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(2) WHAT IS THE BEST WAY TO FUND THE NHS?

(3) WHAT DETERMINES CONSULTATION LENGTH?

(4) EVIDENCE FOR WARTS TREATMENTS IS WEAK

(5) TRUST DOCTORS: THE NEW LOST TRIBE?

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(1) STRETCHING DOES NOT PREVENT MUSCLE
SORENESS

(Effects of stretching before and after exercising on
muscle soreness and risk of injury: systematic review)
http://bmj.com/cgi/content/full/325/7362/468

(Editorial: Reducing risk of injury due to exercise)
http://bmj.com/cgi/content/full/325/7362/451

Stretching before or after exercise does not prevent
muscle soreness or reduce risk of injury, finds a study in
this week's BMJ.

Researchers in Australia reviewed five studies, involving
77 subjects, on the effect of stretching on muscle
soreness. In all studies, participants were healthy young
adults. Three studies evaluated stretching after exercising,
and two evaluated stretching before exercising.

The studies showed that stretching reduces soreness by
less than 2mm on a 100mm scale. Most athletes will
consider effects of this magnitude too small to make
stretching worthwhile, say the authors.

Stretching also does not produce useful reductions in
injury, add the authors. Data from two studies on army
recruits in training, whose risk of injury is high, show that
muscle stretching prevents on average one injury every
23 years. Most athletes are exposed to lower risks of
injury so the absolute risk reduction for most athletes is
likely to be smaller still.

These findings are contrary to what many athletes and
coaches believe and what is common practice, write
experts in an accompanying editorial. Yet much of sport
and exercise medicine and the management of
musculoskeletal injury has developed empirically with
little research evidence. The culture is changing, and this
study makes a valuable contribution to the debate on
stretching, they conclude.

Contact:

Rob Herbert, Senior Lecturer, School of Physiotherapy,
University of Sydney, New South Wales, Australia
Email: R.Herbert@fhs.usyd.edu.au

(2) WHAT IS THE BEST WAY TO FUND THE NHS?

(Social insurance ± the right way forward for health care
in the United Kingdom?)
http://bmj.com/cgi/content/full/325/7362/488

The NHS in the United Kingdom is struggling to meet the
needs of patients as costs continue to rise. A debate
article in this week's BMJ asks: Does the current system
of funding need to change?

David Green and Benedict Irvine believe that the case for
social insurance deserves a more serious hearing than the
British government has so far given it.

For example, social insurance schemes allow individuals
to see clearly (usually on pay slips) how much they are
paying towards care, so they can tell whether they are
getting good value for money. Under social insurance
systems, patients are treated as valued customers. This
may go someway to explaining why satisfaction rates are
generally higher in countries that have a social insurance
scheme, say the authors.

Professional autonomy is more fully respected under a
social insurance scheme, while funding health care from
general taxes has proved to be an ineffective way of
bringing the expectations of patients into balance with the
treatment capacity of the system.

To demonstrate their point, the authors cite the 2000
World Health Organisation ranking of countries
according to the responsiveness of their health systems to
needs. The only tax based system in western Europe
ranked in the top five was Denmark. The United
Kingdom languished in 26th position.

Supporters of change contend that Britain is out of step
with the rest of the world. Yet other countries in Europe
rely largely on taxation and no western European country
has changed from a tax based to an insurance based
funding system, argue Martin McKee and colleagues.

Retaining the ability to raise taxes from various sources,
including investment income and company profits, makes
it possible to compensate for imbalances across the
economic cycle, they write. In contrast, social insurance
seems less sustainable.

Some people suggest that patients should pay more, but
no evidence exists that charges deter only unnecessary
use. It is also wrong to think that social insurance
eliminates waiting lists, they add. Like Britain, the
Netherlands has long waiting lists and sends patients
abroad for elective surgery.

The main advantage of funding from general taxation is
that it recognises that those whose needs are greatest are
least able to pay for care - the young and the rich
subsidise the old and the poor. A shift to competing
insurance funds, no matter how well regulated, and an
increase in what people themselves pay, will inevitably
relieve this burden. Is this the real issue? they conclude

Contacts:

David Green, Director, Civitas (Institute for the Study of
Civil Society, London, UK
Email: david.green@civitas.org.uk

Martin McKee, Professor of European Public Health,
London School of Hygiene and Tropical Medicine,
London, UK
Email: martin.mckee@lshtm.ac.uk

(3) WHAT DETERMINES CONSULTATION LENGTH?

(Consultation length in general practice)
http://bmj.com/cgi/content/full/325/7362/472

Patients are satisfied with the care they receive from
general practice, but often say that consultations are too
short. A study in this week's BMJ finds that
characteristics of patients have as much effect on
consultation length as the characteristics of the doctor
and the doctor's country.

Researchers selected 190 general practitioners from six
European countries with different healthcare systems.
They videotaped and analysed consultations with 3,674
patients.

The average length of consultation was 10.7 minutes.
Belgium and Switzerland had the longest consultation
times, Germany and Spain had the shortest consultation
times, and consultation times for the Netherlands and the
United Kingdom were in between.

Consultations in city practices lasted 1.5 minutes longer
than those in rural practices, those with women patients
lasted about 1 minute longer than those with men, and
those about at least one new problem lasted 51 seconds
longer than those about known problems.. Consultations
were also longer when the doctor or patient felt that
psychological problems were important.

As the patient's age increased by one year, the
consultation time increased by 1.2 seconds, while the
consultation time decreased as the doctor's workload
increased. The doctor's sex or age and patient's level of
education were not related to the length of consultation.

Based on these findings, women consulting general
practitioners in urban practices about problems perceived
as psychosocial by doctor and patient have longer
consultations than other patients, conclude the authors.

Contact:

Myriam Deveugele, Psychologist, Department of General
Practice and Primary Health Care, Ghent University,
Ghent, Belgium
Email: myriam.deveugele@rug.ac.be

(4) EVIDENCE FOR WARTS TREATMENTS IS WEAK

(Local treatments for cutaneous warts: systematic review)
http://bmj.com/cgi/content/full/325/7362/461

Apart from topical treatments containing salicylic acid,
there is currently no clear evidence that any other
treatments for warts are more effective, say researchers
in this week's BMJ.

Sam Gibbs and colleagues reviewed 50 trials of local
treatment for cutaneous warts. Much of the evidence was
of poor quality.

Simple topical treatments containing salicylic acid seemed
to be effective and safe, but no clear evidence was found
that any of the other treatments have a particular
advantage of either higher cure rates or fewer side
effects, say the authors.

Although it is widely believed that cryotherapy may
succeed when topical salicylic acid has failed, there was
no clear evidence to support this, they add. Indeed, some
evidence shows that at best cryotherapy is only equal in
efficacy to topical salicylic acid.

Photodynamic therapy, pulsed dye lasers and
immunotherapy may, the authors say, hold promise for
the future.

Contact:

Sam Gibbs, Consultant, Department of Dermatology,
Ipswich Hospital NHS Trust, Ipswich, UK
Email (home): sgibbs@fish.co.uk

(5) TRUST DOCTORS: THE NEW LOST TRIBE?

(Letter: Are trust doctors the new lost tribe?)
http://bmj.com/cgi/content/full/325/7362/491

Delivery of acute care in the NHS is going to increasingly
depend on doctors who are receiving little educational
supervision as the number of trust doctors (doctors in
non-training grades) rises, say researchers from Leeds
University in this week's BMJ.

Their survey of acute Trusts in Yorkshire found that the
number of trust doctor posts has increased at least
fivefold over the past four years. Furthermore, the current
number will more than double in the near future as trusts
try to meet both service and hours requirements and are
unable to employ more doctors in training.

Thirty-six trust doctors in the region responded to a
separate questionnaire about education and training.
Sixteen reported that they had an educational supervisor
and only six had appraisals. The most common career
aim was a consultant post in the United Kingdom, and
the main reasons for taking a post as a trust doctor were
as a "stop gap" or to gain experience in a particular
specialty.

Although trust doctors come under the legal requirements
of the European working time directive, only 12 reported
working 48 hours a week or less.

"Our survey shows the number of trust doctors is
increasing dramatically," say the authors. These are junior
doctors with educational needs, yet they do not receive
the same educational supervision as their training grade
equivalents.

Trusts say they cannot meet the requirements of the new
deal or the European working time directive without
employing trust doctors. This survey has put figures to a
quietly growing problem that must now be tackled, they
conclude.

Contact:

Nicola Cooper, Specialist Registrar, General Internal
Medicine and Care of the Elderly, Leeds, Yorkshire, UK
Email: nacooper@doctors.org.uk

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