by the British HIV Association last year, around 22% of the 104 respondents (primarily doctors involved in HIV care) reported that training had decreased or stopped as a result of the commissioning changes, and almost three quarters (72%) thought the quality of HIV care would deteriorate.1

The FSRH says that many general practice services face uncertainty about the future funding of contraception, including long acting reversible contraceptives (LARC), and are therefore not prepared to risk investing in the training required. In November it raised


Cuts to public health spending reported by 50 councils responding to freedom of information requests

Another 10 councils that did not cut services in 2015-16 have outlined proposed cuts from April 2016-17.

The remaining 82 local authorities that responded to the request had avoided service cuts but were considering savings plans. Twenty councils did not respond to The BMJ’s request in time for publication.

From the data provided, The BMJ was able to identify where £26m of savings were made by responding councils in 2015-16. They include £7.5m from general prevention (including lifestyle services and health checks), £3.5m from staffing and management costs, £2.4m from substance and alcohol misuse services, £2.3m from weight management services, £2.3m from smoking and tobacco, £1.4m from sexual health,


FIVE WAYS MINISTERS HAVE DEFINED A “SEVEN DAY NHS”

1 Access to “the services patients need”

In March 2015 David Cameron described “a truly seven day NHS .” He said, “Already millions more people can see a GP seven days a week, but by 2020 I want this for everyone, with hospitals properly staffed especially for urgent and emergency care, so that everyone will have access to the NHS services they need seven days a week.”

2 Diagnostic services at the weekend

Referring in May 2015 to weekend services at Salford Hospital, Cameron said, “Everything is working at the weekend. And as a result, actually, they’ve been able to reduce their costs and provide a better service. Will it be easy to achieve? Of course not. Will it require a lot of hard work to put it in place? Yes, it will.”

3 Consultant care at the weekend

In July 2015 the health secretary for England, Jeremy Hunt described seven day working as “timely consultant review when a patient is first admitted, access to key diagnostics, consultant directed interventions, ongoing consultant review in high dependency areas, and proper assessment of mental health needs.”

4 Being able to see a GP any day of the week . . .

In September 2014 Cameron told BBC Breakfast, “People need to be able to see their GP at a time that suits them and their family. That’s why we will ensure everyone can see a GP seven days a week by 2020.” He added, “We will also support thousands more GP practices to stay open longer—giving millions of patients better access to their doctor.”

Junior doctors’ frustrations go beyond contract changesTom Moberly and Jessamy Bagenal argue that junior doctors’ dissatisfaction goes beyond their concerns over proposed changes to pay and conditions

Junior doctors’ anger over proposals for a new contract has been fuelled by a series of frustrations. Trainees believe that their roles and

jobs are more demanding than those undertaken by their predecessors a decade or so ago and that their job satisfaction and career prospects have been steadily eroded. This has left many feeling that the potential rewards of completing medical training no longer justify the sacrifices required.

Increasing demandDoctors’ jobs seem to be more complex as treatment options expand; patients present with multiple concurrent conditions; and the wishes and expectations of patients and their families are increasingly considered in treatment decisions.

At the same time, expanded regulation of the medical profession and the health service, and the drive to eliminate avoidable harm, seem to be increasing the pressure placed on doctors. Doctors are having to cope with this rising demand while under constant pressure to reduce costs by denying treatment, shuffling patients between wards and hospitals, and reorganising care pathways. This drive

to save money is a distraction from doctors’ focus on patient care and adds another layer of stress to their working lives.

Training and incentivesThe increasing demands being placed on the health service mean that junior doctors are increasingly focused on service provision at the expense of training. In specialties such as surgery, training programmes have not adapted sufficiently to the introduction of restrictions on working hours, leaving some trainees struggling to fulfil their training needs in the hours available.

The UK medical establishment has also been slow to take up innovations used in training elsewhere, such as the move towards competency based education. And trainees in all specialties are expected to complete more and more courses, presentations, and publications in their own free time to gain their next job.

As the demands placed on junior doctors have risen, the attraction of a long term career as a doctor in the health service is diminishing. Over the past decade doctors’ pay has not kept pace with increases in the cost

of living, and many doctors have found that their salaries have fallen in real terms in recent years.

The prospect of working for 30 years as a consultant or a GP also seems less attractive. From the point of view of junior doctors, the status and position of consultants and GPs have been eroded. As medicine has become more based on algorithms and driven by guidelines, it seems to many doctors in training that consultants’ and GPs’ roles have become less autonomous and less intellectually rewarding.

Consultants’ roles have changed as the number of junior doctors working at any one time has fallen and the number of consultants working in the health service has risen. This means that consultants are often taking on roles that were previously the domain of junior doctors. GPs report feeling

The attraction of a long term career as a doctor in the health service is diminishing


BMJ CONFIDENTIAL

Geraldine StrathdeeEnd the mental health stigma

Geraldine Strathdee is a consultant psychiatrist at Oxleas NHS Foundation Trust and national clinical director for mental health at NHS England. She’s refreshingly frank: “There’s an enormous amount spent on mental health—the only problem is, it’s spent on dealing with the adverse consequences of not having given access early to e� ective interventions or having a proper prevention programme,” she told a King’s Fund conference in 2015. She believes that people can be coached into becoming literate about their own mental health and that early intervention will improve self management and avoid lifelong bad outcomes for many.

What was your earliest ambition? To be a multilingual diplomat, negotiating peace and collaboration: the ambition of a child growing up in a community with civil unrest and exclusions [Northern Ireland]. I’ve achieved my ambition, if not quite in the way I’d envisaged. Who has been your biggest inspiration? My patients and my first mentor. I went to medical school planning to be a GP, but I met people with psychoses. I was humbled by their courage, creativity, strength, and humour despite a challenging illness and stigma. My first mentor, the Belfast psychiatrist Alex Lyons, was closing big institutions and establishing therapeutic day centres, primary care clinics, and peer support groups in the 1960s. What was the worst mistake in your career? Several times I’ve taken on big roles without negotiating the resources I need. What was your best career move? Discovering that I’m best suited to a portfolio career, which includes frontline clinical practice and a range of policy, academic, clinical management, teaching, and regulatory roles. Bevan or Lansley? Who has been the best and worst health secretary in your lifetime? There has been a quantum change: on a mental health index, they get better. Who is the person you would most like to thank, and why? The army of frontline community leaders rallying to support mental health. To whom would you most like to apologise? My family and friends, for tolerating my absenteeism and presenteeism in the 16 hour national clinical director role. If you were given £1m what would you spend it on? Communication to end stigma. What single unheralded change has made the most difference in your field in your lifetime? Two huge ones: social media and primary care mental health. What book should every doctor read? An anthology of poems by Georgina Wakefield [see www.georginawakefield.co.uk/7-poems/ ]. One poem, Proud , is a mother’s story of her son who develops a life changing illness, and it conveys the personal pain, the 10 year struggle to get the right treatment, and the family’s unfailing courage and care. What is your guiltiest pleasure? Chocolate and coffee, together, often. Summarise your personality in three words Passionate, committed, loyal. What is your pet hate? Bullies, bigots, and healthcare professionals who just can’t “get” that the mind and body are integral. If you weren’t in your present role what would you be doing? I’d set up an organisation to promote new forms of intelligence and leadership that understand the needs of whole communities and maximise improvement. Cite this as: BMJ 2016;352:h7017

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FIVE WAYS MINISTERS HAVE DEFINED A “SEVEN DAY NHS”

5 . . . but not being able to see “your own GP 24/7”

At the Royal College of General Practitioners’ conference in October 2014, Hunt said, “I want to stress this is not a commitment you will be able to see your own GP 24/7. GPs, just like politicians, need a break, and it is not that commitment. They [patients] may or may not be not speaking to their own GP, but what they will be doing is speaking to a doctor who can access their medical record.”

Why more GPs should become involved in humanitarian workGP Hina J Shahid found that her skills were invaluable when she volunteered to help refugees arriving in Greece

The refugee crisis engulfing Europe is one of the worst humanitarian catastrophes since the second world war. Many doctors read and watch helplessly, wishing they could do something. Medical roles in large humanitarian organisations are often limited to hospital specialists, which is disheartening for general practitioners who wish to help. We were fortunate to find short term work in Lesbos with an international non-governmental organisation (NGO), Salaam Cultural Museum.

Clinical casesHumanitarian crises can affect anyone, and as GPs we are in a unique position to work as generalists on the front line. Our confidence in clinical acumen over precautionary investigations to guide decision making is an asset in resource strapped settings.

We worked in a medical tent on the northern shore, providing primary care to refugees arriving from Turkey in overcrowded flimsy rubber dinghies. Fortunately, most ailments were minor, such as headache, sore throat, cough, and myalgia. Refugees with chronic illnesses had run out of medication, including insulin, warfarin, antihypertensives, antiepileptics, and antidepressants.

We assessed refugees with malnutrition and complications of poorly managed chronic illnesses such as hyperglycaemia, hypertension, and leg ulcers. We also encountered pregnant women who had

not received any antenatal care, and unvaccinated children.

Communication and compassionGood communication skills and compassion are at the heart of primary care, combined with a holistic approach that sees health in the broader context. Although most of the physical ailments we treated were minor, the emotional and mental trauma experienced by refugees was immeasurable. Providing reassurance and support was our main role. A non-judgmental attitude, empathy, and respect for cultural beliefs were important. We reflected regularly on ethics, professionalism, and good practice to guide decisions that were clinically, emotionally, and ethically challenging.

Our experience made us appreciate the immense potential of GPs’ skills and knowledge and their transferability in a range of settings, including humanitarian crises.

Many of us entered medicine wanting to make a difference, but ever increasing demands and bureaucracy coupled with cuts to funding are causing rapidly declining morale among GPs. Medical relief work can help us remember why we went into medicine, appreciate our profession, and provide a sense of meaning. We urge humanitarian organisations, professional bodies, and employers to actively support GPs to undertake humanitarian work.Hina J Shahid, freelance GP, London [email protected]

under increasing workload pressure and are dissatisfied with changes that leave them with more administrative tasks and less time with patients.

Balancing prioritiesThese forces leave many junior doctors wondering how the sacrifices they make to complete training balance against the potential rewards. They know that if they make all the sacrifices necessary to do their best and complete medical training they will gain a well paid job with lifelong job security. But many worry that, at the end of their training, the remuneration and job satisfaction in place then will not make the sacrifices they have made seem worthwhile.Tom Moberly, editor, BMJ Careers [email protected] Bagenal, editorial registrar

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