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ARE YOU READY FOR A HEALTH RECESSION? THE MAGAZINE FOR TRAINEE DOCTORS
Presenting History JuniorDr is a free distribution lifestyle magazine produced by doctors for the UK’s Medical Students, Foundation Year Trainees, Specialist Trainees, GP Trainees and Specialist Registrars. You can find us quarterly in hospitals and medical schools throughout England, Scotland, Wales and Northern Ireland, and updated daily at JuniorDr.com. Editor Ashley McKimm, editor@juniordr.com Editorial Team Michelle Connolly, Anita Sharma, Muhunthan Thillai, Grace Bandoy Newsdesk news@juniordr.com Advertising & Production Rob Peterson, ads@juniordr.com JuniorDr PO Box 36434, London, EC1M 6WA Tel - +44 (0) 20 7 684 2343 Fax - +44 (0) 87 0 130 6985 team@juniordr.com Health warning JuniorDr is not a publication of the NHS, Gordon Brown, his wife, the medical unions or any other official (or unofficial) body. The views expressed are not necessarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual orientation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash. Copyright JuniorDr 2008. All rights reserved. Get involved We’re always looking for keen junior doctors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out JuniorDr.com.
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s the UK free-falls into the worst recession of our lifetime it’s not just the public’s pockets feeling the pinch, it’s our health too - and it will suffer long after the mortgage and credit markets start flowing again say the experts. In this issue we look at how the credit crunch is likely to affect our nation’s health and ask if the UK really is on the verge of a ‘health recession’. Our analysis looks at how the KFC Bargain Bucket is becoming the food of choice for cash-strapped families as the cost of fruit and vegetables soar by 15 percent. We also learn that a third of us have already quit our gym memberships while the rest are skipping exercise to spend more time at work. So what are the effects, if any, that we’re likely to see in our clinics? Mental health is already showing the early effects of the credit crunch. Presentations with depression and anxiety are up by a third in some hospitals while others are increasing consulting rooms to deal with the impending surge. Previous recessions in the UK show strong evidence that health inequalities worsen. This one comes at a bad time for the government with the recent launch of key public health strategies to tackle obesity and alcohol. One programme, Change 4 Life, which was launched this year to a fanfare of publicity aims to get families to ‘eat well, exercise more and live longer’ - a campaign that is looking increasingly more difficult as the recession takes grip. As doctors we’ve been relatively immune to the stresses of the global downtrun. Our jobs at least seem secure until the NHS budget gets reviewed in 2011. More noticeable may be effects on our patients and longer term health especially if the current dip turns into a full scale health recession.
“The KFC bargain bucket is becoming the choice for cash-strapped families.”
Ashley McKimm JuniorDr Editor-in-Chief
What’s inside 04 09 14 15 20 22
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TRIAGE
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Tell us your news. Email team@juniordr.com or call 020 7684 2343.
working hours
Irish junior doctors vote for strike action
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unior doctors in the Irish Republic have voted overwhelmingly in favour of strike action if ongoing talks this month over cutbacks in overtime and allowances fail. 99 percent of the returned ballots voted in favour of industrial action, up to and including all-out strike action, according the Irish Medical Organisation - the equivalent of the BMA. Ireland currently has just under 5,000 junior doctors (NCHDs) and the IMO estimates that junior doctor salaries would be cut by as much as 40 percent under the proposals. “Management’s attempt to unilaterally impose rosters irrespective of the consequences for patient care and safety or the training needs of the NCHDs is clearly driven by Health Service Executive (HSE) directions aimed at cutting costs”, said Dr
Dr John Morris
John Morris, Vice President and NCHD Committee Member. “We cannot and will not accept discussion or consideration of breaches to NCHD core contractual entitlements under the heading of cost containment. The overwhelming vote in favour of industrial action demonstrates the level of anger amongst our NCHD members,” he said. The measures are aimed to save €90m per year. The HSE blamed the cutbacks on the need to meet the European Working Time Directive: “The Health Service Executive (HSE) is disappointed that the IMO should feel it necessary to consider embarking upon industrial action. The HSE is only seeking to reduce doctors’ working time to comply with the EU directive. Any action
by doctors which would cause anxiety and upset to patients would be regretted.” Talks are continuing in Dublin to resolve the dispute. www.imo.ie www.hse.ie
Proposed changes
Vice President IMO
• Mandatory 1 hour unpaid meal break
“The overwhelming vote in favour of industrial action demonstrates the level of anger amongst our NCHD members.”
NHS
Doctors still the most trusted profession 4
NEWS PULSE
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Data from the IMO
• Suspension of Training Grant and PGMDB Allowance • Discontinuation of Higher Degree and Diploma Allowance • Attendance at in-house training no longer paid • Discontinuation of Living Out Allowance • Introduction of mandatory unpaid Pre call/Post call • Maximisation of on call off site where feasible • Cross cover across different specialities to be maximised
octors have topped the poll of professionals that the public trust the most for the 25th year running, according to the latest survey commissioned by the Royal College of Physicians. Ipsos MORI polled over 2,000 people as to whether they
trusted different professions to tell the truth. More than 92 percent of the public trusted doctors, closely followed by teachers at 87 percent. Only one in four trusted government ministers, however it was journalists and politician who ranked lowest with just one
in five of the public trusting either of them to tell the truth. Doctors have consistently topped the list of most trusted professions in virtually every year since 1983 when the poll began. www.rcplondon.ac.uk
UK GPs best paid in Europe British GPs are the best paid in Europe according to a study by the Netherlands Institute of Health Services Research and Maastricht University. The survey of earnings in 2005 found UK GPs on top at £108,680 per annum with German GPs the second highest paid at £72,170. The French earned £45,200 on average with Belgium GPs earning the lowest at £21,270. www.biomedcentral.com
Stretch before surgery A warm-up of 15 to 20 minutes with simple surgical exercises prior to an operation leads to a substantial increase in proficiency of surgical skills, according to a paper published in the Journal of the American College of Surgeons. The study of 46 surgeons across varying specialties and experience levels also found the warm-up raised alertness and improved performance of fatigued surgeons. www.facs.org
Quitting the smokers bark Smokers are more likely to quit smoking for the sake of their pets’ health than they are for their own, according to research published in the journal Tobacco Control. The survey of 3300 people found that one in three of the smokers (28.4%) said that being aware that smoking was bad for their pets’ health would spur them to give up.
training
750 UK training placements for overseas doctors M ore overseas junior doctors will be able to take a two-year training placement in the NHS, the Department of Health has announced. The current Medical Training Initiative (MTI) that has offered 250 time-limited placements for doctors from developing countries last year will now be expanded to provide up to 750 opportunities. It will offer international medical graduates from English speaking countries in the developing world - where medical training is not widely available - the opportunity to secure vital training and work experience in the UK. “I am very pleased to be able to expand MTI which will give greater numbers of doctors from developing countries the chance to secure vital training and work experience in this country,” Health Minister Ann Keen said. “We will benefit greatly from their time with us and when they return home, they will be able to apply the skills and knowledge developed during their time here.” The MTI placements can only be made available where a suitable UK doctor cannot be found. The Department of Health has been
tobaccocontrol.bmj.com
New Director of Medical Education
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www.dh.gov.uk
www.bapio.co.uk
Dr Ramesh Mehta BAPIO President
www.dh.gov.uk
“BAPIO is delighted that the Department of Health is expanding this initiative which allows international doctors to train and benefit from medical expertise in the UK.”
medical students
More needed to encourage poor into medicine
Dr Patricia Hamilton has been appointed as the new Director of Medical Education for England. Dr Hamilton is currently President of the Royal College of Paediatrics and Child Health and will be in charge of the Modernising Medical Careers Programme. The post has a remit covering the full range of medical training from undergraduate through to CCT.
working with the GMC, BMA, British Association of Physicians of Indian Origin (BAPIO) and NHS Employers. BAPIO president, Dr Ramesh Mehta said: “BAPIO is delighted that the Department of Health is expanding this initiative which allows international doctors to train and benefit from medical expertise in the UK. We are also pleased that this will ensure the preservation of our strong historical links with the UK.”
ealth ministers must halt spiraling graduate debt and remove the educational barriers that prevent low income pupils attending medical school, the BMA has warned. The statement came in response to the publication of the Public Accounts Committee’s (PAC) report into widening participation in higher education. “While every student has financial worries, medical students face particular pressures as their degrees are longer and more expensive than other undergraduate courses,” said Louise McMenemy, BMA Medical Student Committee lead on widening participation at medical school. At present medical graduates leave university
with £21,000 worth of debt on average, a figure that could rise as high as £37,000 in the next few years now that variable top up fees have been introduced. The BMA did note that improvements have been made for both women and ethnic minorities looking to enter medicine. In 2007 almost one third of students offered a place at medical school were from ethnic minority backgrounds, while just under three in five were women. www.bma.org.uk
NEWS PULSE
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JUNIORDR GLADIATOR
AMAZON
28-
year-old junior doctor Zoe Williams has joined hit TV show Gladiators as ‘Amazon’. Zoe previously worked at the Royal Victoria Infirmary in Newcastle. She can be seen Sundays at 6pm on Sky1 and Sky1 HD. sky1.sky.com/show/gladiators
Image used courtesy of BSkyB
The Health
Crunch Prepare for the ‘health recession’. Believe the media hype and we’ll be a nation of anxious insomniacs surviving on 2p Asda sausages by the end of 2009. City workers with ‘square mile syndrome’ will be jumping from their Vitra designed offices onto the streets below, and our clinics will be overrun with depressed and obese patients with soaring blood pressure and new onset diabetes. As the UK freefalls into the worst recession of our lifetime should we be worried about the impact on public health or are these fears just ‘health crunch hype’? Ashley McKimm looks at how the financial turmoil is likely to affect our nation’s health and asks if the UK really is on the verge of a ‘health recession’.
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hree out of four Brits are already convinced that their health will get worse in 2009 because of the financial downturn - and their habits are already realising this. As fresh fruit and vegetables get replaced by the KFC Bargain Bucket government targets on obesity, alcohol and narrowing health inequalities look likely to go unmet as people make their health a lower priority. What makes the ‘health crunch’ different from most other health issues is that it’s the young that are feeling most vulnerable. Almost twice as many 18-24 year olds believe their health will be effected compared to the over 55s. Women also fear the downturn more with only a tenth reporting no financial anxieties compared to a quarter of men.1
Eating healthy is too expensive In 2008 the government launched its ‘Healthy Weight, Healthy Lives’ initiative.2 The aim was to encourage families to ‘eat well, move more and live longer’ - a strategy that now looks increasingly likely to falter in coming years. Already over half of UK shoppers report they are now buying from supermarket budget ranges to help save money, with 15 percent cutting back on relatively expensive fresh fruit and vegetables. It’s not surprising when you consider the cost of meat and fish has soared by 25 percent in the last year while fruit and vegetables have risen 15 percent.3 Eating healthy is one of the first compromises families make, says Bridget Benelam,
Nutritional Scientist at the British Nutrition Foundation: “There is a danger in the current economic climate that people will forget about 5-a-
THE HEALTH CRUNCH
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The health crunch day and reach for cheap convenience foods that are often high in fat and salt and low in fibre, vitamins and minerals,” she says. “However, with a little planning and preparation, meals can be both cheap and healthy, using plenty of low-cost fruit and vegetables, including frozen and tinned varieties, and cheap ingredients like pasta, rice, potatoes and pulses.” But that might not be so easy. The National Consumer Council, which checks supermarket prices in England found that over half of instore promotions were related to foods high in fat and sugar - despite Food Standards Agency advice that these
Key Statistics • 15 percent cutting back on relatively expensive fresh fruit and vegetables. • A third of UK gym goers have cancelled their memberships. • Seven percent are drinking more alcohol. • Six percent of people have starting smoking again. • Two-thirds blaming money and work worries for their insomnia. • PFI building projects stand at the lowest level for the last decade.
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THE HEALTH CRUNCH
‘occasional’ foods should make up just seven percent of diets. The lowest socio-economic groups are likely to suffer most in the oncoming recession driving health inequalities even further apart. Demand for free school meals is already up in two out of five council areas as low-income and unemployed parents struggle with food prices.4
Too stressed to exercise It’s not just our diet that has been credit crunched - our exercise habits are feeling the pinch too says, Professor Graham Macgregor, Chairman of the Blood Pressure Association. A third of UK gym goers have cancelled their memberships in the past six months to reduce outgoings - with nearly half (42 percent) saying they would like to keep going but couldn’t afford it. Of the remainder, one-fifth have reduced the time they spend on exercise due to working longer hours. “It’s clear that Britons are under pressure and this could have serious health consequences,” says Professor Macgregor. “The dual effect on lifestyles of the credit crunch and lack of concern over long term health is putting the nation at risk of a blood pressure ticking time bomb.” Stressed workers are hitting the bottle too. Seven percent are drinking more alcohol than before the ‘credit crunch’, with nine percent believing this will be the case in the next six months. Six percent of people have started smoking again.3
The Great Depression The Samaritans launched a well publicised campaign to help depressed and suicidal City workers but it’s not just the finance sector that is hard hit. Those in the lowest socio-economic profiles already have a higher incidence of mental illness - a statistic that is likely to be compounded by the latest downturn. Mental health is expected to be most impacted by the economic downturn and service provision is already being affected. Evidence from previous recessions shows that there is a noticeable early spike in incidence of depression and anxiety disorders and that’s already becoming evident to service providers across the country. Glasgow’s Priory Hospital has opened new consulting rooms to deal with the surge, which they attribute to financial concerns and increased work pressures. In London, Capio Nightingale, an independent
mental health hospital, has reported that people seeking advice for mental health disorders has surged by a third. It’s something that has the government and Health Secretary Alan Johnson worried: “In the current economic downturn, the potential exists for more people to become anxious or depressed and experience lower levels of mental well-being,” he said. Johnson has announced an investment of £13 million to create a faster roll-out of therapy services across the UK in 2009 which will be linked to employment support workers. Studies in America of previous economic downturns have found that with each percentage rise in unemployment there was an accompanied seven percent rise in non-psychotic mental health disorders.5
Sleepless Britain Fears over our jobs and livelihoods also appear to be keeping us awake. In a recent survey by NetDoctor nearly half of the 1,000 men and women questioned said they were sleeping worse now than a year ago. Stress was cited as a major factor, with two-thirds blaming money and work worries for their insomnia.
Professor MacGregor Chairman, Blood Pressure Association
“The dual effects on lifestyles of the credit crunch and lack of concern over long term health is putting the nation at risk of a blood pressure ticking time bomb.”
Estate Agents top the sleep deprivation poll getting five hours and 50 minutes sleep a night - more than two hours less than the daily recommended sleep quota.6 When we are awake 15 percent of us claim we’re working longer hours and half of us are less likely to take time off during an economic slowdown. Those living in London are worst - with one-third too busy to have time to see a doctor. Research published in Diabetic Medicine shows that psychological distress such
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Leadership & Management Development
Why all the fuss?
Open any publication offering news and insight into health service matters and you’ll find a reference to the importance of good quality leadership & management at a clinical level. Furthermore, turn up to your consultant interview without a requisite demonstration of both learning and practice in this area and you’ll find yourself on the sharp end of some uncomfortable questions (if you were lucky enough even to get short listed without this heavily referenced in your CV). We examine what leadership and management really are and how to go about ensuring you stack up when the time is right. Leadership & Management – Understanding the difference Do managers need to lead or do leaders need to manage? Are they the same, different or simply is one part of the other and if so which? There is reasonable agreement that leadership is about setting direction and management is about implementing it. However, if we leave it at that, it does raise a question about the enormous emphasis currently on developing leadership in doctors when broadly the Department of Health & Government sets direction. Furthermore, doctors are finding themselves with ever less authority over their own lot, with job planning dictating how they are deployed, targets & finance dictating what they focus on and with many feeling their everyday status has returned to that of worker bee, not clinical leader. ‘Why’ is an issue we’ll return to later but some of the answer lies in ‘what’ – the deeper meaning of leadership & management. Leadership Besides setting direction, leadership is about aligning, enabling and motivating people towards that direction, or vision, as it is often termed. That’s an ‘on the ground’ job and whilst service delivery expectations increase, so does the need for more of this type of leadership. It can also be argued that leaders do the right thing based on the true purpose they serve (welfare of the patient, in the case of doctors) whereas managers follow the instructions of more senior managers. This is readily evidenced by the approach of ‘management’ to the 4 hour target in A&E, where compliance with the 4 hour timeslot often seems to take precedent over the right, sensible or appropriate thing to do. Furthermore, local leaders do set direction by taking a national plan and creating a local vision based upon marrying the principles or requirements of the master plan with local variances & priorities. So, at a service level, leadership is vital to provide:
• Direction aligned with national priorities but locally interpreted • A moral compass to ensure that we do what is right • A driving force that aligns people with direction, whilst keeping their motivation high Management Despite the process-orientation of management, it is difficult to see how you can manage effectively without a strong consideration of people. Management is effectively concerned with taking a strategic direction and turning it into an operational plan, utilising the resources at your disposal (including human resources). The role of management traditionally includes: • Determining objectives • Forecasting & information gathering • Planning & organising • Directing & coordinating • Controlling • Communicating We think this traditional view needs augmenting with the essence of leadership too, as doctors aspire to a role that effectively encompasses both and where both are necessary to operate effectively at a consultant level. The leadership imperative in modern healthcare Returning to that ‘why’ question, there is a far greater imperative to develop leadership skill in our clinical workforce today and it has very little to do with medicine itself. With our population forecast to grow from approximately 60 million to around 71 million over a 25 year period, with life expectancy increasing by 5 years over the same horizon and with the balance of population moving more towards the retirement group, we are going to find ourselves with ever increasing healthcare demand and an ever decreasing ability to pay for it. The magnitude of this set of compounded challenges dictates a complete rethink in our model of healthcare delivery and with that comes a
significant need for the right kind of leader to see us through very turbulent waters. Lord Darzi has outlined a new model, controversial in places, with an increasing emphasis on market forces and new provider types. Under this radical plan the traditional NHS, hierarchical and centrally led, transitions to being locally led through the commissioning process, with ‘any willing provider’ delivering healthcare as long as it matches service specifications and quality controls. That requires a fundamental change to the organisation of the doctor role, to our commonly held models of the medical employment contract and to the activity that senior doctors will be engaging in as the new model takes shape. Forearmed is forewarned, so why is the level of awareness in this area so low? It could just be by design! Effective leadership & management development The attributes of an effective leadership & management development programme become much clearer when you consider the context in which that leadership & management will be dispensed i.e. the changing healthcare landscape. Without delving into the minutiae, a robust programme will include: • Understanding the evolving healthcare environment and how it will change • Both business and clinical leadership skills, including both strategic and operational leadership • Management principles aligned to the new environment, not based on the old healthcare paradigm This suggests some care and attention in your choice of provider, to avoid developing a set of skills matched to a health service model that is rapidly dissolving. Equally, it is vital that doctors in training and consultants alike develop a much deeper understanding of the evolving landscape and what it means to them. Medicology’s Insights Day (www. nhsinsights.co.uk) is designed to provide just such insight and is a good place to start. Mr Andrew J Vincent, Managing Director, Medicology Ltd Dr Sara L Watkin, Medical Director, Medicology Ltd
MEDICAL STUDENTS TRAINING
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Focus on Finance - in association with Wesleyan Medical Sickness
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Sign-up to Saving
ou’re probably now at a stage in your life when, possibly for the first time, you’ve got a regular income and a bit of extra cash in your pocket. The temptation to spend must be strong and there’s nothing wrong with treating yourself especially as you work so hard. But you should also start to think about squirreling some of that cash away. It sounds boring but remember that having savings gives you choices – choice of whether and where to buy a house, where to go on holiday, where to educate your children and, further down the line, choice of when to retire. However if you have any outstanding debts, such as a student loan, pay these off before you start saving. It’s likely that the interest you’re paying on the loan is going to be greater than what you’re going to earn on any savings. You might think that you’ve got plenty of time before you need to start saving but do you know that you have only 432 pay days in your career, assuming you start your medical career at age 25 and retire at 60. By the time you hit 35, when you may be taking up a Principles post, you will have only 300 pay days to go. There are many reasons to save. It’s sensible and re-assuring to have at the very least an emergency fund in place to cover you if you can’t work for any reason or need a cash injection. The size of the fund is up to you but we think three months pay after tax is a good starting point. Another good reason to start saving is to get on the property ladder. You may find it
more difficult in the current climate to get a mortgage and having a good deposit could help. Alternatively you might want to save for a holiday of a lifetime, school fees for children or even, if you’re really planning ahead, for early retirement. It makes sense to stash some cash away on a regular basis. The first question is how much? Obviously that’s your choice but make sure you are comfortable with the amount you choose. You’ll still want to have some fun in life and generally treat yourself. So the question to ask is “How much can I put away and forget about?” Then consider whether you’re saving for a short term objective such as a new car or a longer term project such as amassing funds for further education costs. Equally important is where to house your savings and this will depend on your attitude to risk, as well as any specific savings goals that you have.
Every type of saving carries some degree of risk. Generally the higher the risk, the higher the potential return and vice versa. The level of risk tends to be low for cash deposits increasing with other assets such as government and corporate bonds through to stocks and shares that can carry a high level of risk. However the real return on cash deposits reduces over time. This is because if you put all of your cash into a bank deposit account for a long period of time, the return is affected by inflation. Your risk profile may alter as your situation and saving objective changes. You may feel that you are happy with a greater level of risk for longer term savings such as retirement planning but want a lower risk for a shorter term goal. You should make the most of any tax efficient saving opportunities. If you have money in the bank, consider moving it to an ISA - an individual savings account. You can invest into an ISA on a regular basis or make a lump sum investment. When you withdraw your accumulated capital you won’t pay any income tax on it. You can currently invest up to £3,600 in a cash ISA or £7,200 into a stocks and shares ISA each year. The latter are better suited to longer-tem investments (a minimum of five years) as they are designed to run for a longer time. There are other types of saving vehicles available all with different tax implications and varying levels of risk and return. You should talk with a financial adviser to ensure that you choose the right saving plan to meet your objectives for both short and long-term saving.
The above information does not constitute financial advice. Wesleyan Medical Sickness provides specialist financial advice for doctors. Telephone 0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk
Specialist financial services for doctors • Savings and Investments
• Mortgages and Insurance
• Retirement Planning
• Personal Loans and Bank Accounts
• Life and Income Protection
0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk FINANCE
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