The“weekend effect”

时间：2016-05-20

发布：Fiona Godlee, Editor in Chief, The BMJ

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“Almost nothing is clear in this tangled tale,” says Martin McKee in his editorial on the so called weekend effect (doi:10.1136/bmj.i2750). So this week we try to help make sense of what we know and what we don’t know about the apparent association between weekend admission to hospital and risk of death (doi:10.1136/bmj.i2781).

Recent weeks have seen a flurry of new analyses attempting to enlighten this increasingly heated and politicised debate. Two papers in particular concluded that data artefacts or case mix (or both) were to blame for the apparent effect. The first, published in the Journal of Health Services Research and Policy (doi:10.1177/1355819616649630), found a higher threshold for admitting patients at weekends, which could explain why those who get into hospital at weekends are sicker and more likely to die (doi:10.1136/bmj.i2598). The second, published in The BMJ this week (doi:10.1136/bmj.i2648), finds that some patients recovering from a previous stroke were coded as having had a new stroke. These patients were more likely to be admitted on weekdays and less likely to die. An analysis limited to patients verified to have had new strokes found no weekend effect.

As an aside, both papers have instructive prepublication stories. The first had been rejected by The BMJ, a fact I can share because the authors told the media, along with the identity of a peer reviewer. This led to criticism of The BMJ and, more troublingly, of the reviewer. In answer we have published, with permission from all parties, the four peer reviewers’ comments and an explanation of our decision to reject (blogs.bmj.com/bmj, 16 May). The second paper was under fast track consideration by this journal when the authors released the headline results to the media last week (doi:10.1136/bmj.i2667). We were disappointed by this behaviour, as it left the public unable to assess the validity of the authors’ claims (bmj.com/about-bmj/resources-authors/media-releases). But given that we had provisionally accepted the paper, and the data had not been released, we agreed to continue with publication.

From these and other studies McKee concludes that at least part of the weekend effect is data artefact and that any remaining association does not seem to be due to medical staffing. To the extent that a weekend effect exists, he says, the evidence based response would be to provide more primary care and more nurses. Some increased funding has now come through for primary care (doi:10.1136/bmj.i2357), but as for nurse staffing all we have is empty rhetoric, says David Oliver (doi:10.1136/bmj.i2665).

What’s needed now is more research into seven day NHS services and less political interference. When the health secretary unaccountably alighted on the junior doctors as his first target he picked the wrong fight for the wrong reasons.

BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2801 (Published 19 May 2016)
Cite this as: BMJ 2016;353:i2801

Supporting the next generation

时间：2016-05-20

发布：Tom Moberly, Editor, The BMJ

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Last week the government and the BMA stepped back from the brink in the escalating dispute over the new contract for junior doctors in England (doi:10.1136/bmj.i2635). The five day “pause” for further negotiations offers a last ditch opportunity to tackle outstanding areas of disagreement (doi:10.1136/bmj.i2572), and junior doctors will have the chance to vote on any proposals (doi:10.1136/bmj.i2663).

Before the pause, the government maintained that there was only one substantive area of disagreement: antisocial hours (http://bit.ly/1NqrNWu). The BMA argued that there were at least seven, including safeguards and protection against working excessive hours (http://bit.ly/1TQnEKz). At the time of writing, it seems clear that both sides will need to make major compromises if they are to close the gap. But even an agreement on these outstanding issues is unlikely to diminish junior doctors’ anger or their animosity towards Jeremy Hunt.

Firstly, because reaching a compromise on these areas would not deal with a key criticism of the new contract: that it is “not safe” (http://bit.ly/1Xl5SC5). The junior doctors argue that, although it is designed to support seven day service provision, the contract is not linked to plans to establish adequate staffing levels, especially those needed to provide a seven day service (http://bit.ly/1YlFbLU). In fact, as the Public Accounts Committee has said, there has so far been “no coherent attempt” by the government to assess the staffing implications of its proposal for seven day services (doi:10.1136/bmj.i2664).

Secondly, the anger that has fuelled the junior doctors’ campaign has its roots in far wider issues (http://bit.ly/1TMyy43) that won’t be resolved by any change to the contract. Despite restrictions on hours, junior doctors’ work has become more demanding in recent decades, while changes to training, support frameworks, and team structures have eroded their job satisfaction and career expectations (http://bit.ly/1T4Ibfy). All these factors have contributed to what Neena Modi and David Oliver each describe as “plummeting morale” (blogs.bmj.com/bmj).

The BMA and the government have acknowledged the need to confront these wider issues. The medical profession as a whole needs to consider what part it can play in reversing the decline in junior doctors’ morale. That means improving medical leadership at a local and national level, and working together to find new and better ways to support the next generation of doctors.

BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2681 (Published 12 May 2016)
Cite this as: BMJ 2016;353:i2681

Healthcare in an interdependent world

时间：2016-05-09

发布：Fiona Godlee, Editor in Chief, The BMJ

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Should the United Kingdom stay in the European Union or should it go, and how would a decision to leave (“Brexit”) after the referendum affect the NHS and doctors’ working lives? John Appleby kicks off The BMJ ’s coverage of the issue with his data briefing this week (doi:10.1136/bmj.i2328). The problem for anyone wanting to make an evidence based decision in the referendum, he says, is the lack of a comprehensive and reliable analysis that weighs up the pros and cons.

We hope to help. Starting next week, a series of articles will look at how Brexit would affect key aspects of health and healthcare: drug availability and regulation, public health, the rights of health professionals, cross border movement of doctors and patients, and finally the funding and business model of the NHS itself.

One person in no doubt about the threat that Brexit poses to the NHS is Martin McKee (doi:10.1136/bmj.i2489). The European Parliament has listened to concerns about international trade agreements, many of which have been taken on board, he says, and so these can no longer justify calls to leave. In light of this, McKee asks us who is more likely to protect the NHS: a parliament in Europe that has made clear its commitment to protect public services or those currently campaigning for Brexit? He reminds us that these include Daniel Hannan MEP, who once described the NHS as a 60 year “mistake.”

Not a mistake but a fiction, says Richard Smith in a BMJ blog (http://bit.ly/1UvUgLZ), made up simply of three values: universal healthcare coverage; provision by need rather than ability to pay; and equal quality of care for all. We haven’t fully realised any of them, he says, and our approach must urgently evolve. “To keep the NHS alive we need to move rapidly from a service dominated by hospitals, doctors, disease, death denial, and drugs and surgery to one that is more about community services, teams including patients, life enhancement, and a wider range of interventions, including urban redesign, changes in food supply, and much more.”

This isn’t going to be easy, but at least the UK has a head start. Other countries are just embarking on the journey to universal coverage, and good information to guide them is lacking. Merely increasing access to poor quality health systems could do more harm than good, says our editorial (doi:10.1136/bmj.i2216), not least in diverting resources from public health and education.

To fill this knowledge gap The BMJ has teamed up with Harvard Global Health Institute to encourage the building of a global evidence base for effective universal coverage. “The world has increasingly come to realise that we are interdependent and that a poor performing health system in one place is a threat to us all.”

BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2511 (Published 05 May 2016)
Cite this as: BMJ 2016;353:i2511