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Press releases Saturday 3 February 2007

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(1) Concern over safety of commercial ultrasound scans
(2) Allergy to hair dye increasing
(3) Is doctors± self interest endangering the NHS?
(4) Cataract scheme ±expensive over-reaction± say doctors

(1) Concern over safety of commercial ultrasound scans
(One for the album)
http://www.bmj.com/cgi/content/full/334/7587/232

Expectant parents± desire to see images of their unborn children has given rise to commercial companies offering keepsake ultrasound scans without medical supervision, often referred to as ±boutique ultrasonography.±

In a special report in this week±s BMJ, journalist Geoff Watts considers whether this non-medical use of the technique can be justified.

Improvements in ultrasound technology have transformed antenatal scans from two dimensional black and white images to 3D, 4D and even moving pictures of the unborn child. Expectant parents seeking a CD-ROM or a DVD of their scan can expect to pay ±150-±250 (±230-380; $300-490).

The companies say that ultrasound has not been shown to cause any harm to mother or baby, but the US Food and Drugs Administration (FDA), the American Institute of Ultrasound in Medicine, and the French Academy of Medicine are among several official bodies that have reservations about such use of the technology. The British Medical Ultrasound Society does not have a specific policy on non-medical imaging, but is currently updating its guidance.

The FDA says: ±Although there is no evidence that these physical effects can harm the fetus, public health experts, clinicians and industry agree that casual exposure to ultrasound, especially during pregnancy, should be avoided.±

There are also concerns about how staff deal with the discovery of a fetal abnormality.

Some doctors offer keepsake images after they have performed ultrasound for medical reasons. The FDA takes a dim view of this, but the American Institute of Ultrasound Medicine deems it to be consistent with their ethical principles.

Beyond spreading a little happiness, the case for non-medical imaging relies principally on bonding: the sense of attachment between a mother and her unborn child, says Watts. The evidence that ultrasound images can foster this comes from 2D scans, but there is no evidence that 3D scans are more effective in enhancing maternal-fetal attachment.

The controversy over 3D and 4D imaging would be partially resolved if genuine medical benefit could be shown, he adds. Research is currently under way to find out if seeing the fetus in 3D might help spot abnormalities such as cleft lip. Early indications are that it may be useful but, for the moment, it is by no means self evidently beneficial.

Contacts:
Geoff Watts, Freelance Journalist, London, UK
Email: geoff@scileg.freeserve.co.uk

The British Medical Ultrasound Society, London, UK
Email: office@bmus.org

The American Institute of Ultrasound in Medicine, Maryland, USA
Email: publicrelations@aium.org

(2) Allergy to hair dye increasing
(Editorial: allergy to hair dye)
http://www.bmj.com/cgi/content/full/334/7587/220

Allergic reactions to hair dye are increasing as more and younger people dye their hair, warn researchers in this week±s BMJ.

This can lead to dermatitis on the face and, in severe cases, facial swelling may occur.

More than two thirds of hair dyes currently contain para-phenylenediamine (PPD) and other related agents. During the 20th century, allergic reactions to PPD became such a serious problem that it was banned from hair dyes in Germany, France, and Sweden.

Current European Union legislation allows PPD to comprise up to 6% of the constituents of hair dyes on the consumer market, but no satisfactory or widely accepted alternatives to these agents are available for use in permanent hair dye.

Dermatologists report anecdotally that the frequency of positive reactions to PPD on patch testing is increasing. This was confirmed in a recent survey in London, which found a doubling in frequency over six years to 7.1% in a clinic for adults with contact dermatitis. This trend has also been observed in other countries.

Market research also indicates that more people are dyeing their hair and are doing so at a younger age. A survey in 1992 by the Japan Soap and Detergent Association found 13% of female high school students, 6% of women in their 20s, and 2% of men in their 20s reported using hair colouring products. By 2001 the proportions had increased in these three groups to 41%, 85%, and 33%, respectively.

Severe hair dye reactions among children have also recently been reported.

Wider debate on the safety and composition of hair dyes is overdue, say the authors. Cultural and commercial pressures to dye hair are putting people at risk and increasing the burden on health services.

It may not be easy to reverse these trends, however, as some patients have continued to use such dyes even when advised that they are allergic to them and risk severe reactions, they conclude.

Contact:
John McFadden, Senior Lecturer, St John±s Institute of Dermatology, St Thomas± Hospital, London, UK
Email: john.mcfadden@kcl.ac.uk

(3) Is doctors± self interest endangering the NHS?
Head to head: Is doctors± self interest undermining the NHS?
http://www.bmj.com/cgi/content/full/334/7587/234

Recent newspaper headlines have suggested that doctors± pay is responsible for the financial crisis in the NHS. In this week±s BMJ, two experts go head to head over whether the remuneration is justified.

Alan Maynard, Professor of Health Economics at York University argues that doctors± self interest manifests itself in two ways: enhancing personal income and protecting clinical autonomy fiercely - the right to do what they think is best for their patients.

He maintains that the first type of self interest has enhanced average UK earnings to over ±100,000 for both general practitioners and consultants, with little observable improved activity or patient outcomes.

The general practice quality and outcomes framework raised earnings, but, he argues, with a limited evidence base and little baseline data its benefits are uncertain. The consultant contract and the cost of replacing out-of-hours cover with other providers have also increased expenditure.

Professor Maynard writes that this pay increase has inflated NHS expenditure with all too little benefit to patients or taxpayers, while giving more general practitioners incentives to deliver what good practitioners were already providing.

The second area of doctors± self interest is the understandable desire to do the best for their patients. But he believes that this can lead to inefficient practice that ignores the opportunity costs of decision making. For example, a decision to give Jones a marginally cost effective treatment deprives Smith of cost effective care. Such inefficiency in the use of society±s scarce resources is surely unethical, he asks?

These pay increases, together with workforce management which has led to unaffordable employment increases, are creating deficits and undermining patient care and the financial performance of the NHS, he argues. Instead of talking simply about money, we need to determine whether its use benefits patients or is merely a form of social security for providers.

But Laurence Buckman, a GP in London believes that demanding and receiving proper pay and conditions is everyone±s right, even in the public sector. This is not self interest. Self interested doctors would go and work elsewhere, he writes.

Until 2003, general practitioners were working long hours, including nights and weekends, and out of hours pay was low. The new contract was an attempt to correct that by placing contracts with practices rather than general practitioners, setting limits to what a practice could be asked to do, and creating a total budget for staff and expenses. General practitioners± pay became the profit that was left after expenses.

The main source of extra income into practices from the new contract is the quality and outcomes framework, which accounts for 40% of practice income. The government claims that general practitioners± pay has risen unexpectedly, but this is not so. The BMA predicted the rise quite accurately, he says.

Total pay has been deliberately misquoted by adding the employers± pension contribution that general practitioners have to pay for themselves ± which makes pay seem 14% higher than it is.

Government figures show a shortage of general practitioners. If self interest had been pandered to there would be a glut of doctors. That there isn±t is because of the dreadful way that the NHS is managed by a government bereft of ideas and the honesty and wit to tackle the problems that deter young people from joining us, he argues.

Doctors are fed up with being told that the small percentage of the NHS that they cost is the reason why the NHS is in financial trouble. Most patients see us as part of the solution and are willing to pay.

Contacts:
Alan Maynard, Professor of Health Economics, Department of Health Sciences, University of York, UK
Email: akm3@york.ac.uk

Laurence Buckman, General Practitioner, Temple Fortune Health Centre, London, UK
Email: lbuckman@ntlworld.com

(4) Cataract scheme ±expensive over-reaction± say doctors
(Letter: ISTC programme is an expensive option)
http://www.bmj.com/cgi/content/full/334/7587/222

The independent sector treatment centre (ISTC) scheme for NHS cataract services was an expensive over-reaction to the need to increase rates of cataract surgery, say senior doctors in this week±s BMJ.

Many ophthalmology departments had improved cataract surgery pathways before the ISTC programme was proposed, writes Consultant Ophthalmic Surgeon, Simon Kelly in a letter signed by the President and Vice President of the Royal College of Ophthalmologists and the Chair of the BMA's Ophthalmic Group Committee.

Had the Department of Health followed the advice of clinicians, the royal colleges, and the BMA when the cataract and other ISTC schemes were proposed, improved access to cataract surgery would have been realised with much less expenditure, without adverse effects on surgical training, and without destabilising NHS eye departments.

However, an alternative direction was taken, they say. And despite the paucity of clinical outcome data, and the lack of evidence of cost effectiveness of phase 1 of the ISTC programme, further investment in cataract surgical facilities continues in phase 2.

Meanwhile, for long term stability of the service, the best option for the public is to support local NHS units, which brought down cataract waiting times, which patients need to call on in an emergency or for chronic eye disease, and which train the next generation of surgeons while meeting waiting time targets.

A constructive partnership of clinicians, managers, and commissioners is a surer way to achieve sustained improvements in access and quality of care, rather than centrally imposed initiatives and diktat, such as the needless cataract ISTCs, they conclude.

Contacts:
Simon Kelly, Consultant Ophthalmic Surgeon, Bolton Hospitals NHS Trust, Bolton, UK
Email: spkelly@ntlworld.com
or
Richard Hayhurst, Hayhurst Media, London, UK
Email: richarda@hayhurstmedia.com

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