Press releases Monday 7 March to Friday 11 March 2011

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 website (http://www.bmj.com).

(1) Academic performance of UK doctors and medical students varies by ethnicity

(Research: Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis)
http://www.bmj.com/cgi/doi/10.1136/bmj.d901
(Editorial: Ethnicity and academic performance in the UK)
http://www.bmj.com/cgi/doi/10.1136/bmj.d709

UK trained doctors and medical students from minority ethnic groups tend to underperform academically compared with their white counterparts, finds a study published on bmj.com today. This attainment gap has persisted for many years and must be tackled to ensure a fair and just method of training and assessing current and future doctors, say the authors. A third of all UK medical students and junior doctors are from minority ethnic groups. Although universities and the NHS are legally required to monitor the admission and progress of students and staff by ethnic group, evidence remains patchy. So researchers at University College London analysed the results of 22 reports comparing the academic performance of 23,742 medical students and UK trained doctors from different ethnic groups. They found that candidates of non-white ethnicity underperformed compared with white candidates. The effect was statistically significant and widespread across different medical schools, different types of exam (including those marked by machines), and in both undergraduate and postgraduate assessments. Ethnic differences in attainment seem to be a consistent feature of medical education in the UK, say the authors. They have persisted for at least the past three decades and cannot be dismissed as atypical or local problems. While exam performance is by no means the only marker of good performance as a doctor or medical student, they add, the fact remains that without passing finals, medical students cannot become doctors, and without passing postgraduate exams, it is much harder for doctors to progress in a medical career. The authors call for more detailed information to track the problem as well as further research into its causes. "Without these actions, it will be a struggle to ensure a fair and just method of training and assessing our future and current doctors," they conclude. "Such complex problems are unlikely to have simple solutions - what happens in medical schools is a reflection of wider society," argues Professor Aneez Esmail from the University of Manchester in accompanying editorial. He believes the solutions will be found "through critically appraising assessment methods, curriculums, the way that we engage with students in an increasingly multicultural society, and the role models that we provide."

Contacts:
Research: Katherine Woolf, Lecturer in Medical Education, Academic Centre for Medical Education, UCL Division of Medical Education, London, UK
Email: kwoolf@medsch.ucl.ac.uk
Editorial: Professor Aneez Esmail, Professor of General Practice, University of Manchester, UK
Email: aneez.esmail@manchester.ac.uk

(2) Health Bill unlikely to improve children's health services, warn child health experts

(Analysis: Improving child health services in the UK: insights from Europe and their implications for the NHS reforms)
http://www.bmj.com/cgi/doi/10.1136/bmj.d1277

The coalition government's Health and Social Care Bill is a missed opportunity to deliver the improvements in children's health services in England that are urgently needed, warn experts in a paper published on bmj.com today.

Ingrid Wolfe and some of the country's leading experts in child health propose a fundamentally different way of delivering children's health care that is long overdue in the UK.

The authors argue that care provided by UK children's health services is inferior in many regards to that in comparable European countries. However, the government's proposals fail to learn the lessons from how those countries deliver healthcare for children and risk making the situation worse, they write.

Death rates from illnesses that rely heavily on rapid access to care, such as meningococcal disease, pneumonia, and asthma, are higher in the UK than in Sweden, France, Italy, Germany, and the Netherlands. Planned care for children with long-term conditions also gives cause for concern, with fragmented inconvenient services and poor outcomes.

"If the UK performed as well as Sweden, the best performing country in our sample, as many as 1,500 children might not die each year," say the authors.

Yet they argue that the government's proposals to reform the NHS in England fail to recognise the distinct health care needs of children.

Specifically, the proposals fail to address the dangerous gap between general practice and specialists, where many of the problems lie. General practitioner commissioning may lead to a conflict of interest in developing innovative pathways of care for children, they say.

The proposals to increase competition between providers pose risks of even greater fragmentation than at present, they add, while creating barriers to development of appropriate pathways to care for acutely sick children and children with chronic illness.

The proposals risk creating even greater problems in effective information sharing, while the potential loss of regional and national planning of children's services poses significant threats to quality and safety, they write. The proposals also disregard the importance of networked care and training across organisational boundaries.

The authors point to Sweden, where care for children is provided by general practitioners with enhanced training in paediatrics working closely with paediatricians in local health centres, while the system in the Netherlands contains measures to improve coordination between primary and specialist care.

"Our analysis leads us to recommend that comprehensive integrated teams in primary care settings should provide the majority of children's healthcare. These new children's healthcare teams should comprise general practitioners with dedicated training in paediatrics and paediatricians with dedicated training to provide care for children with conditions that could better be managed in the community than hospitals. We believe such teams stand the best chance of delivering the right care, at the right time, in the right place, and by the right people."

"We believe that the coalition government's proposed changes to the NHS in England do not address children's needs and, worse, risk exacerbating the problems we have described," they conclude.

Contact:
Ingrid Wolfe, Specialist Registrar Public Health and General Paediatrician, London School of Hygiene and Tropical Medicine, Whittington Hospital, London, UK
Email: Ingrid.Wolfe@lshtm.ac.uk

(3) Chronic disease care poorer in nursing and residential homes under GP target scheme

(Research: Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study)
http://www.bmj.com/cgi/doi/10.1136/bmj.d912

The quality of chronic disease care under the GP pay for performance system is poorer for residents of care homes than those living in the community, according to a study published on bmj.com today.

The Quality and Outcomes Framework (QOF) for general practice is a voluntary system of financial incentives, which has been in place since 2004. Part of the programme includes specific targets for GPs to demonstrate high quality care for patients with chronic diseases.

The study found that, although pay for performance systems do not invariably disadvantage residents of care homes, GPs are much more likely to exclude them from quality targets, which may compromise their care.

The authors, led by Dr Sunil Shah from St George's, University of London, say that pay for performance systems should include measures relevant to care home residents to improve chronic disease care in this often vulnerable group.

Dr Shah and his team studied data from The Health Improvement Network (THIN), a large database of primary care records from 326 UK general practices, to assess the quality of chronic disease care for care home and community residents.

They identified 10,387 care home and 403,259 community residents aged 65 to 104 years who were registered for 90 or more days with their general practitioner.

Even after adjusting for age, sex and dementia diagnosis, they found that attainment of quality targets was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators suitable for older people in care homes.

The largest differences were for prescribing in heart disease and monitoring of diabetes. Smaller differences were seen for use of antiplatelet therapy and monitoring of blood pressure.

Residents of care homes were also more likely to be excluded from all QOF targets for a condition. For example, 34% of patients with stroke in care homes were excluded compared with 17% in the community, and 35% compared with 9% for diabetes.

This difference persisted even after taking account of patients with dementia or with limited life expectancy.

This is the first study to examine quality of care for residents in care home since the introduction of pay for performance in the primary care contract and shows a need to improve care for chronic diseases among older people in care homes, say the authors.

They acknowledge that, for some interventions, lower attainment of quality indicators may be appropriate, but argue that "high disease wide exceptions suggest a less individualised approach and may act as a disincentive to good disease management."

They conclude: "Our current findings support enhancement of pay for performance systems to include measures that are particularly relevant to residents of care homes and vulnerable older people in the community, such as pain management, falls and continence care."

Contact:
Sunil Shah, Senior Lecturer in Public Health, Division of Population Health Sciences and Education, St George's, University of London, UK
Email: sushah@sgul.ac.uk

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

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