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Online First articles may not be available until 09:00 (UK time) Friday.

Press releases Saturday 22 September 2007

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's web site (http://bmj.com).

(1) Should NHS training posts be reserved for UK graduates?
(2) Government immigration policy to blame for medical unemployment
(3) New study questions the validity of publishing hospital mortality rates
(4) School, family and community involvement are all needed to increase the activity levels of adolescents
(5) Physiotherapy has short term benefits for patients after knee surgery

(1) Should NHS training posts be reserved for UK graduates?
(Head to Head: Should postgraduate training places be reserved for UK graduates?)
http://www.bmj.com/cgi/full/335/7620/590
http://www.bmj.com/cgi/full/335/7620/591
(Personal View: MTAS or a tale of evidence heedless medicine)
http://www.bmj.com/cgi/full/335/7620/615

After many young doctors failed to get NHS jobs this summer, two experts in this week's BMJ debate whether training posts should be reserved for UK graduates.

Society has a moral obligation to ensure that young people who successfully complete a demanding primary medical course have the opportunity to complete their training and enter medical practice, argues Edward Byrne, Dean at the Faculty of Biomedical Sciences, University College London.

He acknowledges that we live in a global world and free exchange of expertise is clearly desirable. However, this needs to be balanced against the training needs of UK graduates. One possible solution, he says, would be to encourage a period of work in other countries towards the end of specialty or family medicine training.

Medical training in the UK is among the best in the world and it is appropriate that a country with the wealth and stature of the United Kingdom cover its medical workforce needs without drawing doctors from less well advantaged countries in Europe or elsewhere, he writes.

If the UK can contribute a relatively small number of fully trained doctors to work in other countries, that would be a useful contribution to international health. But, he argues, a failure to provide training opportunities for the great majority of UK graduates and enable them to enter practice would represent a waste of human potential and a failure of care for young doctors.

Restricting access would damage the profession, argues Edwin Borman, Consultant Anaesthetist at Coventry and Warwickshire NHS Trust and Chairman of the BMA's International Committee.

For most of the lifespan of the NHS, the UK has had an implicit policy to rely on international medical graduates to "top up" the number of UK graduates, he writes. Currently, 36% of doctors registered to practise in the NHS qualified abroad.

It is to the credit of the medical profession that during the crisis of the medical training application service (MTAS), all eligible applicants have been treated equally and posts have been allocated according to merit, he says.

The good name of the medical profession in the UK already has been damaged by the Home Office which introduced changes, without notice, to the immigration rules. It would be a tragedy for the profession itself to sully its reputation by abandoning the principle of solidarity that goes back as far as the Hippocratic Oath.

And he suggests that the blame for the chaos that is MTAS should be placed with those in the Department of Health who decided that medical staffing no longer needed to be planned centrally. Instead, he argues that training places should be limited to numbers that reflect the projected future need for consultants and general practice principals.

The anger of those caught up in the MTAS debacle is expressed in a personal view by Parashkev Nachev, a clinical research fellow at Imperial College London. He argues that the system has damaged professional standards and blames the royal colleges for "failing to act when there was still time to do so."

Contacts:
Edward Byrne, Dean, Faculty of Biomedical Sciences, University College London, UK
Email: ebyrne@medsch.ucl.ac.uk 
Edwin Borman, Consultant Anaesthetist, University Hospitals, Coventry and Warwickshire NHS Trust, Coventry, UK
Email: edwin@borman.demon.co.uk 

(2) Government immigration policy to blame for medical unemployment
(Medical immigration: the elephant in the room)
http://www.bmj.com/cgi/full/335/7620/593

The threat of unemployment among UK medical graduates is being blamed on the failed computerised recruitment system (MTAS), but an article in this week's BMJ argues that the real problem is government policy on medical immigration.

In the late 1990s UK medical schools produced nearly 5,000 graduates each year, considerably fewer than the NHS needed, writes Graham Winyard, a retired Postgraduate Dean. But in 1997, an expansion of medical school places began and the number of graduate doctors is set to rise to 7,000 in 2010, an increase of 40%.

The planners assumed that UK qualified doctors would replace those from overseas. But Government immigration policies have encouraged thousands of overseas doctors to compete for postgraduate training posts, and it is of course illegal for trusts and deaneries to discriminate on the basis of country of qualification when making appointments. Expanding medical schools makes little sense if extra graduates cannot pursue a career in medicine, says Winyard.

UK trained doctors began to voice concerns about possible unemployment in 2005 and these concerns were dramatically realised this summer, when MTAS was introduced to select doctors for training posts.

While there were broadly sufficient posts to accommodate UK applicants, together with those from the rest of the European Economic Area, he argues, the inclusion of thousands of overseas doctors has transformed the prospects for all applicants and has made widespread failure to secure a proper training post inevitable.

The UK urgently needs policy coherence on immigration and medical training, he writes. The direct connection between policy on medical immigration and the likelihood of unemployment for UK medical graduates is inescapable.

The most obvious action, he says, would be to suspend the Highly Skilled Migrant Programme - a scheme allowing highly skilled people to migrate to the UK to seek work without a specific job offer - as it applies to doctors, and establish a two stage recruitment process similar to that used in other countries, whereby overseas applications are considered after those of domestic graduates.

The rights of overseas doctors already in the system must be safeguarded, but if decisive action is not taken the situation will be worse next year, he warns.

This muddle is in no one's best interests and needs open and honest discussion and clear leadership, however difficult that may be, he concludes.

Contact:
Graham Winyard, Retired Postgraduate Dean, Winchester, UK
Email: gwinyard@doctors.org.uk 

(3) New study questions the validity of publishing hospital mortality rates
(Comparison of hospital episode statistics and central cardiac audit database in public reporting of congenital heart surgery mortality)
http://www.bmj.com/cgi/content/full/bmj.39318.644549.AEv1

A previous study of mortality rates for congenital heart surgery used routinely available hospital data that were misleading, according to a report published today on bmj.com which questions the validity of such data being made public.

Professor Westaby and colleagues found the system of information gathering used in the study had underestimated the number of infant deaths. In the previous BMJ study, published in 2004, Oxford had been singled out as having significantly higher mortality than the national average for open heart surgery on infants. Yet this new paper, using data from a different source-the Central Cardiac Audit Database - shows that the hospital's mortality statistics were not actually different from the mean for all the centres (10% compared to 8% between 2000 and 2002).

The authors looked at a report from the 'Dr Foster' unit at Imperial College which was published in the wake of the inquiry into the Bristol congenital heart surgery deaths. That inquiry, which drew widespread publicity and had a profound effect on surgical practice in the UK, used Hospital Episode Statistics (HES) to compare mortality rates among cardiac surgical units across the country. The 2004 study by Dr Aylin described these mortality statistics.

The authors of the current study compared the mortality rates reported by the administrative HES database and an alternative system, the clinically based Central Cardiac Audit Database, for infants under 12 months undergoing cardiac operations. The statistics were gathered between 1st April 2000 and 31st March 2002.

They found HES did not provide reliable patient numbers or 30-day mortality data. On average HES recorded 20% fewer cases than CCAD and only captured between 27% and 78% of 30-day deaths, with a median shortfall of 40%.

In Centre A, with the largest number of operations, 38% of all patients were missed by HES and only 27% of the total deaths were recorded. Overall, mortality statistics were underestimated by 4% using HES data.

The authors say publication of inaccurate statistics detracts from public confidence and that: "If mortality statistics are to be released their quality must be beyond reproach."

They acknowledge the media are keen to publish such statistics and pinpoint 'Dr Foster' who have pioneered this by providing newspapers with information on heart disease, for example, in return for a fee.

They conclude: "Given the problems with data quality, the imprecision of risk stratification models, and the confrontational agenda in the media, we question the value of placing mortality statistics in the public domain."

Contact:
Professor Westaby, Consultant Cardiothoracic Surgeon, John Radcliffe Hospital, Oxford, UK
Email: Stephen.Westaby@orh.nhs.uk 

(4) School, family and community involvement are all needed to increase the activity levels of adolescents
(Pharmacovigilance in developing countries)
http://www.bmj.com/cgi/content/full/bmj.39320.844347.BEv1

Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials.

Programmes aimed at increasing physical activity in adolescents need to cover both school and family or community life if they are to be effective, according to a study published today on bmj.com.

The researchers from the Medical Research Council Epidemiology Unit also found significant positive results for multi-component interventions aimed at adolescents. These are programmes which along with traditional health education included policy or environmental changes, for example additional PE classes.

The authors say the programmes that work can make important differences and should be actively promoted.

The review, which looked at all the published literature on the effectiveness of promoting physical activity to children and adolescents, also found some evidence that programmes which change children's environments, for example, improving a playground, can have significant effects. Programmes aimed at children from lower socioeconomic backgrounds can also have some impact on activity levels. However, the researchers say both these areas need to be investigated more closely.

Increasing physical activity among young people has been identified as one of the key ways to tackle obesity. The authors say children who are inactive tend to remain inactive as adults, which means their risk of developing cardiovascular disease, cancer and osteoporosis in later life is increased. They argue this means developing and evaluating these sorts of programmes is therefore a priority. To date it has been unclear how successful efforts to increase the activity levels of young people have been.

The reviewers found no evidence that initiatives which use education alone had any effect on children's activity levels and there was inconclusive evidence of the benefit to adolescents.

The evidence for the benefit of programmes which used a variety of components, for example additional PE classes, PE teacher training or the availability of extra equipment, was found to be inconclusive for children. There was strong evidence however that this is an effective strategy for adolescents.

They found strong evidence to support the use of programmes where adolescents were involved in school-based initiatives but where the family or community had to become involved as well, for example, through homework assignments or incorporating physical activity into existing community events. The effects seen in the studies ranged from 3 minute increases during PE to a 50% increase in the number of participants being regularly active.

Overall they say there was stronger evidence for the effectiveness of physical activity programmes among adolescents, yet that could be because the studies were of higher quality and they also included large sample sizes. One of the reasons for the increased effectiveness among adolescents could also be that they are known to be less active than children so there could be greater potential for change.

Contact:
Dr Esther MF van Sluijs, MRC Epidemiology Unit, Cambridge, UK
Email: press.office@headoffice.mrc.ac.uk 

(5) Physiotherapy has short term benefits for patients after knee surgery
(Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials)
http://www.bmj.com/cgi/content/full/bmj.39311.460093.BEv1

Government reforms to primary care have shifted professional control away from general practitioners and financial control away from government, argue senior doctors in this week's BMJ.

Physiotherapy can improve the daily lives of patients who have had knee replacement surgery due to osteoarthritis in the short term, according to a study published on bmj.com today.

Osteoarthritis is the commonest form of disability in older people. Total knee replacement surgery (knee arthroplasty) is a common procedure but even after surgery patients may still experience problems carrying out everyday tasks.

At present, it is not clear whether physiotherapy should be routinely provided after discharge from hospital. So researchers reviewed the evidence to determine the effectiveness of physiotherapy after elective surgery in people with osteoarthritis.

Six trials involving 614 patients were included overall in the review. Effectiveness was measured in terms of improving function, quality of life, walking, range of motion in the knee joint, and muscle strength.

The review showed a small to moderate effect of functional exercise on joint motion and quality of life at three to four months after surgery, but the effect was not sustained at one year.

The evidence is not conclusive but, given these results, it seems reasonable to refer patients for a short course of functional physiotherapy exercise after discharge to provide short term benefit, say the authors. These tentative findings also suggest that further research would be worthwhile to reduce the current level of uncertainty.

This review highlights the lack of high quality research into the effectiveness of physiotherapy exercise programmes after total knee replacement, says an accompanying editorial.

Contact:
Catherine Minns Lowe, Research Fellow, Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Oxford, UK
Email: catherine.minnslowe@noc.anglox.nhs.uk 



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