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• NHS should have a 4% funding rise every year until 2030, peers are told

• Collapse of £800m NHS contract was “grossly irresponsible,” say MPs

• US task force recommends statins in healthy people despite limited benefits

Incontinence drug risks are too highThe antidepressant duloxetine shouldn’t be used to treat stress urinary incontinence in women because the harms outweigh the benefits, authors of a new study have said.

Although duloxetine reduced the symptoms of stress urinary incontinence and improved women’s quality of life, the harms related to suicidality and violence were 4-5 times more common with duloxetine than with a placebo, a Nordic Cochrane Centre meta-analysis showed.

The researchers analysed clinical study reports submitted to the European Medicines Agency for approval of duloxetine for stress urinary incontinence. One of the authors, Peter Gøtzsche, told The BMJ that the conclusions could not have been drawn by looking only at published trials.

“Our systematic review underlines that antidepressants not only increase the risk of suicide in children and adolescents but also in much older people,” he said. “The women in the trials had a mean age of 52 years.”

The authors said,“Given the uncertainty as to whether duloxetine leads to clinically significant improvement in quality of life . . . we question the rationale for using duloxetine for stress incontinence.”

Gøtzsche advised doctors treating women for stress urinary incontinence with the

selective serotonin and noradrenaline reuptake inhibitor to gradually withdraw it.

Duloxetine, manufactured by Eli Lilly, has been approved in Canada, Europe, and the US for the treatment of major depressive disorder. It is also approved in Europe for the treatment of stress incontinence—marketed as Yentreve. In 2015, over £1.3m was spent in England on prescriptions for Yentreve.

Of 1913 women, 187 in the duloxetine group and 42 in the placebo group experienced core or activation events such as self harm, agitation, anxiety, and psychotic behaviour. The risk of discontinuing because of an adverse event was more than five times as high among patients receiving duloxetine as in the placebo group.

Gøtzsche said: “Given that the slight effect we found of duloxetine on urinary incontinence was questionable, whereas duloxetine increases the risk of suicide, I do not consider it justifiable to use duloxetine for stress urinary incontinence.”

J Scott MacGregor, global communications director for Eli Lilly (US), said, “Lilly remains committed to duloxetine and its safety and benefits.”Barbara Kermode-Scott, Vancouver IslandCite this as: BMJ 2016;355:i6103

Cochrane’s Peter Gøtzsche said, “I do not consider it justifiable to use duloxetine for stress urinary incontinence”

the bmj | 19 November 2016 295

SODA TAX page 297 • VIRGIN CARE CONTRACT page 298 • BABY CAR SEATS page 299

SEVEN DAYS IN

NHSNursing assistants are linked to higher death riskReplacing professionally qualified nurses with lower skilled nursing assistants is linked to a raised risk of patient death and other indicators of poor quality care, a large European study showed in BMJ Quality and Safety. In every 25 patients just one professional nurse substitution was associated with 21% higher odds of dying in a hospital with an average nurse staffing level and skill mix, the findings showed, prompting researchers to conclude that “diluting” the hospital nurse skill mix “is not in the public interest.”

Public must pay for better NHS, says StevensPeople must pay more if they want a better NHS, the chief executive of NHS England said. Asked about the possibility of rationing NHS services at the King’s Fund’s annual conference in London on 9 November, Simon Stevens (right) said that he would have to be “persuaded of the

benefits” of limiting healthcare, adding, “At some point the British people will need to put their hands in their pockets if they want to see continued improvement and growth in what the NHS can do for each and every one of us.” (doi:10.1136/bmj.i6069)

General practiceSchools demand antibiotics for conjunctivitisAn estimated 160 000 appointments a year could be freed up at UK general practices if schools stopped sending home children with infective conjunctivitis, the Royal College of General Practitioners claimed. It said that some schools defy clinical guidance by refusing to admit children with the condition

unless they have an antibiotic prescription. It has written to the schools regulator, Ofsted, to request that nurseries, preschools,

and other childcare providers rethink policies that unintentionally “clog up” the GP appointments system. (doi:10. 1136/bmj.i6109)

Public healthNHS can fund HIV prevention drugNHS England does have the power to commission pre-exposure prophylaxis (PrEP) for HIV infection, the Court of Appeal found. The case arose after NHS England refused to include PrEP using Truvada (tenofovir disoproxil/emtricitabine) in a list of potential specialist services. It argued that preventing HIV infection was a public health obligation and that local authorities should pick up the tab. The ruling means that NHS England must consider commissioning PrEP, at an estimated cost of £10m-£20m a year. (doi:10.1136/bmj.i6082)

RegulationGP is struck off for poor care of three patientsKlaas Bogena, a GP in Germany who then worked as an out-of-hours locum in Cornwall, was struck off the UK medical register for providing inadequate care to three patients in 2013 and 2014. In one case, “Patient A,” who was 33 weeks pregnant and an insulin dependent diabetic patient, saw Bogena out of hours to complain of vomiting, headache, and lower back pain.

He prescribed migraine drugs and told her to stop her insulin. That night she was diagnosed with diabetic ketoacidosis in hospital. She delivered a stillborn baby eight hours after seeing Bogena. (doi:10.1136/bmj.i6076)

Research newsSponge test for Barrett’s oesophagus

Researchers used the “cytosponge”—a pill on a string that expands when swallowed—to collect throat cells in nearly 500 people with Barrett’s oesophagus. They found that 35% (162) were at low risk of developing oesophageal cancer by looking for genetic markers and cell changes and combining these with information such as age and obesity. “Compared with endoscopies performed in hospital, the cytosponge causes minimal discomfort and is a quick, simple test that can be done by a GP,” said the lead researcher, Rebecca Fitzgerald. (doi:10.1136/bmj.i6080)

Antibiotic prescribing by GPs in England has fallen markedly in the past year, show figures from Antibiotic Research UK, a charity created to develop new antibiotics.

The average prescribing rate has fallen by over 5% in a year, dropping from 0.63 antibiotic prescriptions per head of population in 2014-15 to 0.59 a person in 2015-16, and by 11% since its peak in 2012. Most importantly, seasonal variation has halved from 68% to 31% in a year, suggesting that GPs are prescribing fewer antibiotics for winter colds caused by viruses.

However, analysis of GPs’ prescribing data from August 2010 to August 2016 by the analytical database company EXASOL showed that one antibiotic prescription is still given out every second in England and that regional variation remains high.

The district of Tendring in Essex—which has a high elderly population, and has the most deprived town in the UK (Jaywick)—is the highest prescribing district in the country, prescribing 40% more antibiotics than the average. In contrast, three areas that were in the top 10 for high prescribing in 2014-15 have made progress: Rochdale in Greater Manchester, Halton in Cheshire, and Wakefield in West Yorkshire all achieved double digit percentage decreases. Overall, 14 districts cut prescribing by more than 10%.

Antibiotic use falls more than 5% in a year

Ingrid Torjesen, London Cite this as: BMJ 2016;355:i6115SPL

296 19 November 2016 | the bmj

Stroke prevention drugs are underusedJust over half (54%) of patients (9579/17 680) with a first stroke or transient ischaemic attack had not received at least one prevention drug that was clinically indicated, an analysis of UK primary care data found: 49% had not received lipid lowering drugs, 25% were not given antihypertensives, and 52% of patients had not received anticoagulants. “We estimate that approximately 12 000 first strokes could potentially be prevented annually in the UK through optimal prescribing of these drugs,” said researchers. (doi:10.1136/bmj.i6105)

Maternity servicesPilot sites to improve services are namedSeven sites were named as early adopters of recommendations set out in February’s Better Births report to test ways to transform England’s maternity services. The sites are sustainability and transformation plan areas in Birmingham and Solihull, Cheshire and Merseyside, Dorset, north central London, northwest London, Somerset, and Surrey Heartlands. They will test ideas such as using small teams of midwives, making better use of electronic records, and improving postnatal care.

NICE recommends test for fetal rhesus D status Maternity services should offer pregnant women who are rhesus negative a test to identify the status of their fetus, under final NICE guidance. Non-invasive prenatal testing during routine antenatal appointments analyses the baby’s DNA. This test means that only women whose baby is rhesus D positive will be treated with anti-D immunoglobulin, saving more than £500 000 a year spent treating 40 000 women who do not need anti-D.

A ‘SODA TAX’? WE’RE NOT IN THE US (THANK GOODNESS!)I know, but soda sounds much snappier than sugar sweetened beverages. Anyway, the NHS has launched a consultation on whether to introduce a levy on the sale of sugary drinks or to ban them from NHS premises. NHS England’s chief executive, Simon Stevens, said he did not want hospitals to be “marketing joints for junk food and unhealthy sodas.”

QUITE RIGHT, PATIENTS SHOULD NOT BE EXPOSED TO UNHEALTHY FOODNor should staff and visitors, says Stevens.

SO WHAT’S THE PLAN?Under the first proposal the levy would be paid by the vendor directly to the hospital or NHS host organisation. That money would then have to be spent on staff health and wellbeing or donated to charity.

OH, NO, NOT MORE FREE ZUMBA CLASSES. MAYBE A BAN IS BETTERIn a two month trial at Liverpool’s Walton Centre NHS Foundation Trust, sugared drinks were removed from cafes and restaurants. Sales of drinks rose by 0.1% during the trial, and the increased volume of non-sugary drinks sold almost exactly matched the volume of sugary drinks removed, “suggesting the intervention was highly effective in bringing about change in consumers’ purchasing behaviours,” said a government report. The ban remains.

HASN’T THE GOVERNMENT ALREADY ANNOUNCED A SUGAR TAX?Indeed. In this year’s budget the then chancellor, George Osborne, announced that from April 2018 manufacturers will have to pay a tax on any drink with more than 5g of sugar per 100 mL, as a key part of the childhood obesity strategy. Details will be included in next year’s finance bill.

ANYONE ELSE HAVE A SUGAR TAX?You may not have noticed, but last week

US voters in the California cities of Oakland, Albany, and San Francisco

opted for a tax on soda after the introduction of a tax in Berkeley in 2014 led to a 20% fall in sales

of sugary drinks in the poorest neighbourhoods. Mexico and France have also seen reductions in consumption after similar taxes.Anne Gulland, LondonCite this as: BMJ 2016;355:i6094

SIXTY SECONDS ON . . . SODA TAXES

BREAST CANCERIn England

25% of black African women

and 22% of black Caribbean women are diagnosed with breast cancer at stage three and four, compared

with 13% of white British women, show figures from Cancer Research UK and Public Health England

MEDICINE

AntibioticsStop antibiotic misuse in farming, say doctorsFifteen senior medics, including presidents of 13 royal colleges, wrote to the UK government calling for urgent action to tackle the routine misuse of antibiotics in UK farming. They called on Jeremy Hunt, England’s health secretary, and Andrea Leadsom, secretary of state for environment, food and rural affairs, to ban the routine preventive mass medication of animals, curb farm use of “critically important” antibiotics, and support action during upcoming negotiations in Europe.

Climate changePlan to phase out coal power is welcomedThe UK Health Alliance on Climate Change welcomed the UK government’s plan to phase out coal power by 2025. A consultation document outlined government plans to fulfil a 2015 pledge to replace coal power with cleaner technology, such as gas, to help significantly reduce emissions from the UK’s energy use. It set out a roadmap for closing unabated coal power stations by 2025 and suggested proposals for constraining coal generation by 2025. The alliance said that ending coal power would prevent 1600 premature deaths and save as much as £3.1bn in health costs each year. (doi:10.1136/bmj.i6066)Cite this as: BMJ 2016;355:i6106


GPs on a clinical commissioning group and local councillors have awarded a contract that could be worth £700m to the private health company Virgin Care to run or oversee 200 types of NHS and social care services to people in Bath and northeast Somerset.

The decision, announced last week, will be one of the largest handovers of public services to a private firm when the deal begins next April.

Three year extensionBath and North East Somerset Clinical Commissioning Group (CCG) and Bath and North East Somerset Council announced on 10 November that they had awarded a seven year contract to Virgin Care. The contract, worth £70m a year, has the option to extend for a further three years, meaning it could be worth £700m between 2017 and 2027.

The decision was made, said the CCG, after extensive consultation with service users, members of the public, and health and care professionals.

Under the agreement, Virgin Care will deliver some services directly, as part of a mental health collaboration, and will subcontract others. The services include community health and care services such as diabetes nursing, physiotherapists, speech and language therapy, independent living services, and district nurses, together


GPs award £700m contract to Virgin Carewith mental health services, public health nursing, the NHS Health Checks programme, and dementia support.

A CCG spokesman said it wanted community services to work with general practices through specific hubs that align with the area’s 26 practices, allowing for closer collaboration.

The other bid for the contract was from a local consortium led by Sirona Care and Health, a not for profit firm, partnered by NHS trusts and charities.

“Right organisation”Ian Orpen, the CCG’s clinical chair, said, “Following a very rigorous procurement process, the CCG board is assured that Virgin Care is the right organisation to deliver the personalised and preventative care that local people have asked for.

“We will work closely with the council and Virgin Care to ensure that services and staff are transferred across safely on 1 April 2017, and to minimise disruption to the care and support that people currently receive.”

However, Chaand Nagpaul, chair of the BMA’s General Practitioners Committee, told The BMJ, “The BMA believes services should be delivered by NHS providers who have the experience, expertise, and commitment to the values of the NHS necessary to provide patients

History has shown that private sector companies are driven by desire to make a profit – Chaand Nagpaul, BMA

Failure to engage clinicians and the public is hindering the development of plans to reconfigure NHS services in England, an analysis by the King’s Fund think tank has concluded.

The 44 draft sustainability and transformation plans to improve services and save money have been drawn up in haste by the NHS and local authorities, the report said. MPs, local authorities, and patients’ groups have criticised the process for its lack of transparency. The King’s Fund interviewed senior leaders from four STP areas for the report, which found

1LIMITED INPUT There has been a lack of time to

adequately involve clinicians and staff, a lack of public consultation, and a patchy local council role.

2 CONFUSED GUIDANCE STP leaders were confused

by unclear guidance from national NHS bodies and were hamstrung by a lack of a governance structure or formal authority in their roles.

3WAY FORWARD STPs represent “the best hope”

for health and care services but “meaningful engagement” with clinicians, local authorities, and the public is essential.

4CLARITY OF ROLE Governance role of STP

leaders needs to be clarified and NHS regulation changed to enable organisations to collaborate.

5TEST PROPOSALS National NHS bodies must

“stress test” plans to ensure they are credible and that proposed changes are realistic.

6NO PLAN B Chris Ham, King’s Fund chief executive,

said, “The introduction of STPs has been frustrating for many, but it is vital we stick with them. If STPs do not work there is no plan B.”Gareth Iacobucci, The BMJ

Cite this as: BMJ 2016;355:i6090

The sweep by Republicans in the US elections last week that secured the presidency and both houses of Congress gave them a free hand to overturn President Barack Obama’s signature legislative accomplishment, the Affordable Care Act, but also brings other important changes.

AbortionBefore the election Trump said that he would nominate “pro-life” justices to the Supreme Court who would overturn the court’s landmark 1972 Roe v Wade decision that established a woman’s right to an abortion in the US. Trump also promised to repeal provisions in the Affordable Care Act that require

US election threatens abortion rights

“STPs need transparency”

‘‘We don’t have precise figures on how many babies die in car seats, because there is no central collection of data.

But, based on findings in our region, we estimate that 10 to 15 babies die suddenly of unexplained causes in car seats in the UK each year. This compares to only one, or less, dying as a result of a road traffic accident.

“Infant car seat manufacturers have carried out a huge amount of research on how they prevent injury in crash situations. But they have not looked at the baby’s safety just sitting in a moving car.

“We carried out a pilot study to look at the physiological effect of vibration on infants. When a baby is put in a car seat in a car the angle is steeper, at around 40°, compared with about 30° when [the seat is] flat on the floor. The angle has to be steeper for the safety system dynamics to work.

“Once a car is moving, the seat is shaken about. We measured oxygen saturation and respiratory and heart rates in babies aged 2-3 weeks while lying flat, static in a car seat at 30° and at 40°, and at 40° during simulated motion of a 30 mph [48 kph] car journey.

“We found very little effect on the babies’ breathing rate, heart rate, or saturation at 30°, but at 40° babies started to show desaturation, and their heart rate and breathing rate increased. The frequency of desaturation increased with duration of sitting, and adding very gentle vibration greatly increased the potentially adverse cardiorespiratory effects, with a striking increase in desaturation.

“We discussed our findings last week with the Lullaby Trust, which funded our study, and car seat manufacturers, which are taking this very seriously. We are planning a larger study, using car seats fitted with sensors.

“For now, we recommend avoiding journeys longer than 30 minutes for babies in their first 2-3 weeks. If longer journeys are essential, have an adult sitting with the baby to watch for signs of distress. It is also important to lie a baby flat to sleep at the end of a journey.”

Susan Mayor, The BMJCite this as: BMJ 2016;355:i6104

FIVE MINUTES WITH . . .

Peter Fleming The infant health expert explains the implications of his research questioning the safety of infant car seats

GPs award £700m contract to Virgin Care

with the most effective and safe care. History has shown that private sector companies are driven by a desire to make a profit, which can lead to a focus on providing services at the lowest possible cost.”

A petition by the campaign group 38 Degrees saying, “If this contract is awarded to Virgin, it will contribute to

the rapidly advancing privatisation of the NHS” has been signed by almost 3000 residents.

A Virgin Care spokesman said, “We are really pleased to have been chosen to deliver more joined-up care across Bath and northeast Somerset.”Adrian O’Dowd, LondonCite this as: BMJ 2016;355:i6130


PETER FLEMING, professor of infant health and development physiology, Bristol University

insurers to provide free contraceptive services. Campaigners are urging women to get health coverage through the Affordable Care Act while they still can and to avail themselves of free contraceptive services.

MarijuanaVoters in California, Nevada, Maine, and Massachusetts agreed to legalise the recreational use of marijuana, joining Colorado, Oregon, Alaska, and Washington. The ballot victories mean a fifth of US residents can now legally use marijuana recreationally. Arkansas, Florida, and North Dakota voted to legalise the medical use of marijuana, while in Montana voters passed a measure to loosen restrictions on doctors prescribing the drug.

Soda taxIn California, Albany, Oakland, and San Francisco followed Berkeley by introducing a 1 cent per ounce tax on sugar sweetened beverages (See 60 Seconds, p 297).

Lethal drugs for terminally ill patientsColorado voters passed a law to let doctors prescribe lethal drugs to patients who are expected to die within six months, joining California, Montana, Oregon, Vermont, and Washington, which have similar laws.

Death penaltyVoters in Nebraska chose to reinstate the death penalty.Michael McCarthy, SeattleCite this as: BMJ 2016;355:i6138

US election threatens abortion rights

SPL


Talks over a new contract for UK consultants have been under way for more than three years, and full details of the contract

offer were due to be published at the end of 2015 (box). But progress has been slow and, beyond some information presented at the BMA’s consultants’ conference in March, full details of what consultants can expect have yet to emerge.

Last month the department gave some details about the headway being made in its annual submission to the Review Body on Doctors’ and Dentists’ Remuneration (DDRB).

The government said the aim for negotiations was to develop a “better” contract that rewarded consultants more fairly, engaged consultants as senior decision makers, and improved support for seven day services.

One of the reform drivers, the government said, was a review of consultant clinical excellence awards, which “highlighted the need to look at the totality of the reward package for consultants,” and a Public Accounts Committee report that recommended “linking pay to outcomes.”

The government said that NHS Employers and the BMA continued

to engage in “constructive discussions” but negotiations were paused in October 2014 when the BMA withdrew.

Talks resumed in September 2015, after publication of a DDRB report that, the government said, took into account evidence from organisations including the royal colleges and the BMA. It made several observations on contract changes which were accepted by the government.

Among its recommendations was to remove the “opt-out” clause that enables consultants to choose whether to provide non-emergency weekend care.

“Building on these observations, the renewed discussions with the BMA have been constructive and are continuing,” the DDRB said.

Earlier this year consultants voted against stopping talks despite unhappiness with the government’s proposals. Delegates at the BMA’s consultants’ conference in March were told that there had been no firm offer and that the health department was “negotiating in bad faith.”

SAS contractsIn its submission to the DDRB, the Department of Health also said that it was likely that staff and associate

What’s happening with the consultant contract negotiations?Details of talks on a new contract for consultants have been published by the Department of Health. Abi Rimmer reports

1 FOR MEDICINE IS HARDER FOR MEN

“We have lopsided the entry criteria to be biased towards us, because we are cleverer at a younger age, much more diligent, much more able to pass exams.”Clare Gerada, former chair of the Royal College of General Practitioners

2 FOR BANG FOR BUCK

“Consider that women are more likely to work part time than men. Therefore the efficiency of training female GPs is lower than training male GPs. With male doctors you get more bang for your buck.”Paul Gosney, year 5 specialty trainee in general psychiatry

3 FOR WORKFORCE ISSUES

“If we don’t start to increase the number of men entering our profession, we are going to run into serious workforce problems. For every man retiring we have to replace him with 2.2 women.” Clare Gerada

4AGAINST LEVEL PLAYING FIELD

“If my son wants to go to medical school, all he has to do is work as hard as my daughter; that is a level playing field.” Victoria McCormack, specialty registrar in anaesthesia and intensive care medicine

SHOULD THERE BE QUOTAS FOR MEN IN MEDICINE?

At its autumn conference the Medical Women’s Federation held a tongue in cheek debate. Here are some of the arguments for and against

Consultants voted against stopping talks despite unhappiness with the proposals

Developing the new contract

December 2012: DDRB adviceThe DDRB recommends that pay for most UK consultants should be limited to the first five points of the current eight point pay scale, and high performing consultants should be moved on to a new “principal consultant” grade.

October 2013: Talks startContract negotiations for consultants and junior doctors begin, with NHS Employers announcing that it has been given a formal mandate to negotiate with the BMA.

October 2014: Talks stallNegotiations between the BMA and the government on consultant and junior doctor contracts come to a standstill.

November 2014: Referral to DDRBThe government asks the DDRB to develop recommendations about changing the consultant contract following the breakdown of negotiations with the BMA.

September 2015: Talks restartConsultant contract negotiations resume between the BMA and NHS Employers.


The BMA has given up its ability to take industrial action over changes to the junior doctor contract in England.

In an email to members sent on 10 November, Peter Campbell, interim chair of the BMA’s Junior Doctors Committee (JDC), said that it had decided to end its current mandate for industrial action. The decision means that there would need to be a fresh ballot before any future industrial action could take place.

The phased implementation of the new junior doctors’ contract began in October, with trainees in obstetrics being the first to move onto the new terms and conditions.

Expressing support for the decision, Ben Dean, an orthopaedic registrar in Oxford, said, “The BMA’s decision is eminently sensible and strategic. It is time to take stock, to gather evidence and opinion, while assessing whether the government is genuinely willing to listen to the concerns of junior doctors.”

Michael Moran, a clinical lecturer and ear, nose, and throat registrar in London, said that he understood the BMA’s decision but that members were concerned about the clarity of the association’s communication.

“I would now prefer focused negotiations between key individuals—as opposed to widespread industrial action—and I believe in those on the JDC and in their commitment to work as our elected representatives in negotiations with the government,” he said.

“That does not mean that JDC negotiators have my blessing to

concede to the government’s wishes, and I do not predict that they will.

“On a practical level, with rota gaps across the board as we enter the winter season, I feel that most junior doctors would simply be too busy to follow every step in the negotiation process and should instead have faith that the interests of the JDC will mirror their own. Now, more than ever, we need to stand united as a profession.”

Writing on Twitter, Emma Coombe, a paediatric junior doctor in Devon, said, “Am I the only one relieved that the mandate for strikes has now been withdrawn by BMA JDC?”

Working togetherIn his message to junior doctors, Campbell said that the Junior Doctors Committee had decided that it would achieve the best outcome for its members by working with the government and NHS Employers to monitor the implementation of the contract and raise additional issues.

“To this end, the committee has taken the decision to end the current mandate for industrial action and re-engage with the government and NHS Employers, as well as work with Health Education England to ensure they implement the programme of improvements to your working lives,” Campbell said.

The committee will meet again on 2 December to review progress and answer questions from members.Abi Rimmer, BMJ CareersCite this as: BMJ 2016;355:i6116

specialist doctors would have their contracts renegotiated after changes had been made to the consultant contract.

“The SAS contracts include incremental pay scales, though progress is linked to meeting specified criteria, with additional criteria at threshold one and further additional criteria at threshold two,” it said.

“There might be a case for some alignment of arrangements; for example, unsocial hours periods and the payment structure for work at those times.”

But it added that there were no immediate plans to make changes to SAS contracts.

“In the absence of any evidence of pressing concerns, or any recommendation from the review body that immediate changes are needed, our intention is to consider this once we have agreed and begun to implement changes for consultants and for doctors and dentists in training,” it said.

A BMA spokesperson said, “The SAS contract currently isn’t under review and we haven’t been approached about any future review.”Cite this as: BMJ 2016;355:i6114

BMA gives up strike mandate on junior doctor contract

SHOULD THERE BE QUOTAS FOR MEN IN MEDICINE? The decision is eminently sensible and strategicBen Dean, left, orthopaedic registrar

5AGAINST LEGALITY

“A revision to the [2010] Equality Act would be required, and I somehow don’t see that. Moreover, the reputational damage to the federation would be immense.” Michael Rawlins, chair of the Medicines and Healthcare Products Regulatory Agency

Now more than ever we need to stand united Michael Moran, ENT registrar

A new exhibition in London considers a fundamental, yet little examined, aspect of life at the capital’s former Foundling Hospital: food. “Feeding the 400” represents the multifaceted effect of food and eating regimens on children at the hospital from 1740 to 1950.

The exhibition at what is now the Foundling Museum shows how the institution’s food choices were far more than just questions of economy, nutrition, and health. In addition to the physical realities of food at the hospital, Feeding the 400 considers its social context, the children’s experience of eating, and testimonies from former pupils.

Curator Jane Levi said, “Far from the miserable gruel of the stereotypical workhouse, the foundling children ate three balanced meals a day off Spode china. However, they had to eat in silence; their Sunday dinners were often open to spectators; and the quality of the ingredients the staff fed them was not always exactly what the governors had in mind.

“Their food helps us to understand many of the complexities of growing up as a foundling.”

Feeding the 400 runs until 8 January 2017 (http://foundlingmuseum.org.uk/events/feeding-the-400)Cite this as: BMJ 2016;355:i6154


THE BIG PICTURE

No gruel, and Spode china: eating at the Foundling Hospital

The boys’ dining room, Foundling Hospital 1940s


BMJ CONFIDENTIAL

Helen Stokes-LampardGP leader and champion

Helen Stokes-Lampard, 46, becomes chair of the Royal College of General Practitioners this week, succeeding Maureen Baker. Currently a GP partner at the Cloisters Medical Practice in Lichfield, she qualified at St George’s Hospital Medical School in London and has combined primary care with research and teaching at the University of Birmingham since 2000. She was clinical director of the Primary Care Trials Unit until 2012 and then head of undergraduate GP teaching, and she has been a mentor for doctors in difficulties in the Midlands. She believes that funding for core general practice should increase to 11% of the NHS budget to avert the collapse of primary care and that, if general practice thrives, the NHS can survive.

What was your earliest ambition?To beat my dad, at anything.Who has been your biggest inspiration?My dad. His values driven ethos has underpinned everything he’s done, and he always encouraged me to be the best that I could be while being true to myself.What was the worst mistake in your career?I don’t believe that I’ve made mistakes. Everything I’ve done has provided valuable experience. I’ve learnt more from some of my failures than from my more overt successes.Who has been the best and the worst health secretary in your lifetime?Being health secretary is a terribly difficult job, and I’m not sure that I can judge, as it takes decades to be sure of any one person’s impact.If you were given £1m what would you spend it on?We need to encourage new doctors to seriously consider a career in primary care, so I’d invest in initiatives to showcase the amazing diversity of what goes on, the career opportunities, the academic opportunities, and the intellectual challenge.Where are or were you happiest?In the company of friends and family, sharing a good meal while having great conversations and laughing together.What single unheralded change has made the most difference in your field?The increasing use of IT in the clinical environment. Being able to search clinical notes, undertake meaningful audit, and conduct pragmatic research on our complex multimorbid patients is transforming the way we work. Do you support doctor assisted suicide?Yes, because I really do value control in my own life and would want that option for the people I care for. However, it’s a desperately personal issue.What book should every doctor read?I’m a big fan of Iona Heath, Ben Goldacre, and, recently, Margaret McCartney. But I recommend reading any book as an escape from the stress of being a doctor.What is your guiltiest pleasure?Champagne truffles, really good quality ones . . . but strictly rationed to just one a day, so that they last longer.

What, if anything, are you doing to reduce your carbon footprint?I walk and take the stairs whenever I can, as well as using public transport when possible (and I’m now adept at working on trains). My colleagues laugh at my “walking shoes”/high heels transitions, and I’m frequently seen in the Royal College of GPs’ headquarters running upstairs carrying my heels.What personal ambition do you still have?To make a positive difference in general practice.Summarise your personality in three wordsEnergetic, enthusiastic, dedicated.Do you have any regrets about becoming a doctor?None whatsoever. I love being a doctor. I found my niche.Cite this as: BMJ 2016;355:i6089

ILLUSTRATION: DUNCAN SMITH


EDITORIAL

Sustainability and transformation plans: a troubled startChanges envisaged by the STPs can work if the right decisions are taken now

Ever since 1948 the NHS in England has needed an intermediate tier between the national and the local to plan and

govern services. So, it is no surprise that three years after the 2012 Health and Social Care Act removed strategic health authorities, NHS England reintroduced regional governance in the form of sustainability and transformation plans (STPs).

STPs are a way of introducing regional planning without formal reorganisation, a workaround designed to avoid the cost of creating an intermediate tier and legislative changes. They bring together NHS commissioners and providers with local government, and inject greater collective urgency into decision making on integration, reconfiguration, and development of “place based” health and care services. Encouragement comes in the form of additional finance from the Sustainability and Transformation Fund.

The varied progress of the 44 STPs is captured in an insightful report from the King’s Fund that focuses on their establishment (January to July 2016). Interviews with senior staff in four geographically diverse STPs show that, although some progress has been achieved in a short time, there are serious threats to success.

The first is that those entrusted with the task, although talented, have no formal authority. This is exacerbated by lack of resources. There is no additional budget, so local leaders have to cram their STP work into already highly pressured jobs. In addition, leaders believe there is insufficient know-how, both locally and at the centre, on how to shift from a formally competitive system to a collaborative one. And the government’s

requirement for local health economies to achieve financial balance jeopardises local initiatives.

Concerns about participationThe report also raises concerns about participation. Acute hospitals continue to dominate, encouraged by their financial difficulties; local authority involvement is variable, despite its strategic importance; GPs participate as secondary care commissioners rather than primary care providers; and the public has largely been excluded until plans are well developed.

Finally, transformation to a collaborative culture of governance struggles against the persistence of competitive requirements. Despite attempts to change, the national governance framework remains oriented to the performance of individual provider organisations rather than places. Tension is perceived between NHS Improvement’s and the Care Quality Commission’s focus on provider performance, and NHS England’s requirement for STPs to consider system-wide performance. Locally, this leads to relational difficulties.

Support for changeGiven that the expectations of STPs are immense, are there ways to enhance their prospects of success? Reflecting

on the King’s Fund report, the main thing to emerge is the need to bolster governance arrangements. A series of similar initiatives in the recent past have stalled at the vision and broad planning stage because there was no robust way of reaching agreement and making decisions stick across separate organisations. Local governance and decision making processes do not seem up to the task. All that has been achieved so far is a set of plans. While wholesale structural reorganisation can be avoided, changes to governance arrangements seem necessary.

Expecting radical change to take place on the basis of an informal cooperative model is not realistic within a system that continues to hold competing individual organisations hierarchically accountable. The government could take the lead—for instance, by rejuvenating the care trust option introduced in 2001, which allows local integration of commissioning and provision of health and local authority services in a single organisation.

The government also needs to be realistic in its expectations of how long it will take to realise the profound changes envisaged, and widely supported, in the Five Year Forward View, and what can be provided with the current uniquely constrained level of resources. That leaders have, in some STPs, made progress at all is an achievement.

Uncomfortably, such successes often reflect local cooperation going back over a decade or more. Further success seems to be dependent on local organisations being prepared for greater pooling of resources and sovereignty while ensuring transparency. With no obvious alternative, the public and the health and care system need STPs to succeed.Cite this as: BMJ 2016;355:i6064Find this at http://dx.doi.org/10.1136/bmj.i6064

Nick Black, professor of health services research Nicholas Mays, professor of health policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine [email protected]

That leaders in some STPs have made progress at all is an achievement

Authors

Hugh Alderwick

Phoebe Dunn

Helen McKenna

Nicola Walsh

Chris Ham

November 2016

Sustainability and transformation plans in the NHSHow are they being developed in practice?


For too long the debate about illicit drugs has been dominated by ideology. Punishment may deter drug use, but at what cost? Other countries are doing things differently. Doctors, with their expertise and rational and humane approach, should lead calls for pragmatic policies that prioritise health, human rights, and respect for dignity, as we explore in the next six pages

Why drug policy should put health first


EDITORIAL FIONA GODLEE AND RICHARD HURLEY

A quarter of a billion adults—one in 20 worldwide—took an illegal drug such as cannabis, cocaine, or heroin in 2014.3 A quarter of 15 year olds in the UK have ever

taken an illegal preparation of unknown quality and potency,4 and most street sex work and much acquisitive crime funds drug taking.5 6

Three United Nations treaties seek to “advance the health and welfare of mankind” by prohibiting the non-medical use of some drugs. To this end, countries criminalise producers, traffickers, dealers, and users at an annual cost of at least $100bn.7

But this “war on drugs” too often plays out as a war on the millions of people who use drugs.

Prohibition and stigma encourage less safe drug consumption and push people away from health services.1 Sharing of injection equipment has led to huge epidemics of bloodborne infection, including HIV and hepatitis C.1 And just one in every six of the 29 million people worldwide with a drug use disorder received treatment in 2014.3

The ideological goal of a “drug-free world” encourages ideologically driven medical practice. The UK government’s promotion of abstinence at the expense of proved maintenance treatment may have contributed to a doubling in opioid related deaths between 2012 and 2015.

All wars cause human rights violations, and the war on drugs is no different. It is no surprise, then, that there have been calls for reform, including from the World Health Organization, UNAIDS, the UN Development Programme, and the UN human rights agency,15 as well as non-governmental organisations,16 former heads of state,10 UK parliamentarians,17 some law enforcers, and medical journals.

Many countries have removed criminal penalties for personal drug possession. Portugal replaced criminal sanctions with civil penalties and health interventions 15 years ago.10

Jurisdictions such as Canada and several US states, now including California, have gone further, to allow regulated non-medical cannabis markets, retaking control of supply from organised crime. The Netherlands has

tolerated regulated cannabis sales for decades.Of course, drug use without medical

indication has particular risks, and harmful substances should not be available without restriction. Tough enforcement of prohibition surely reduces drug use but at what cost? Jurisdictions with low drug use—for cultural reasons perhaps—have less impetus for change. But where harms are higher there is an imperative to investigate more effective alternatives to criminalisation of drug use and supply.

This year a thorough review of the international evidence concluded that governments should decriminalise minor drug offences, strengthen health and social sector approaches, move cautiously towards regulated drug markets where possible, and scientifically evaluate the outcomes to build pragmatic and rational policy.1

Different drugs with different harms in different contexts may need different approaches. And any change must be supported by investment in evidence based education and treatment services.

Health should be at the centre of this debate and so, therefore, should healthcare professionals. Doctors are trusted and influential and can bring a rational and humane dimension to ideology and populist rhetoric about being tough on crime.

Some doctors’ organisations have called loudly for change, including the Faculty of Public Health.19 Recent BMA policy is for the Department of Health to take responsibility for UK drug policy and for “legislative change” to prioritise treatment over punishment of drug users.20 But such calls are far from universal—and far from loud enough.

Doctors and their leaders have ethical responsibilities to speak out where health and humanity are being systemically degraded. Change is coming, and doctors should use their authority to lead calls for pragmatic reform informed by science and ethics.Fiona Godlee, editor in chief Richard Hurley, features and debates editor, The BMJ, London, UK [email protected] this as: BMJ 2016;355:i6067

‘‘Doctors are trusted and influential and can bring a rational and humane dimension

to rhetoric about being tough on crime


Drug policy has been irrational for a long time—for 55 years to be precise. The United Nations drug

conventions of 1961, 1971, and 1988 were rooted in the belief that banning a list of substances including heroin, cannabis, and cocaine would lead to a steady reduction in their use and the damage they cause. In turn, this would achieve the overarching objective of the conventions—to advance human health and welfare.

Yet no evidence has ever suggested that such a hypothesis was valid. Indeed, a growing body of evidence gathered since 1961 shows no correlation between the severity of the laws that prohibit drugs and the level of drug use. Far from diminishing over time, drug use has grown substantially worldwide. Many drugs are stronger and more dangerous now than they were before prohibition. “Skunk” has largely replaced lower potency cannabis; crack provides a more intense high than powder cocaine; and recently we have seen an explosion in use of potent new synthetic drugs. In short, the simplistic prohibitionist interpretation of the UN conventions has failed to achieve their overarching objective.

Finally, in April this year, the rhetoric changed fundamentally. After much discussion with reformers, the UN Office on Drugs and Crime, which helps member states meet their treaty obligations, made clear at a special session of the UN General Assembly that drug policies must be evidence based and aim to improve public health.

Development of an evidence base requires trying different approaches. These should be rigorously evaluated to identify policies or models that can best reduce addiction, minimise harm, cut violence, and reduce profits for organised crime. Whereas in the past

ESSAY Molly Meacher and Nick Clegg

Our drug laws are broken UK parliamentarians are calling for medicinal cannabis and an end to criminal sanctions for the possession and use of all drugs

Nick Clegg is a Liberal Democrat politician and was deputy prime minister in the coalition government from 2010 to 2015 and leader of the Liberal Democrats from 2007 to 2015. He is a member of parliament, for Sheffield Hallam. He is a member of the Global Commission on Drug Policy.

Baroness Molly Meacher worked in mental health on the front line and as a board member and NHS trust chair for several decades. She became a crossbench peer in 2006 and has for the past decade chaired the All Party Parliamentary Group for Drug Policy Reform. She also worked with Mexico, Colombia, and others to reform global UN drug policy.

the UN discouraged policy reform, we believe it will now support member states that pursue evidence based public health policies. What might this mean for the UK?

Cannabis for medical purposesCannabis was placed in schedule 1 of the Misuse of Drugs Regulations, the schedule for dangerous drugs with no medicinal value, in 1985. This explicitly forbids doctors from prescribing it and inhibits research.

The classification is irrational: first, cannabis has low toxicity5 and is much safer than many established medicines, not to mention two legal recreational drugs, alcohol and tobacco. Second, people have used the cannabis plant for its medicinal properties for centuries, if not millennia. Recent years have seen the discovery of the human endocannabinoid system and a growing literature on the medicinal value of cannabis for specific conditions.

On behalf of the All Party Parliamentary Group for Drug Policy Reform, Mike and Jennifer Barnes recently published a robust review of the global evidence on the medicinal properties of cannabis. They concluded that “good” evidence supports medicinal use of cannabis for chronic pain (particularly, neuropathic), seizures, nausea, and anxiety. For sleep disorders, appetite stimulation in the context of chemotherapy, fibromyalgia, post-traumatic stress disorder, and some symptoms of Parkinson’s disease, they found “moderate” evidence.

In this light, the UK’s scheduling, denying any medicinal value for cannabis, looks ever more absurd.

Ministers urgently need to revisit the scheduling of cannabis and move the drug from schedule 1 to schedule 4—which includes benzodiazepines, for example—in recognition of the limited

risks and the medicinal value of the plant and its constituent parts. This would allow research into the many conditions for which cannabis may be an inexpensive but effective treatment. But, above all, it would enable patients with a wide range of conditions to obtain cannabis medicines to alleviate their symptoms.

As well as the encouraging evidence from international clinical trials, we have heard striking testimonies from patients with epilepsy whose fits have reduced or ceased altogether; and others with chronic pain say that cannabis has “given them their life back” or “enabled them to sleep through the night for the first time for years.”

Different preparations are needed for different conditions, from quality controlled, chemically consistent herbal cannabis such as Bedrocan10 to pharmaceutical products with more conventional delivery mechanisms such as pills, creams, and inhalers. We would expect pharmacies to stock these preparations in the normal way. Encouragingly, the Royal Pharmaceutical Society voted in favour of rescheduling cannabis at its annual conference in 2015.

Eleven European countries and many others already formally recognise that cannabis has legitimate medicinal uses. Germany is in the process of passing a government backed bill to enable cannabis to be grown and supplied by licensed suppliers, prescribed, and made available through pharmacies. Canada has recently done the same. Surely it is time for the UK to follow suit.

Heroin assisted treatmentSwitzerland offers people dependent on heroin a safer way back to a normal life. The model includes consumption rooms, treatment with the opioid substitute methadone, and the option of heroin assisted treatment (HAT).


HAT is not a soft option. Patients must be alcohol-free when they attend the clinic, and in the early stages they must hand over most of their benefits to staff, who ensure their rent and utility bills are paid. In return, patients receive medical grade diamorphine, free of charge and administered at the clinic. The service also seeks to tackle patients’ complex and often deep seated problems.

The results of HAT in Switzerland and elsewhere are impressive.11 Every published evaluation has shown positive outcomes: reductions in the use of controlled drugs, in crime, disease, and overdoses and improvements in health, wellbeing, and rehabilitation. Within one cohort of around 300 heroin users in Switzerland, 81% of people were using heroin illicitly on a daily basis to begin with compared with 6% reporting almost daily illicit heroin use at six months. People reporting an income from illicit sources reduced from 69 to 10%.12

Decriminalise drug possession and useA third policy deserving immediate attention is well established in Portugal, where since 2001 the personal possession and use of all drugs have not been subject to criminal penalties.

Decriminalisation is a widely misunderstood term and often wrongly seen as synonymous with legalisation. If a drug is decriminalised, production and supply remain illegal but users will not be subject to criminal sanctions or a criminal record for the possession or use of the drug. They may be subject to administrative sanctions if they fail to comply with a “treatment contract,” as in Portugal. Legalisation refers to a system of regulation where a drug may be produced, sold, possessed, and used in accordance

with regulations. This is a much more radical reform than decriminalisation.

The Portuguese system is far from soft: police apprehending someone in possession of a small amount of a drug (calculated as up to 10 days’ supply) refer the person to a multiagency “dissuasion panel.” The panel interviews the person and determines whether he or she is drug dependent. If drug dependent, the person will be referred for treatment and encouraged to complete it with the goal of recovery. If treatment is not completed, the dissuasion panel will impose a civil rather than criminal sanction for breach of contract. The majority of non-dependent users attending a panel for the first time receive no sanction. A subsequent appearance may result in a fine of €30-40 (£27-36).

The policy transfers resources from criminal justice to drug treatment, and although the production and trafficking of drugs remain in the hands of organised crime and subject to criminal penalties, the police, courts, and prisons have been freed to focus on drug supply and conventional crime.

The Portuguese model has been evaluated by Alex Stevens, professor in criminal justice at the University of Kent, and others, with encouraging findings. Between 2000 and 2005, the number of problematic drug users fell from 7.6 to 6.8 per 1000 of the population. Most particularly there is evidence of a decrease in drug use among 14 to 19 year olds under the policy. There have also been reductions in HIV infections from more than 1000 new diagnoses in 2001 to fewer than 100 in 2013. Drug related deaths have reduced from more than 70 in 2001 to fewer than 20 in 2012. Despite initial scepticism, all Portuguese political parties now support the policy.

Drug related deaths in England and Wales—that is, those with an

underlying cause of drug misuse, dependence, or poisoning—are running at a record 3674 a year, with 2479 related to illegal drug use alone. British politicians should seriously consider introducing a version of the Portuguese model in the UK, allowing a substantial transfer of resources from criminal justice to treatment services.

The government took tentative steps towards decriminalisation this year with the Psychoactive Substances Act 2016. This excluded the possibility of criminal penalties for personal possession or use of “new psychoactive substances,” such as Spice (a synthetic cannabinoid). If such a policy is right for potentially dangerous synthetic drugs it surely is right for drugs derived from natural plants like cannabis and coca leaf.

Indeed, more sensible policies for other drugs might reduce the temptation for people to experiment with unknown synthetic substances, whose acute side effects and long term harms are much less well understood. The government hopes its ban on the sale of such substances will reduce use. The experience of Ireland, which introduced similar legislation in 2010, suggests otherwise. There, the prevalence of use of “legal highs” among 15 to 24 year olds has increased from 16% of those studied in 2011 to 22% in 2014, and deaths related to these drugs increased from 6 in 2010 to 28 in 2013.

The radical shift in UN opinion in April this year, and its call for evidence based policy, make this the right time for the UK government to reschedule medical cannabis without delay and to establish a review of drug policy more widely.Molly Meacher, chair of the All Party Parliamentary Group on Drug Policy Reform [email protected] Clegg, member of parliament Cite this as: BMJ 2016;355:i6006

Drug related deaths in England and Wales are running at a record

3674 a year, with

2479 related to illegal drug use

More than 70 in 2001 to fewer than

20 in 2012: fall in drug related deaths in Portugal since decriminalisation

British politicians should seriously consider a version of the Portuguese model [decriminalisation of use], involving a significant transfer of resources from criminal justice to treatment services


In June the BMA quietly set policy that moves towards supporting an end to criminal penalties for non-medical drug use. An emergency motion at its Annual

Representatives Meeting supported “legislative change so treatment and support are prioritised over criminalisation and punishment of individual drug users.”1

The motion also called for the Department of Health to take over responsibility for drug policy from the Home Office. It passed with little discussion and received little publicity.

The BMA had no detail of its plans to share with The BMJ but suggested that because of a lack of political appetite in the government the policy was a longer term goal to be achieved through low key lobbying.

Health problemIn 2013 the BMA’s Board of Science, led by Averil Mansfield, published Drugs of Dependence: The Role of Medical Professionals—a culmination of two years’ work to establish impartial evidence around drug taking, treatment, and policy in the UK, to reframe drug use as a health problem, and most of all to prompt debate.

In the foreword Mansfield, a former BMA president, wrote, “The present approach is not satisfactory.

She continued, “The medical

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INSIGHT

The strange silence of doctors’ leaders Most organisations have no line on policies that make criminals of drug users, finds Richard Hurley

profession would never condone drug taking. . . But those who fall into drug dependence become a medical problem from which we, as a society, cannot escape and they badly need our help.”

Mansfield wants to get all doctors talking about drug use. “I’m a surgeon not an expert on drugs,” she told The BMJ, “but as a caring and compassionate profession this is something that we ought to have much more interest in.

“We need to treat drug misuse as a medical problem rather than necessarily as a criminal one, and doctors should be part of the debate.”

Opioid deaths doubledIn 2015 the UK had its highest recorded drug related mortality (figure). Between 2012 and 2015 deaths from opioid misuse doubled in the UK, to 1201. More than 80% of shoplifting and burglary may be to fund drug dependency, costing the country £16bn a year. And despite the current policy a quarter of UK 15 year olds are estimated to have ever taken an illegal preparation of unknown quality and potency.

Mansfield is also concerned about the prison sentences and criminal records for non-violent drug offences that ruin lives and make drug users fear asking for help: “Lots of jobs and

Drug related deaths in England and Wales, 1993-20153

careers are scuppered. It’s tragic.”As for how policy might be

reformed, Mansfield is unsure, but she suggests looking to countries such as Portugal, where for 15 years personal drug use has been managed not through criminal processes but through civil ones that prioritise health (box). “I’m not trying to give a cut-and-dried answer to what society should do,” she said. “But we need some changes so that people have less fear and we can give them the help they require.”

Mansfield wanted her report to prompt the BMA to hold a debate, including voices opposed to legal reform. “The BMA has never really wanted to declare its hand on what we’re doing wrong and what we could do better,” she said. “It should look at the issue openly and not be afraid that the ‘red tops’ [tabloid newspapers] are going to say that the BMA has gone soft on drugs. None of us are soft on drugs.”

Sympathetic coverageThe BBC covered Mansfield’s report sympathetically, and the more reactionary media showed surprisingly little interest.

The Royal Society for Public Health (RSPH), which has 6000 members including directors of public health, and the Faculty of Public Health (FPH), which has 4000 members, mostly doctors, also found support among the media when they called for decriminalisation of personal drug use last summer, with their report Taking a New Line on Drugs. This report made the front page of the Times.

“The media you’d think were most conservative were interested in the report and positive,” said Shirley Cramer, chief executive of the society.

“The report is pragmatic about helping people to become healthier: this must be the priority,” she said.

It also calls for the Department of Health to lead on UK drug policy; for closer alignment of drug strategy with

WHO THINKS WHAT

BMA—Supports moves towards decriminalisation of drug use, with no current plan actively to advance this aim

Royal Society for Public Health—Vocal support for decriminalisation of drug use

Faculty of Public Health—Vocal support for decriminalisation of drug use

No formal stanceRoyal College of General PractitionersRoyal College of PsychiatristsRoyal College of Emergency MedicineRoyal College of Physicians of LondonRoyal College of Surgeons


“Drug policy is a complete disaster, and it’s within doctors’ remit when it’s killing people” Clare Gerada

From the BMA report Drugs of Dependence: The Role of Medical Professionals 2013“We do not have a predetermined medical position on the ways in which policy might be changed

“We have vast expertise to call upon and compassionate understanding to offer. Our involvement, indeed our leadership, will ensure that the criminal justice aspects are put into a more accurate context.

“We owe it to the patients, their families and those around them to get actively involved in the debate and so to ensure that the medical aspects are at the heart of the discussions.”

those for alcohol and tobacco; and for statutory and evidence based drugs education in schools to encourage prevention.

“Portugal has been so successful,” Cramer said (box). “It’s closest to the model we’d like to see in this country.”

Some jurisdictions, now including California, have gone further than decriminalising cannabis use to allow regulated supply. “We found a lot of international evidence for decriminalisation where it has worked well,” said Ed Morrow, the RSPH’s campaigns manager. “We are interested in the emerging evidence base around regulated supply but it’s not yet of sufficient standard or broadness for us to take a position.”

Logic of decriminalisationMorrow thinks that the new UK Psychoactive Substances Act, which bans distribution and sale but not possession and use, shows “inherent acceptance of the logic of decriminalisation.”

“We want to extend that logic to traditional illegal drugs,” he said.

The UK Misuse of Drugs Act makes unauthorised possession of some drugs illegal, punishable with prison

The Portuguese experience after 15 years of decriminalisation“In Portugal there has been a slight increase in drug use but many people will use drugs once or twice and that’s it,” said Ed Morrow, campaigns manager at the Royal Society for Public Health.

“Decriminalisation is not a silver bullet,” he says. “But it’s an enabler: it removes a barrier that makes everything else you need to do easier, in terms of harm reduction, education, and getting people into treatment.” Problematic drug users fell from 7.6 to 6.8 per 1000 population from 2000 to 2005.

“In the 18-24 year old age group use has gone down, and the level of use overall is still below the European average,” he says. “It’s not had the cataclysmic effect on use people feared. Drug related deaths are massively down and so are infection rates. It’s been a huge success.”

HIV infections dropped from more than 1000 new diagnoses in 2001 to fewer than 100 in 2013. Drug related deaths fell from more than 70 in 2001 to fewer than 20 in 2012.7 All Portuguese political parties now support the policy.

From the RSPH-FPH report Taking a New Line on Drugs 2016“RSPH is calling for the UK to consider exploring, trialling and testing such an approach, rather than one reliant on the criminal justice system.“ Levels of drug harm, not simply levels of drug use, should be taken into account when considering the success of drugs policy.

“This could include decriminalising personal use and possession of all illegal drugs, and diverting those whose use is problematic into appropriate support and treatment services instead, recognising that criminalising users most often only opens up the risk of further harm to health and wellbeing.”

DRUGS OFDEPENDENCE THE ROLE OF MEDICALPROFESSIONALS

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sentences up to seven years and unlimited fines. But several police commissioners support the report, Cramer said, and many already practise de facto decriminalisation in the way they enforce the law.

John Middleton, chair of the Faculty of Public Health, agreed: “We got a lot of support for the report. We didn’t get any negative feedback from the royal colleges. There’s a broad degree of acceptance, and they see that the tough on drugs approach is not working, as we’re now seeing with the rise in drug related deaths.”

No formal stanceThe BMJ spoke to several royal colleges. The surgeons and the physicians had no comment to make on drug policy. The psychiatrists, the general practitioners, and the emergency medicine doctors also have no formal stance on government drug policy but emphasised their commitment to treating individual patients with drug use disorders. They expressed concern about cuts to drug treatment services that have been moved out of the NHS to local authority control and the government’s switch from evidence based treatment, including maintenance with opioid

substitutes, to approaches that prioritise abstinence.

“Drug policy should be centred on the health of drug users,” said Simon Wessely, chair of the Royal College of Psychiatrists. “But the legal status of drugs is for government to decide, not doctors. We don’t think there’s much evidence that legal status has much impact on drug use.”

Johann Grundlingh, toxicology lead at the Royal College of Emergency Medicine, said, “We’re not a political organisation. But we don’t want people to take drugs and die. And we don’t want people who take drugs to feel segregated so they can’t get help.”

Clare Gerada, former chair of the Royal College of General Practitioners, was more direct. “Drug policy is a complete disaster,” she said, “and it’s within doctors’ remit when it’s killing people,” adding that the college didn’t discuss drug policy while she was its chair. “I personally support decriminalisation. The BMA and colleges should be calling for sensible drug policies based on evidence of risk and harm.”

International actionThree United Nations conventions aim to protect people by banning all non-


The failures of prohibition—the attempt to eliminate illicit drugs for non-medical purposes through measures such as criminalisation or militarisation—and other repressive strategies are well documented.

Over the past 50 years, they have been unable to curb either global supply or demand at global or local levels. In fact, drug use, production, and trafficking, and concern about the issue among the general public, grow ever higher, while prohibition continues to exact a tragic toll on individuals and societies. Effective and humane drug policies are needed more urgently than ever.

This urgency can be felt at the international level, with growing criticism of an outdated drug control system built on three UN conventions. Even though these conventions do not specifically insist on harsh punishment for drug use, national interpretation has favoured prohibitive approaches, with many harmful consequences.

Inappropriate treatmentDespite evidence of the efficacy of harm reduction measures for people who use drugs, such as clean needles and access to opioid substitutes, these are far from being implemented on the scale needed.

Furthermore, drug users with medical problems are often handled by the judicial system rather than treated by doctors, and in some cases are given custodial sentences or pushed into mandatory treatment. These approaches have poor results in terms of drug users’ recovery and do little to help users achieve better balance in their lives, in terms of maintenance or rehabilitation.

The current UN drug scheduling system, which assigns levels of danger to psychoactive substances, denies many people in need access to recognised essential medicines such as morphine and prevents research into the dangerousness versus medical effectiveness of products.4 For instance, the UN classifies cannabis as one of the most dangerous drugs, with “no currently accepted medical use.” This scheduling has not been reviewed in 81 years, and scientific investigation continues to be severely limited.

We need a pragmatic approach to drug policy reform, starting with the recognition that the idealised notion of a “society without drugs” is an unattainable fantasy.

Reforms must then prioritise public health, social integration, and security, while strictly respecting human rights and due judicial process.

Evidence based policies should therefore include decriminalisation of personal drug use because this has been shown to be effective and respectful of human dignity.

Like our fellow commissioner Jorge Sampaio, a former president of Portugal [when Dreifuss was president of Switzerland and Bém was mayor of Prague], we were faced with situations where the response to drugs was undermining the social fabric of our country or city.

The reforms enacted in Portugal, Switzerland, and Prague were different, tailored to specific needs, but all have reduced the social and health harms related to drug use, such as crime, drug related deaths, and HIV infections.

We also believe that decriminalisation can and must go further. As the Global Commission on Drug Policy lays out in its upcoming report, Advancing Drug Policy Reform: A New Approach To Decriminalization, drug use and possession should not be penalised with any criminal or civil action, and alternatives to punishment, such as counselling, community service, or educational workshops, should be developed for all low level actors in the drug trade.

The commission takes this a logical step further and calls for governments to regulate all illicit drugs. This would curb a massive revenue stream for organised crime, worth globally an estimated £260bn. It would also allow further research to inform policy and facilitate restriction of drug use—for example, setting the age of the user, maximum quantities allowed for sale or possession, and where drugs can be used.

And it could help to shift perceptions from considering drugs as inherently “evil” to a more pragmatic mindset in which scientific evidence, not ideology, drives drug policy.Ruth Dreifuss, chair of the Global Commission on Drug Policy, GenevaPavel Bém, member, Global Commission on Drug Policy [email protected] this as: BMJ 2016;355:i5921

medical use of some substances, such as heroin, cocaine, and cannabis. Many countries try to fulfil this prohibition by making production, trafficking, sale, and possession of drugs subject to criminal penalties.

“The current UN embargo is not helping and in fact causes harm,” said Mansfield, who is on the board of International Physicians for Healthier Drug Policies, which campaigns for reform.

Chris Beyrer, professor of public health and human rights at Johns Hopkins Bloomberg School of Public Health and corresponding author of a substantial review of the international evidence on the health implications of drug policy earlier this year, is also on the board.

“Mobilising physicians has been a challenge,” Beyrer said. “They don’t necessarily want to engage with the political but want to stick to our tract—that is, clinical care. That is a challenge when you have policy so clearly harmful to health—for example, the criminalisation of petty use and possession. Being tough on crime is popular with politicians. And it’s hard for them to back away from those positions.”

Some people maintain that prohibition enforced through criminalisation of drug users is necessary, but Cramer thinks there are few with such views in the mainstream medical world. “You’ll have a lot of trouble finding someone in public health who doesn’t now see the merits in decriminalisation,” she said.

Doctors’ dutyDainius Pūras, UN special rapporteur on health, believes that healthcare professionals should be leading policy reform. Clinicians have an ethical responsibility to champion the health and dignity of their patients, he says, as well as to publicise the harms caused by criminalisation.

Mansfield agrees: “It’s part of our job as doctors to try to ensure that society is looked after in a general sense.

“As a profession we could be doing more about drug misuse. The BMA could be doing more. Most of the doctors in the UK belong, and we could easily give them a nudge to think about it at least.”Richard Hurley, features and debates editor, The BMJ [email protected] this as: BMJ 2016;355:i6087

OPINION RUTH DREIFUSS and Pavel Bém

A drug-free world is a fantasyProhibition has failed: we urgently need humane drug policies

The commission calls for governments to regulate all illicit drugs

incontinence drug risks are too high - bmj...every year until 2030, peers are told • collapse of...

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