Na'eem Ahmed

NHS junior doctor contract proposal: risks and prejudices.

Proposed changes to junior doctors’ contracts working within the NHS have been met with fi erce opposition, attracting widespread media coverage in recent weeks. Heavy criticism of the changes has led to a stall in negotiations and threats of possible industrial action led by the British Medical Association. Several Royal Colleges have also called on the government to reassess its position, citing longer working hours and reducing pay as detrimental to staff morale and patient safety. Most of the reaction has centred on the physical and financial effects this proposal will have on junior doctors, although there has been limited emphasis on the wider long-term eff ects and unintended consequences that will prevent the NHS meeting the demands of patients in the future. The proposed contract penalises clinicians who take time out of their training to pursue their interests in research or elsewhere, as they will no longer receive annual wage increments on returning to clinical practice. Alternative career routes will become increasingly undesirable given the pressure to complete protracted specialty training programmes even faster. This approach will deter clinicians from engaging in cutting-edge research to pioneer new treatments, which is necessary to maintain the NHS’s reputation as a world-class health system. Doctors who embark on leadership pathways might also be affected despite the growing need for clinical leaders, as set out in the NHS Five Year Forward View. Furthermore, removing pay protection for women on maternity leave could potentially widen gender inequalities and discourage female students from embarking on a career in medicine, exacerbating staff shortages in the future. The changes will also have serious implications for global health and surgery. Junior doctors often travel abroad to not only develop their clinical skills but also contribute as global citizens committed to realising the new Sustainable Development Goals. Such cross-cultural professional experience enables them to give back much more to the NHS when they return and also cogently expresses the government’s commitment to the developing world. In conclusion, the junior doctor contract in its proposed form will create a homogeneous workforce that will be insular and stagnant. Our workforce must be diverse, multitalented and multifaceted to meet the complex needs of the future.

Can the Accountable Care Organization model facilitate integrated care in England

Following the global economic recession, health care systems have experienced intense political pressure to contain costs without compromising quality. One response is to focus on improving the continuity and coordination of care, which is seen as beneficial for both patients and providers. However, cultural and structural barriers have proved difficult to overcome in the quest to provide integrated care for entire populations. By holding groups of providers responsible for the health outcomes of a designated population, in the United States, Accountable Care Organizations are regarded as having the potential to foster collaboration across the continuum of care. They could have a similar role in England’s National Health Service. However, it is important to consider the difference in context before implementing a similar model, adapted to suit the system’s strengths. Working together, general practice federations and the Academic Health Science Networks could form the basis of accountable care in England.

Can diaspora-led organisations play a prominent part in global surgery?

The high number of trained staff in countries with a disproportionately small burden of disease has exacerbated inequalities in global health and surgery. It is estimated that in low-income countries there is a shortage of about 2·5 million members of staff , including surgeons and midwives, to provide essential health interventions. Better fi nancial and education opportunities have been cited as common incentives for workers to emigrate, with risk of conflict and disease threatening their safety and security in their own countries. By training providers who later migrate overseas, lowincome countries are losing more than

Mobilising the Campaign to End Fistula

500 million each year as they effectively subsidise their wealthier counterparts. D i a s p o r a l e d o r g a n i s a t i o n s (DLOs) can have an important role in addressing unmet surgical need in low-income and middle-income countries. These organisations have the unique advantage of being able to relate to the cultural sensitivities of local populations, which is particularly pert inent with mult ifaceted conditions such as obstetric fi stula. In many ways, obstetric fi stula represents a microcosm of the international community’s failure to emphasise the need for cost-effective surgical interventions, and the inability to encourage community-level initiatives that empower women. Although maternal mortality has almost halved over the past two decades, there exists a need to address underlying social causes such as early marriage, which substantially contribute to maternal morbidity. By facilitating clinical and reproductive sexual health programmes for women in rural Bangladesh, DLOs such as Selfl ess are well placed to achieve this. DLOs are better able to expand community links and develop longterm partnerships, contributing to a more meaningful collaboration between high-income and low-income countries. In an era of globalisation, policy makers must capitalise on this underused resource by supporting diaspora communities to improve care in their countries of origin. In so doing, this support will not only alleviate the burden of the so-called brain drain but also address widening inequalities in surgical care. If low-income countries do not address such issues by seeking solutions from within its own communities both at home and overseas, they will struggle to achieve sustainability in the post-2015 agenda.

Smart cities: health and safety for all

246 www.thelancet.com Vol 386 July 18, 2015 mHealth where so-called fistula ambassadors deployed to rural areas help identify aff ected women, confi rm their likely diagnosis, and arrange transport for them to reach surgical centres. Transport costs often operate through a payment infrastructure already provided by mobile phone companies. Mobile phone use is high in low-income and middle-income countries and will continue to rise, off ering a relatively inexpensive yet accessible intervention to improve maternal health in these countries. Although more rigorous evidence is needed to assess the effect and cost-effectiveness of mHealth programmes, their future remains promising. Innovative strategies to address obstetric fi stula through improved access to antenatal care must be welcomed to help make this disorder one of the past.