this week MORAL INJURY page 129 • PENSIONS page 130 • GP TECHNOLOGY page 130

On-call trainees face £65 fee to rest

EXCLUSIVE Junior doctors are calling predominantly a non-resident on-call Many junior doctors are forced for their contracts to stipulate they will not pattern,” she said. “The time sensitive to sleep where they can on be charged to stay overnight in hospital nature of our on-call work means that it is night shifts, or pay an average of £25 a night for a room accommodation, after an investigation usually not possible to live within a safe found one in five acute trusts in England distance. So, staying on site for on-calls is charge—some as much as £65 a night. something we expect. This issue can affect The trainees’ section of the British any doctor working a non-resident on-call Association of Urological Surgeons (BAUS) rota, not just .” sent freedom of information requests to She added that a trainee working a non- 213 trusts for accommodation charges for resident on-call shift once every eight days doctors working a 24 hour non-resident and paying £25 each time would spend on-call shift as part of its #DontPayToStay £1140 in a year. BAUS is calling for contract campaign. It received responses from 182 changes to make time critical specialties (93%), of which 145 had rooms available exempt from room charges. for non-resident on-calls, and 30 trusts Sheona MacLeod of Health Education (20%) charged to use them. England said, “It is essential doctors in LATEST ONLINE Charges ranged from £65 a night at St training have access to somewhere to sleep. A&E consultant whose George’s University Hospitals in to This is something we highlighted in our wife skipped triage £9.14 at Warrington and Halton Hospitals. NHS Staff and Learners’ Mental Wellbeing and was treated at The median charge was £25 a night. Commission. It is also part of the BMA’s home is suspended Three trusts said the charges were fatigue and facilities charter, which we for a month reimbursed, and one said it waived the encourage trusts to adopt.” Congo’s fight against charge if trainees were using the room A St George’s spokeswoman said the Ebola stalls after because they were too tired to drive home. trust organised rotas to minimise the need epidemiologist is Although non-resident on-call trainees for junior doctors who live far away to stay shot dead can stay at home until they are called overnight, but when that was not possible Cancer drug into the hospital, this is not feasible in it offered a reduced rate with a local resistance needs some cases, explained Katie Chan, a accommodation provider. urgent attention, urology trainee and the founder of the Abi Rimmer, The BMJ says research chief #DontPayToStay campaign. “Urology is Cite this as: BMJ 2019;365:l1836 the bmj | 4 May 2019 127 SEVEN DAYS IN Doctors who make one-off clinical mistakes are unlikely to face full GMC inquiry The GMC is to reduce the number of full investigations into single, one-off mistakes by doctors, after its two year pilot of an inquiry process for single clinical incidents. Under the pilot a complaint or referral prompted a rapid gathering of information from sources such as medical records, responsible officers, and the doctors themselves to assess any ongoing risk to patients. Only then did the GMC decide if a full investigation was required. Of the 309 cases considered during the pilot, 202 were closed after initial inquiries without the need for a full investigation, the GMC said. Charlie Massey (left), GMC chief executive, said that although the new process would not be suitable for all complaints, it would allow the regulator to deal with concerns more quickly, reduce the impact of investigations on doctors, and better protect patients. However, he said that the GMC was still required by law to investigate any allegation that a doctor’s fitness to practise was impaired. “We continue to ask the government for legislation to give us more flexibility, and which would allow us to further improve the ways we can resolve fitness to practise concerns,” he said.

Abi Rimmer, The BMJ Cite this as: BMJ 2019;365:l1829

Career development over-the-counter drugs delivered Lung health Survey of non-traditional only £25.9m of savings in 2018, Opioids to carry addiction NRT combinations show working practices the government disclosed, as the warning in UK better success rates The GMC’s first comprehensive year’s total spending fell from All opioid will carry a Just over 17% of people who used survey of specialty, associate £475.3m to £449.4m. Andrew message warning they can cause a nicotine patch and another type specialist, and locally employed Green, clinical and prescribing addiction, including those for of nicotine replacement doctors opened on 1 May (see policy lead for the BMA’s General sale over the counter. England’s (NRT) such as gum (left) or www.gmc-uk.org) for feedback Practitioners Committee, was not health secretary, Matt Hancock, lozenges to stop smoking on working practices, workplace surprised, saying that most GPs said, “Things are not as were successful, support, and opportunities for were already prescribing sensibly bad here as in America, compared with about career development. This is before the guidance was issued. but we must act to protect 14% who used the regulator’s first dedicated people from the darker side to only one type of survey of the 45 000 UK doctors Athletics painkillers.” From 2008 to 2018 NRT, a Cochrane review working outside traditional End unethical rules on the number of opioids dispensed found. Higher dose nicotine training routes, which will classifying women—WMA in the community increased by gum (containing 4 mg nicotine) include questions on bullying, Doctors should have no more than 60% from 14 million to also worked better than lower undermining, and burnout. part in implementing new 23 million, while codeine related doses. Although higher dose eligibility regulations requiring deaths in England and Wales nicotine patches (25 mg or 21 mg General practice female athletes with specific more than doubled. nicotine) probably increase quit Record numbers enter differences in sex development rates, said the reviewers, more GP specialty training to medically cut their natural Cosmetic clinics to assess evidence was needed. Recruitment to GP specialty blood testosterone, said the patients’ suitability training was the highest ever for World Medical Association. The The Joint Council for Cosmetic Lung cancer is missed in this time of year: 2598 trainees regulations were introduced Practitioners is to train its “never” smokers were accepted on courses, up last year by the International members to spot mental ill Some 6000 people in the UK who from 2533 in the same period Association of Athletics health in clients and refer them have never smoked die of lung last year, showed figures from Federations after a South to NHS services. Stephen Powis, cancer a year—about a sixth of Health Education England. The African runner, Caster Semenya NHS national medical all such deaths, doctors wrote in GP specialty training fill rate for (right), had to undergo gender director, said the checks the Journal of the Royal Society of round 1A is up 2% on last year verification testing to confirm were a “major step” in . Secondhand smoke, and, if the trend continues, HEE is her eligibility for women’s improving the duty of care occupational carcinogens, on course to meet its 3250 target. events. The Court of companies show to pollution, x rays, and radon Arbitration for Sport clients. But he exposure were largely to blame. Drive to curb OTC is due to issue warned not But recognising cases could be prescribing falls short a decision all clinics difficult, they warned, especially A major policy push by NHS on the were for GPs who must balance England to save £100m a year IAAF rules council over-investigation with early by curbing GPs’ prescribing of next week. members. diagnosis.

128 4 May 2019 | the bmj SIXTY SECONDS MEDICINE ON . . . Children should be Child health kept active from the MORAL INJURY WHO advises physical age of 1, says WHO activity from age 1 THAT SOUNDS . . . PAINFUL? Young children should engage It could be. The term was originally used to in at least 180 minutes of describe soldiers’ responses to their actions physical activity a day from in war. It’s now used in the US to describe age 1 to improve their health, what we would call burnout in the UK. the World Health Organization IT DOES SOUND LIKE AN AMERICANISM recommended. New guidelines The term was first used in a medical context for children under 5 also by US based psychiatrist Wendy Dean. recommend no sedentary screen (below), Royal College of time for children under 2 and a ’ president, has suggested it could limit of one hour a day for children also be used in the UK instead of “burnout.” aged 2-4. It recommends 14-17 WHAT EXACTLY IS BURNOUT ANYWAY? hours of good quality sleep a day at age 0-3 months, 12-16 hours at Depression The RCP defines it as “a syndrome of emotional exhaustion, involving the 4-11 months, 11-14 hours at age Guided self led or group ASSISTED development of negative self concepts, 1-2, and 10-13 hours at age 3-4. CBT is effective negative job attitudes, and a loss of concern A meta-analysis of 155 DEATH and feeling for patients.” Scotland randomised clinical trials of CMO promotes more cognitive behavioural therapy In the first 10 IS IT COMMON? personalised care (CBT), reported in JAMA months of 2018, It would seem so. A Health professionals throughout , found no significant 2614 people died recent BMA survey, Scotland were encouraged to difference between the with medical found that 80% of doctors were at a high deliver a more personalised effectiveness of individual, group, assistance approach to care, as part of the telephone, or guided self help or very high risk of chief medical officer’s goal of CBT in reducing the severity of in Canada, burnout, with trainees “realistic medicine.” Catherine depression. All were considerably most at risk. Calderwood introduced the more effective than being on a 1.12% of WHY DROP THE WORD BURNOUT? concept three years ago, arguing waiting list or unguided self help deaths during At the RCP conference, Goddard said burnout the NHS needed to do more to put CBT with no therapist. Patients that period implies a doctor has failed. “That despair, patients at the centre of decision who had individual and group CBT [Health Canada] hopelessness, and loss of joy—is not a failure making to reduce harm, waste, were the least likely to drop out. of the individual,” he said. “Moral injury” and unwarranted variation. puts the onus on the system, he added. Many clinical teams have now Heart devices THIS ALL SOUNDS FAMILIAR . . . adopted a “what matters to you” More day case procedures You may be thinking of doctors’ rejection of conversation in their practice, she could save NHS £5.6m resilience training. As Clare Gerada, medical said, and have personalised the The NHS could save £5.58m director of the NHS Practitioner Health treatment and care they provide. a year if 75% of procedures Programme, put it in 2015, “You can no more to implant complex cardiac teach resilience than you can integrity or Cervical screening devices, including defibrillators, courage—so let’s stop blaming doctors for Uptake fell after NHS pacemakers (right), failings of their working environment.” reorganisation in 2013 and resynchronisation CAN WE DO MORE THAN BAN WORDS? The reorganisation of England’s devices, were Good question. Goddard focused on primary care trusts into clinical performed as day changing culture. He said, “Until we sort commissioning groups in 2013 cases, a study in Open out the workplace we will all continue to be led to a fall in cervical screening Heart estimated. A ‘injured’ by it.” He added, “How we treat each uptake, a study found. Areas that freedom of information other and work together impacts directly on experienced more disruption request found that 80% our patients.” from the Health and Social Care of UK centres already implanted AND TAKE MORE BREAKS? Act 2012—for example, where some complex devices as day CCGs worked with several local case procedures, but only a third Yes! The BMJ has launched a campaign calling for doctors to be able to take the councils—saw the biggest performed more than 75% this breaks they need—not only for their decline, found a data analysis by way. Each day case is up to £2169 wellbeing but for patient safety. You can take the University of Manchester and cheaper than an overnight stay. part on Twitter using #giveusabreak. the London School of Hygiene and . Cite this as: BMJ 2019;365:l1947 Abi Rimmer, The BMJ Cite this as: BMJ 2019;365:l1933

the bmj | 4 May 2019 129 Health secretary says inequality in NHS is draining the workforce

The NHS in England must deal with its problems with gender and racial inequality if it is to stem the flow of staff leaving the service, the health secretary, Matt Hancock, has said. “Too often we’ve lost talented people because we haven’t done enough to convince them to stay,” he said. “The most troubling statistic I’ve seen is this: one in 11 staff leave the NHS entirely every single year. It’s something we urgently “Get IT basics right,” need to address, and I believe a large number of those people leave because we haven’t done RCGP tells Hancock enough to make the NHS a great place to work.” he government should outdated IT systems, and that some Working culture focus on creating a “robust practices remain reliant on outdated fax Hancock made the comments in a speech at the and joined up” IT system machines that the health secretary, Matt Royal College of Physicians’ annual conference in across general practice Hancock, has pledged to dispense with. Manchester on 25 April. He said that, as well as and the NHS before At the manifesto’s launch Hancock tackling resourcing and contractual issues, a key Tembarking on a full scale technological also promised to fulfil one of its part of increasing retention rates would involve revolution, the Royal College of General recommendations by upgrading every improving working culture, which would in turn Practitioners has said. hospital, GP practice, and community drive up organisational performance. The RCGP’s new manifesto stresses service to full fibre connectivity as “In every trust where there is a problem with the importance of “getting the basics soon as possible. “We need healthcare unequal treatment there is a problem with right first.” The college said it recognised professionals to feel confident they can performance, across the board,” he said. the potential of genomics, artificial access fast, reliable broadband to give The gender gap was a “barometer” of the intelligence, digital medicine, and patients the best possible care,” he said. health of the NHS, he said, pointing to figures robotics to “potentially revolutionise The manifesto also calls on the showing that men in the NHS earn patient care and improve safety.” government to ensure that all practices on average 23% more than But it argues that they will only be their female counterparts. possible if all GP practices have robust, “It’s clear that things secure IT systems, and all parts of the The MANIFESTO must change, and I’m NHS have access to networks which highlights that up to determined to change “seamlessly link up the patient journey.” 80% them,” he said. The manifesto highlights that up to of practices could soon be using Hancock said a culture 80% of practices could soon be using outdated IT systems of transparency in pay, We haven’t promotion, and reward was essential. “We need BMA calls for chancellor to reform done enough to create a working culture to convince that puts flexible working at pension rules to keep doctors in NHS people to stay the heart, that encourages women to stay in the NHS family and take the The BMA has warned the chancellor of some NHS trusts were topping up opportunities to progress; that helps women to the exchequer, Philip Hammond, that consultants’ salaries with cash rather move up the career ladder, even when they have doctors will reduce their NHS working than putting money into the NHS children and caring responsibilities.” hours unless reforms are made to the pension scheme, to avoid triggering tax He added that inequality went beyond NHS pension scheme. charges and to help retain staff. gender, to affect people from minority ethnic Changes to pension allowance rules backgrounds and those with disabilities. “Only that limit what can be saved into a Serious consequences by embracing equality of opportunity are we pension each year before tax charges In the latest of several letters to going to be able to address the staff shortages, apply have landed some consultants Hammond, the BMA says the loss of get the people we need to create the sustainable with huge unexpected tax bills and have experienced clinicians will have serious NHS we want, and make sure we can harness already prompted 3500 doctors to retire consequences for patient care and the everyone’s potential,” he said. early since 2016, while many others are service’s sustainability. The association, Tom Moberly, The BMJ avoiding taking on additional work. which has been calling for a rethink of Cite this as: BMJ 2019;365:l1937 The BMJ reported on 18 April that pension rules since last August, says the

130 4 May 2019 | the bmj Widen inquiry into sexism at BMA, say women behind the allegations Tech opportunities have to be embraced safely and sustainably A group of female doctors who that “appear to fall short of the Helen Stokes-Lampard, RCGP drew public attention to alleged standards of behaviour expected sexism and inappropriate of members,” the doctors have modern, digitally enabled premises behaviour from BMA members concerned would be referred with fully interoperable systems, and are have challenged the terms of for “appropriate action,” the given access to a single shared electronic reference of an inquiry set up to statement added. patient record that documents patient investigate their concerns. In response, the women wrote interactions across the NHS. In March GP Online reported a joint letter to the BMA’s chair Helen Stokes-Lampard, chair of the allegations of sexist comments of council, Chaand Nagpaul, RCGP, said, “GPs want the latest tech, being made to BMA members and requesting changes to the terms but we need the basics to work first. That GPs Zoe Norris and Katie Bramall- means everything from making sure that Stainer at a conference of UK of reference. In the letter, shared our computers don’t crash while issuing a local medical committees. These with The BMJ, they said the inquiry was too limited and asked prescription, to making sure our systems allegations prompted others, It is impossible that its focus on sexism and talk to those in hospitals. including Stephanie deGiorgio to separate sexual harassment be broadened “We want the NHS to be a world leader and Amy Small, to speak out other types in technology, and we are ready for a about their experiences. to include “poor behaviour.” of bullying new wave of opportunities which have The BMA responded “Our experience is that the potential to revolutionise patient by committing to a “fully it is impossible to separate towards care, but work is needed before that can independent investigation,” other types of bullying and women happen. We need to ensure that these and an investigator is due to be inappropriate behaviour towards from more opportunities are embraced safely and appointed this month. Now the women from more explicit sexual explicit sexual sustainably with GPs at the centre.” four women have asked for the harassment,” they wrote. They harassment inquiry’s scope to be broadened. also suggested the inquiry Zoe Norris (top) and Fit for purpose In a website update the BMA should review the BMA’s internal Amy Small Farah Jameel, IT lead for the BMA’s said the inquiry would examine communication systems and how GP Committee executive team, said, all the allegations and assess its senior appointments are made. “Ensuring IT systems and infrastructure response. “When considering are fit for purpose is fundamental for feedback on individual incidents, Finally, the group asked for improving patient care and increasing the investigation will consider reassurance that doctors would productivity. As the RCGP points out, whether the complaints and not suffer retribution. getting the basics right must be the disciplinary procedure in place The BMA said it would respond priority ahead of any ‘digital revolution.’” at the time were used,” the directly to the women. He added that the digital commitments statement said. Where the Melanie Newman, London the GPC negotiated as part of this year’s inquiry identified incidents Cite this as: BMJ 2019;365:l1984 GP contract deal were designed to create a “fully resourced IT infrastructure.” Gareth Iacobucci, The BMJ Cite this as: BMJ 2019;365:l1981 “Incredulity” blamed for 169 million TOP 10 RICH COUNTRIES FOR NUMBER OF CHILDREN WHO DIDN'T RECEIVEchildren FIRST MEASLES missing VACCINE measles (2010-17) vaccine BMA calls for chancellor to reform government knows of the problem, but it 2,593,000 1 US has not proposed any solutions. 608,000 France pension rules to keep doctors in NHS Rob Harwood, chair of the BMA’s 2 Consultants Committee, said, “It cannot 527,000 3 UK be right that doctors working extra hours 438,000 Argentina to reduce waiting lists or cover rota gaps 4 are then hit with tax bills greater than the 435,000 5 Italy value of the extra hours worked. Unless 374,000 6 Japan action is taken, our only option is to reduce 287,000 Canada the time we work for the NHS—exactly 7 what the BMA has been trying to avoid.” 168,000 8 Germany At the Royal College of Physicians’ 138,000 Australia conference health secretary Matt Hancock 9 136,000 urged doctors not to take early retirement The US topped the10 list of Chile high income countries for the number of children who didn’t get the first dose of measles vaccine between 2010 and 2017, a report from Unicef because of the pension issue, adding that Source: Unicef showed. The global figure was 169 million children. A key factor was “incredulity and he was working to resolve the issue. hostility” towards doctors and government who promote the importance of vaccination— Zosia Kmietowicz, The BMJ exacerbated by a suspicion of experts propagated by populist political parties. Cite this as: BMJ 2019;365:l1885

the bmj | 4 May 2019 131 QI falters after trial fails to reduce abdominal mortality

quality improvement programme aimed working out their baseline, and implementing the best at reducing mortality after emergency perioperative practices. The order in which the clusters abdominal surgery had no eff ect, a large implemented the programme was randomised so that some randomised trial in the NHS has shown. began sooner than others, in a stepped wedge trial design. Just as many patients died in the hospitals This meant that the duration of the QI period varied Aimplementing the programme as in those providing usual from 80 weeks for the fi rst cluster to fi ve weeks for the last. care, the EPOCH (enhanced perioperative care for high risk Patients who presented during the fi rst fi ve weeks after the patients) trial showed. QI programme began were excluded from the analysis. The result casts a cloud over eff orts to improve The results showed no change in mortality 90 days after outcomes in healthcare by using the formal and surgery. In the usual care group, 8482 patients were treated, systematic methods known as QI. Rupert Pearse, professor of whom 1393 died (16%). In the QI group, the fi gures were QI programmes and consultant in intensive care at Queen Mary University 7374 treated and 1210 who died (16%). Mortality at 180 are not a quick of London and senior author, said, “QI programmes are not days after surgery was 20% in both the usual care and the and easy a quick and easy solution to improving care. We are now QI groups. solution to taking a much more realistic approach to this work.” Reporting in the Lancet , the team said that the failure improving care was likely to be due to the varying compliance of clusters to List of activities the QI programme, diff ering prioritisation of the pathway The trial, which involved 93 hospitals, recorded all deaths components, and the time needed for eff ective change. after emergency abdominal surgery from March 2014 to October 2015 in patients aged over 40. The hospitals were divided into 15 “clusters,” each MORTALITY at 180 days after surgery was of which was given a list of activities that were designed to improve care, such as holding preparatory meetings, 20% in both the usual care and the QI groups

Peanut immunotherapy increases allergic reactions, finds study Oral immunotherapy for peanut was just over three times exposure to peanut than those Peanut is common, allergy, in which patients are the risk in those given not given immunotherapy. affecting 2% of children and exposed to increasing doses of no oral immunotherapy, “Safer peanut allergy 1% of adults in high income the allergen, heightens the risk increasing from 7.1% without treatment approaches countries, and is a leading cause of of allergic and anaphylactic immunotherapy to 22.2% and rigorous randomised reactions despite inducing with immunotherapy. controlled trials that food associated allergic reactions, desensitisation, a review The rate of anaphylaxis in evaluate patient important anaphylaxis, and deaths has found. the oral immunotherapy group outcomes are needed,” “Our study synthesises was more than double that in concluded the authors, who all randomised clinical the no immunotherapy group. received no funding for the Interest is growing in peanut trials comparing peanut Oral immunotherapy review. oral immunotherapy, after clinical oral immunotherapy with was associated In an accompanying trials showed that it induces no immunotherapy,” said with a higher comment, Graham lead author Derek Chu, risk of serious Roberts and desensitisation, but there had from McMaster University, adverse Elizabeth Angier, been no comprehensive review of Canada. “It shows that current events than in from the University the available evidence peanut oral immunotherapy the no immunotherapy of Southampton, said, regimens can achieve the goal group, and non-anaphylactic “Although oral immunotherapy of desensitisation, but this reactions such as vomiting, undoubtedly reduces the The review combined results outcome does not translate angioedema, and upper likelihood of reacting to from trials of peanut into fewer allergic reactions respiratory tract reactions were peanuts in a controlled clinic 12 and less anaphylaxis. Instead, also increased. setting, its overall side effect oral immunotherapy involving the opposite occurs.” In terms of desensitisation, profile means that patients 1041 patients with Results, reported in the patients given oral seem to have more allergic peanut allergy, with a median Lancet , showed that the risk immunotherapy were more reactions while on therapy.” of anaphylaxis in patients than 12 times as likely to pass Susan Mayor, London age of 8.7 years given oral immunotherapy a supervised challenge of Cite this as: BMJ 2019;365:l1912

132 4 May 2019 | the bmj QI falters after trial fails to reduce Doctors fear their abdominal surgery mortality mental ill health “is a sign of weakness”

mployers in the medical profession must take steps to reduce the stigma of mental illness among their workforce so that doctors feel able to get help, researchers from Swansea University have said. EThe recommendation came as a BMA survey of UK doctors found that most doctors (80%) were at a high or very high risk of burnout, with junior doctors most at risk. The results indicate that the scope for improvement Future QI The researchers spoke to 10 trainee doctors from a range was, in many cases, small. The programme indicated programmes of specialties in England and Wales about whether being a that a consultant should take the decision to operate, should doctor had affected how they accessed support for mental which was the case in 90% of patients under usual care. implement health problems. The study, to be published in an upcoming After QI, this figure did not change. fewer, more edition of the International Review of Psychiatry, found that The team suggested that earlier successes in small discrete the view that “mental illness is equal to weakness” was still QI interventions may have encouraged the belief that common among doctors and that some continued to work changes they were easy to implement. “Future QI programmes even when their ability to do so was impaired. should implement fewer, more discrete changes and ensure leadership teams have enough time to achieve Support junior colleagues sustained improvements” they said. The researchers suggested one way to tackle stigma Nigel Hawkes, London was for NHS employers to include information about the Cite this as: BMJ 2019;365:l1924 prevalence of illness among doctors at induction sessions. Board members and senior managers should help to create a culture that encouraged Clinical trials in Europe: less than doctors to seek help, the study said, while doctors a fifth report within 12 months who were managers needed to learn how to support European universities are failing to by the university. Their results junior colleagues. meet EU rules on reporting clinical show that 940 trials should have The survey, which was trial results within 12 months reported their results to the register open to all UK doctors, of registering the trial, a survey by now but that only 162 have received more than 4300 shows. The results come just two done so (17%). UK universities responses, including weeks after a similar survey showed performed the best in Europe, with a around 1400 from medical WE NEED TO ADDRESS that, despite initial problems, UK reporting rate of 69%. Excluding UK students. It found that more THE STIGMA THAT universities were now ahead of universities brought the overall rate than a quarter (27%) of INHIBITS DOCTORS others in the EU in filing results. down to 7%. respondents reported having SEEKING HELP The survey showed that the top a mental health condition EU regulation medical universities in France, Italy, diagnosed at some point and that 40% currently had a The survey looked at the 30 Norway, and Sweden failed to post psychological or emotional condition. European universities (including any clinical trial results. Danish Dinesh Bhugra (above), BMA president and emeritus in the UK) that have sponsored the universities reported on just 9.9% professor of mental health and cultural diversity at King’s largest numbers of trials governed in 12 months. Dutch universities College London, called for a cultural shift in the way mental by the EU Clinical Trials Regulation 8.7%, Austrian 7.9%, Belgian health was viewed. “As well as focusing on addressing register (EudraCT). The regulation 3.9%, and German 2.5%, the immediate pressures, such as long working hours, was set up in 2014 to ensure Regulators have limited sanctions unmanageable workloads, and rota gaps, we need to see a standard reporting procedures if universities fail to report. A wider cultural shift that addresses this stigma that inhibits throughout Europe. spokesperson for the Danish doctors seeking help and ensures that support is publicised The researchers monitored trials Medicines Agency said it could only and readily available,” he said. lodged by each country’s trials send a reminder to a university that “A system that fails to support and protect the health of regulator as completed 12 months had not filed its results. its own workforce will only flounder, and this is as clear a or more ago and noted where the Lynn Eaton, London call to action as ever there was.” results had not yet been uploaded Cite this as: BMJ 2019;365:l1963 Abi Rimmer, The BMJ Cite this as: BMJ 2019;365:l1861

the bmj | 4 May 2019 133 THE BIG PICTURE Bee campaign stings Bayer Around 500 environment campaigners gathered outside the annual meeting of chemical giant Bayer, in Bonn, Germany, last week, to protest at its takeover last year of the US biotechnology and seed company Monsanto. Among the protesters were beekeepers, who dropped thousands of dead bees on the pavement and used their smokers to draw attention to their claim that Bayer’s pesticides are destroying hives and jeopardising the world’s food chain. The activists’ placards mocked Bayer’s corporate motto “science for a better life” and demanded that it “stops glyphosate,” the herbicide made by Monsanto, which legal action in US courts claims is carcinogenic. A BMJ study in March found an association between prenatal exposure to pesticides, including glyphosate, and risk of autism. ЖЖEDITORIAL, page 136

Alison Shepherd, London Cite this as: BMJ 2019;365:l1983

134 4 May 2019 | the bmj MARTIN MEISSNER/AP/SHUTTERSTOCK MARTIN the bmj | 4 May 2019 135 AFP/GETTY IMAGES AFP/GETTY

EDITORIAL Probable carcinogenicity of glyphosate Independent investigation must continue

n 2015, the World Health Glyphosate Changing circumstances influenced the outcome of some of these Organization’s International typifies the One aspect of the controversy is evaluations and media coverage and Agency for Research on Cancer problems that formulations of glyphosate and led US government officials to question (IARC) identified glyphosate, associated exposure patterns have changed over supporting the IARC/WHO. the world’s most commonly with research, time, and the many positive case- What next? “More research is Iused herbicide, as a probable human control studies cited by the IARC now needed” is still (unfortunately) evaluation, carcinogen.1 2 reflect older exposure circumstances. an inescapable recommendation. IARC’s assessment prompted and regulation The IARC working group on Although existing evidence could a major controversy between of pesticides pesticides identified non-Hodgkin’s justify the classification of glyphosate health evaluation agencies, led to lymphoma as a leading risk, and in as a probable human carcinogen, unprecedented lobbying by Monsanto 2018 a man from California became substantial gaps remain, including (the primary manufacturer of the first person to be compensated for information about the relative effects glyphosate and genetically modified non-Hodgkin’s lymphoma linked to of different product formulations, the products resistant to glyphosate), and glyphosate exposure.3 timing of exposure, and additional data resulted in high profile court cases in More recent evidence showed no on mechanism of action in humans. the US.3 association between non-Hodgkin’s Glyphosate typifies the problems lymphoma and glyphosate but instead Non-cancer risks associated with research, evaluation, suggested an increased risk of a rarer Although the focus so far has been and regulation of pesticides. These leukaemia subtype.4 5 And a new on glyphosate and cancer, potential include serious difficulties in analysis pooling the three largest non-cancer health risks should also be the conduct of human research; cohort studies on pesticides showed investigated further.9 The few existing important gaps in post-market an association between glyphosate epidemiological studies with robust research into exposure and risk and one non-Hodgkin’s subtype.6 assessment of exposure were not assessment, particularly in low These new analyses do not modify the conducted in low or middle income and middle income countries; lack IARC’s evaluation, but they do have countries such as India or Brazil, where of information on environmental implications for quantifying the risk use is highest. effects; extensive industry from glyphosate. This lack of evidence and difficulty in involvement in evaluation and The IARC’s evaluation of glyphosate replication will inevitably lead to more regulatory processes; and the in 2015 was followed by other controversies when other pesticides are major legal implications of these evaluations, many of which reached evaluated. Pesticides have hundreds evaluations. different conclusions, including one of active ingredients, and less than a IARC’s 2A grouping of glyphosate by the European Food and Safety dozen have been formally evaluated by as a probable human carcinogen is the Authority (EFSA). These evaluations the IARC as group 1 or 2A carcinogens. second strongest category of evidence followed different protocols and Some of these, such as DDT in a four tier scale. The strength of the some considered different evidence, (dichlorodiphenyltrichloroethane) and evidence against agents in this group including unpublished and non-peer lindane, are already banned in most varies; some agents lie close to a group reviewed data from industry funded countries. But responsible companies 1 designation (human carcinogen), studies. marketing products that may pose but the evidence is weaker for others, Manolis Kogevinas, Undisclosed industry involvement a risk to human health and the researcher, including glyphosate. However, has emerged in evaluations by EFSA, environment should be collaborating Barcelona Institute substantial published evidence from the UN’s Joint Meeting on Pesticide internationally to gather evidence for Global Health human, animal, and mechanistic (ISGlobal), Residues, and the US Environmental of possible harm, rather than attacking 7 studies at the time of the IARC Barcelona Protection Agency. Lobbying by authoritative science. evaluation indicated that adverse manolis. industry was widespread and well Cite this as: BMJ 2019;365:l1613 effects from exposure to glyphosate documented.8 Although it is difficult kogevinas@ Find the full version with references at could be classified as probable. isglobal.org to quantify, lobbying probably http://dx.doi.org/10.1136/bmj.l1613

136 4 May 2019 | the bmj EDITORIAL A lesson for health professionals We must learn from the schoolchildren’s action and campaign relentlessly for carbon net zero by 2030

n March, hundreds of We enjoy what David Wallace-Wells thousands of schoolchildren in calls “an anthology of comforting 2000 cities from 123 countries delusions: that global warming is an left school to call for action on Arctic saga, unfolding remotely; that climate change. They inspired it is strictly a matter of sea level and Imillions more, including the non- coastlines, not an enveloping crisis violent direct activists participating sparing no place and leaving no life in the Extinction Rebellion protests, undeformed; that it is a crisis of the and set an example for those of us “natural” world, not the human one; who are older (and possibly less that those two are distinct, and that wise). Now the Friday strikes happen we live today somehow outside or in many countries every week beyond or at the very least defended (#FridaysForFuture). against nature, not inescapably It is young people who will be most within and literally overwhelmed affected by the floods, desertification, by it.” 3 He lists other delusions in fires, hunger, disease, mass migration, his book The Uninhabitable Earth: and wars caused by climate change. A Story of the Future Life, but the These disastrous consequences have greatest may be that technology alone already begun and will grow rapidly can save us. worse without urgent action, which With their relentless protests, must include the abandonment of REX/SHUTTERSTOCK Thunberg and other schoolchildren fossil fuels. It is young everything in our current societies . . . around the world have shown a The movement began with Greta people who Adults keep saying: ‘We owe it to the commitment that other groups, Thunberg, a 16 year old Swedish will be most young people to give them hope.’ But including health professionals, student who in August 2018 started to affected by I don’t want your hope. I don’t want have not managed. Despite the miss school every Friday and protest the floods, you to be hopeful. I want you to panic efforts of, for example, the Global about inaction on climate change desertification, . . . If you have a child that is standing Climate and Health Alliance outside the Swedish parliament. fires, hunger, in the middle of the road, and cars (climateandhealthalliance.org), the For weeks she protested alone, are coming at full speed, you don’t Lancet Countdown on Health and disease, mass but slowly and exponentially others look away because it is too hard to see, Climate Change (lancetcountdown. followed her example. Since then, migration, and you run out and get that child away org), and the UK Health Alliance on Thunberg has spoken at the World wars caused by from there.”1 Climate Change (ukhealthalliance. Economic Forum and attended the climate change The schoolchildren’s action org), the commitment of health United Nations meeting on climate follows last year’s warning by the professionals to this issue has been change. She has been nominated for Intergovernmental Panel on Climate patchy, intermittent, and sotto voce. a Nobel Peace Prize and has 400 000 Change that raising the global Now is the time for them to share followers on Twitter. During her Easter temperature by more than 1.5°C could the demands of schoolchildren and holidays she travelled to London, make the world uninhabitable—and Extinction Rebellion activists, to where she spoke to politicians from yet we are heading towards a 3°C insist that all governments tell the all parties and joined the Extinction increase.2 Keeping below 1.5°C of truth about climate change, declare Rebellion protests. warming requires “rapid, far-reaching an ecological and climate change Thunberg has Asperger’s syndrome, and unprecedented changes in all emergency, and act urgently to which she calls “a gift.” She speaks aspects of society,” says the report.2 halt biodiversity loss and to reduce bluntly: “Why should I be studying greenhouse gasses to carbon net zero for a future that soon will be no more, Ominous warnings by or before 2030. when no one is doing anything to save Yet despite the increasingly ominous We call on governments to create that future? . . . We must change almost warnings of the past 30 years no and be led by citizens’ assemblies on country in the world has acted on the climate change and ecological justice, Robin Stott, executive member, UK Climate and Health Council, scale needed. We carry on arguing and on health professionals to vote London [email protected] about Brexit, prioritise curing disease only for representatives who prioritise Richard Smith, former editor, The BMJ, London rather than preventing it, plan new climate change. Rowan Williams, master, Magdalene College, Cambridge airports, go to work, and bring up our Cite this as: BMJ 2019;365:l1938 Fiona Godlee, editor in chief, The BMJ, London children as if nothing was happening. doi: 10.1136/bmj.l1938 the bmj | 4 May 2019 137 ESSAY Why medical cannabis is still out of patients’ reach The plant has been used as a medicine for millennia, writes David Nutt, who charts its relatively recent prohibition, the effect on patients such as Billy Caldwell, and the failure of legal reform to make much difference

BIOGRAPHY annabis is arguably the world’s oldest denial of the value of medical cannabis, just as it did David Nutt is the Edmond J medicine, with evidence of such use from when the US similarly attempted to eliminate heroin as Safra professor of 3000 year old tombs in Egypt and Siberia. a medical treatment. Cannabis continued being used neuropsychopharmacology It had a place in Indian and Chinese as a medicine in the UK until the 1971 Misuse of Drugs and a psychiatrist at medical writing from nearly as long ago. Act, when it was relegated to schedule 1, for harmful Imperial College London. He CIt didn’t enter the UK until the late 1600s, but by the drugs with no unique medical value. trained at Cambridge, Guy’s 1800s it was widely used, sold over the counter as an The driver for this ban was continued pressure Hospital, London, and Oxford alcoholic tincture for problems such as tetanus and from the US, which still cherished the illusion that, University, and at the US seizures. Its efficacy more broadly became apparent, by disallowing medicinal use, recreational use National Institutes of Health. and the definitive overview was published in the could be restricted. The ban’s pretext was misuse of His research focuses on the use of positron emission Lancet in 1890 by . Because he cannabis medicines by two GPs in Ladbroke Grove in tomography and functional was Queen Victoria’s it is believed that she London who were prescribing tincture of cannabis to magnetic resonance imaging used cannabis medicines, particularly for period and treat heroin addiction, not a recognised indication. to understand how drugs childbirth pains. Rather than just having the GPs struck off the work in the brain and the The demise of cannabis as a medicine began medical register, the government decided to accede mechanism underpinning rather surprisingly when in 1933 the US Senate to decades of US pressure. psychiatric disorders, voted to rescind the law on alcohol prohibition. Subsequently, many states in the US and now 20 particularly addiction, This left the threat that 35 000 officers of alcohol countries have reinstated cannabis medicines, but depression, and anxiety prohibition enforcement (now the Drug Enforcement UK governments, Conservative and Labour, resisted disorders. In 2008-09 he Administration) would lose their jobs, along with their this trend, despite the remarkable 1998 House of chaired the government’s independent Advisory director, Harry Anslinger. So Anslinger created a new Lords report that recommended that cannabis again

Council on the Misuse of drug scare in alcohol’s place: cannabis. be made a medicine.At first Tony Blair’s government Drugs. This essay is based He used its Mexican name, marijuana, to associate was supportive. Then, for reasons still unclear on his 2019 Royal College its use with unofficial immigrants. Then, working but probably in response to pressure from certain of Psychiatrists president’s with the less scrupulous media, he created scare newspapers, it made a sharp U turn. Cannabis lecture, available to view stories about the damage wrought by cannabis: that possession offences were made a target for the police. at https://www.rcpsych. its use would destroy Americans’ lives and result in Hundreds of thousands of people—mostly black or ac.uk/members/presidents- white women being raped by drug crazed foreigners, other ethnic minority young men—were convicted in lectures and so on. Though fanciful and dishonest, these the decade of the 2000s. stories created the intended public moral panic. Cannabis became public enemy number one common justification for ignoring among drug threats, and the DEA was saved. To the Lords’ recommendations was further vilify cannabis, and to prevent its cultivation that, because WHO hadn’t changed for medical use, cannabis was removed from the US the status of cannabis, for the UK to pharmacopoeia in 1934. The rest of the world was do so would breach international encouraged to support the ban: in its 1934 report the Aprotocol. There was also significant political benefit League of Nations’ health committee agreed with the in keeping cannabis illegal. Medical cannabis was US that cannabis medicines had no value. sucked into this policy on the grounds that it might This report was relied on to control cannabis leak into the black market and that its use could be under the 1961 United Nations Single Convention seen as a route to legalisation. on Narcotic Drugs and amazingly persisted as the Attacks on medical cannabis were relentless, and international medical guidance on cannabis until thousands of self medicating patients were prosecuted. 2018, being used as the justification by the World Worse, when patients started to justify their use The ban’s pretext was Health Organization for keeping cannabis a schedule 1 of cannabis through the common law defence of controlled drug until then. Even more absurdly, the necessity, this was abolished by Labour under Gordon misuse by two GPs 1934 report has been lost, so we can’t explore its Brown. Magistrates hated this decision because who were prescribing evidential base or reasoning. it removed any latitude in their decision making: tincture of cannabis At first the UK held out against this outrageous everyone brought to court was guilty. It also gave

138 4 May 2019 | the bmj enormous power to the police: they could guarantee a The absurdity of for nausea and vomiting induced by chemotherapy conviction simply by making an arrest. the prohibition was and for cachexia, and later nabiximols (Sativex), To justify keeping cannabis illegal, claims of harms, clearly exposed. containing equal amounts of d9THC and CBD, such as from use while driving, were publicised, The UK had some licensed for pain and spasticity in multiple sclerosis. and the danger of its causing schizophrenia of the highest However, neither was much used, partly because was repeatedly raised. Sanctions for possession of their controlled drugs status and, in the case of rates of cannabis and selling were cranked up and efforts made to stop Sativex, the high cost. These preparations also lack imports from abroad. Supplies began to dry up, but use in the world the many other components of the cannabis plant, this had the disastrous perverse result of cannabis use despite some of the such as the cannabinoid tetrahydrocannabivarin becoming more harmful. harshest penalties (TCHV), which preclinical studies indicated could be This paradoxical effect of zealous prohibition a potent anti-epilepsy agent and which was predicted increasing harms is not a new phenomenon. For to boost the therapeutic effects of d9THC and CBD. more than a century attempts to prohibit drugs Although most of the world fell in line with the have led to the development and use of more 1961 UN convention banning medical cannabis, harmful alternatives. So, when in the early 1900s the Netherlands decided to allow medical and smoking opium was banned, users switched to recreational use despite US pressure not to do so. injecting morphine and heroin. Alcohol prohibition More recently, 30 US states have now allowed use in the US led to hooch and methanol substitution. of medical cannabis. By January 2018 more than 200 million US citizens had access to medical istory repeated itself with cannabis. cannabis—but not a single UK When customs agencies cracked resident. In 2017 German down on importation, suppliers started growing their own in the UK. But to maximise their investment Hthey grew a new form known colloquially as skunk. This contains much higher amounts of Δ-9-tetrahydrocannabinol (d9THC), typically over 10%, and the plant is depleted of the other major bioactive ingredient, cannabidiol (CBD). CBD acts as a functional antagonist to the most problematic effects of d9THC, and especially it can attenuate the psychotomimetic and cognition impairing effects of d9THC. For this reason, recently, CBD has been used successfully as an adjunctive treatment for schizophrenia. The double whammy of losing CBD and increasing d9THC content in skunk was the worst possible outcome, as it engendered more psychotic-like experiences and more dependence. A recent analysis by researchers at King’s College London found that traditional herbal or resin cannabis, with its balance of d9THC and CBD, doesn’t cause schizophrenia—but that skunk might. The absurdity of the prohibition of medical cannabis was clearly exposed by data on cannabis use. When medical cannabis was banned in 1971 fewer than half a million UK adults had used cannabis, yet by 2005 this number had risen 20-fold to over 10 million. The UK had some of the highest rates of cannabis use in the world despite some of the harshest penalties. The ban on medical cannabis certainly The public outcry hadn’t reduced recreational use but had almost totally to this cruel denial denied access for patients. of a proved therapy Two exceptions were nabilone, a synthetic was profound form of d9THC,

BELLE MELLOR BELLE which is licensed

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authorities allowed medical cannabis for 57 severe juvenile epilepsies are PATIENT different indications. being treated, and many others COMMENTARY The UK government resisted any softening of continue to have multiple approach until 2018, when the case of the boy seizures because neurologists The law Billy Caldwell became public. Billy has a rare will not prescribe. form of childhood epilepsy, Dravet syndrome, There are several likely which results in thousands of seizures a reasons for this. One is changed month that are unresponsive to conventional ignorance of the value anticonvulsant drugs. of cannabis medicines, so why because few doctors have any is mother tried to obtain medical training or experience in this are we cannabis in the UK but was denied, area and are fearful of prescribing them off licence. so she took him to the US and Another reason for resistance could be that parents still Canada to seek treatment. This and patients lead this initiative rather than the was remarkably successful. With medical profession. Some doctors fear that medical fighting? HCBD Billy’s seizures reduced hugely, and with cannabis will lead to severe adverse effects such The high profile case the addition of full extract cannabis oil they as psychosis, and others that it will lead to more disappeared completely, probably because the oil recreational use, which seems unlikely given the of Alfie Dingley’s contained some d9THC and TCHV. He was able to current wide use and availability of black market intractable epilepsy stop his other medications, and his cognitive and cannabis. was key to last motor abilities markedly improved. Additionally, some pharmacists and clinical When his mother returned home to Northern commissioning groups are refusing to pay. year’s law change. Ireland Billy’s GP was so impressed by the Another substantial challenge is obtaining His mother, transformation that he agreed to prescribe the supplies, because currently all medical cannabis Hannah Deacon, cannabis oil. But when local medical authorities has to be sourced from foreign producers in the found out they threatened the GP with a charge Netherlands and Canada. explains why she of gross medical misconduct if he continued to now advocates prescribe an “illegal” drug, so he stopped. e must hope the situation for the families still To prevent Billy’s condition deteriorating, will soon improve. One way his mother took him back to Canada for forward would be to use the fighting for access more supplies and tried to import them into cancer research model, where to life-changing the UK, declaring them at Heathrow airport small expert groups aligned to medicines customs. The drugs were confiscated, and Wa specific indication, such as Tourette’s syndrome Billy’s condition rapidly worsened. His seizures or adult epilepsy, are set up. These could conduct returned, and he went into status epilepticus open effectiveness studies in this indication all that required his admission to the intensive care using the same form and strength of medical unit at St Thomas’ Hospital, London, where he cannabis and all collecting data on outcomes and was sedated and ventilated. adverse effects in the same way. The public outcry to this cruel denial of a Something similar has already been developed proved therapy, coupled with the possibility of for ketamine for depression. Because such studies Billy experiencing more brain damage or even would come under the ambit of clinical audit dying, was profound. It persuaded the home rather than be a formal clinical trial they would be secretary to give Billy a special licence to use much easier to start and much less expensive than cannabis oil, so his supplies were returned and traditional trials. Any practitioners interested in his seizures stopped. joining such groups should email me. The chief medical officer for England then One final point: about 70 years ago another reviewed the schedule 1 status of medical natural medicine came into the medical arena. cannabis. She stated that cannabis was clearly This was welcomed enthusiastically by UK a medicine, so on 1 November 2018 cannabis doctors even though there had been no placebo products were moved into schedule 2 under the controlled trials of its efficacy because it was Misuse of Drugs Act, but limiting prescription to seen to fulfil a major clinical need. That drug specialists, or a GP acting under the instructions was penicillin. If today’s medical profession of one. There are no specified medical indications could embrace cannabis in the same way as it did for medical cannabis in the UK: as long as penicillin then the true value of this plant medicine the specialist has evidence of efficacy—from should rapidly be realised. published reports or personal patient testimony—a David Nutt, Edmond J Safra professor of prescription as a “special” can be offered. neuropsychopharmacology, Imperial College London Hannah Deacon, Kenilworth, However, the roll out of medical cannabis has [email protected] Warwickshire deaconhannah4@ been much slower than patients and parents had Cite this as: BMJ 2019;365:l1903 googlemail.com hoped. Still only a tiny number of children with For competing interests: see bmj.com Cite this as: BMJ 2019;365:l1921

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y son Alfie, born in 2011, One doctor threatened to report the British Paediatric Association’s was perfect until he was me to social services. One said that guidance against prescribing full extract 4 months old, when he cannabis medicines costs too much medical cannabis was just that—guidance— became constantly sick. At and that 95 000 doctors in the UK could 8 months he had his first contains other cannabinoids. Over three prescribe. So why are families still not getting Mtonic clonic seizure. He continued to have months Alfie’s seizures became less frequent. prescriptions? Why was the law changed if seizures in hospital for nearly four months. We added tetrahydrocannabinol (THC) oil access was not to be forthcoming? Intravenous steroids eventually stopped this (Bedrocan’s Bedica) under our paediatric I know of a child taking Bedrolite and cluster of seizures. neurologist’s guidance, and Alfie went Bedica in the UK, funded by the parents. He lost every skill he’d developed, and he without seizures for 40 days. When he did Their doctor is overjoyed at the results yet was diagnosed as having immune responsive have clusters they were less intense and says he cannot prescribe because of the epilepsy. Alfie had clusters of seizures every controlled much more easily. His cognitive BPNA’s guidance. This is not an isolated eight months until he was 4 years old. Then development greatly improved. incident and must be dealt with urgently. they occurred every three weeks, and by the Living abroad, was tough. After five months I have spoken to many doctors about time he was 5, every week; needing up to five we ran out of money. We had to come home. cannabis. One threatened to report me to doses of intravenous steroids each time. In the UK we had to fight for a prescription social services. One told me that cannabis Then, Alfie was diagnosed with a rare containing both CBD and THC. We wanted to medicines cost too much. On our return epilepsy syndrome caused by a mutation work with the Home Office but faced many from the Netherlands a doctor said that we in the gene that codes for the protein obstacles. Finally, Mike Barnes, honorary must change Alfie’s medicine to pure CBD protocadherin 19. We were told that he professor of neurological rehabilitation at (Epidiolex). I refused: Alfie already had an might get better with age, but as far as we Newcastle University, successfully applied effective medicine. could see his health was getting worse. Only for the first UK licence for medical cannabis I know the NHS is underfunded. But nine known boys worldwide have PCDH19 products for Alfie. Alfie received the first consider the long term care needs if a child epilepsy, so prognosis was impossible. NHS prescription, for the products he’d been deteriorates. And in families with a child prescribed in the Netherlands, on 7 November with epilepsy, the social impact on the full Treatments that worked 2018, after UK law changed on 1 November. time carer (usually the mother) is immense. I researched treatments for epilepsy. Medical Cannabis medicines are not cure-alls. Alfie Consider the mental health problems, the cannabis kept coming up. In 1841 the Irish still has occasional clusters, but they stop in family breakdowns. The costs to society and physician William Brooke O’Shaughnessy hours rather than after days in hospital. to the NHS far exceed those of a product that documented using cannabis for epilepsy. I Many children in similar situations have may give all these families a life worth living. learnt about the human endocannabinoid not been able to get these medicines despite system and how cannabis medicines may now being legal. Reasons given have included Struggle to breathe work. Alfie’s doctors told us that regular lack of evidence, money, and support from I am often asked why I campaign. My family steroids would eventually kill him. Cannabis NHS managers. I work with the campaign is everything to me. I have watched my son medicines seemed his only chance to live. We group End Our Pain, currently supporting struggle to breathe when he is having a started to campaign for a prescription in the 16 such families. It is heartbreaking that seizure, seen my daughter cry when I leave UK, where they were illegal. seemingly no NHS doctor is willing or able her, and noticed my partner anxious about Once we’d raised enough money, to prescribe medicines that could help these the future. We became campaigners because in September 2017, we moved to the children who have been very sick, some for we had no choice. We are our child’s only Netherlands. There we legally gave Alfie oil many years, after trying many other drugs. advocates, and must do all we can to be heard. prepared from Bedrolite (produced by the I have watched my son develop and enjoy Dutch company Bedrocan), a standardised Guidance is just that life, and every child with intractable epilepsy strain of cannabis plant. The full extract England’s health secretary, Matt Hancock, should have the right to cannabis medicines cannabidiol (CBD) oil from this strain also told the House of Commons on 8 April that that could save them from a life of suffering.

Hannah Deacon (centre) and her son Alfie campaign for access in the UK to the medicines he used in the Netherlands that drastically reduce his seizures the bmj | 4 May 2019 141 BRIEFING Breast ironing Recent media reports allege under-reported physical abuse of UK girls to flatten their breasts, writes Francesca Robinson. What should doctors do if they suspect this?

What is breast ironing? Margaret Nyuydzewira, who experienced the practice as a girl, estimates that 1000 women and Breast ironing, or breast flattening, is a practice traditional to some girls in the UK have been subjected to this abuse parts of Africa, considered by the United Nations to be gender based violence. Young girls’ breasts are ironed, massaged, flattened, or The National FGM Centre, a partnership between the children’s pounded down over a period of sometimes years, to reduce their charity Barnardo’s and the Local Government Association in size or delay their development. England and Wales, works to improve services for families affected Relatives aiming to protect young women from unwanted by female genital mutilation (FGM). In 2017 its remit grew to include sexual attention or rape, and to delay sexual activity and potential breast ironing. It says that some girls may ask for help or may talk pregnancy, may use large heated stones or implements such as about pain or discomfort in their chest, but they may not be explicit hammers or spatulas to compress breast tissue. Others may use belts about their experience because of embarrassment or fear. or binding. This abuse often begins at the first signs of puberty. The practice can persist in emigrant populations, and the What should doctors do if they suspect it? Conservative MP Jake Berry raised the matter in the House of Commons in 2016. Recent campaigning by the health charity It’s not only paediatricians and GPs who should be aware of the CAME Women and Girls Development Organisation (CAWOGIDO), practice, says Morgan, but also obstetricians and gynaecologists. which claims that the practice is increasing in the UK, led to a flurry “Similar to FGM, if you notice it in a woman who is pregnant, and of media reports. she gives birth to a girl, then you need to do a risk assessment on the mother and the family to see whether the child is at risk.” How prevalent is it? The Royal College of Paediatrics and Child Health is aware of the practice but has had no reports of it from its members. A Breast ironing has been recorded in parts of Cameroon and other spokeswoman told The BMJ, “This is a form of child abuse, causing African countries. Nearly a quarter of Cameroon’s female population the child significant harm, and child protection services need to be have experienced the practice, which is usually carried out by informed if anyone suspects it has happened or is happening.” female relatives, says Gender Empowerment and Development, a Cameroonian non-governmental, non-profit organisation. However, What resources exist for professionals? no systematic study or formal data collection about breast ironing has been done in the UK, and only anecdotal reports exist. Very few. CAWOGIDO is working with London’s Metropolitan Police Margaret Nyuydzewira, the head of CAWOGIDO who experienced Service to educate health authorities and other organisations the practice as a girl, says that an estimated 1000 women and girls about the practice. But it warns that authorities’ awareness is in the UK have been subjected to this abuse. low in other parts of the country: a quarter of child services have Sian Morgan, associate specialist in community paediatrics at received no training to deal with breast ironing, and only one in Lewisham and Greenwich NHS Trust in London, has never seen seven police forces is aware of it. The National Education Union a case but told The BMJ that, since she first heard about breast has called for breast ironing awareness to be made part of the ironing, she has included education about it in all of her induction mandatory school curriculum. and safeguarding training. The National FGM Centre has a leaflet on the practice, and “The more people know about it, raise awareness, and think videos on its website discuss the safeguarding duties of healthcare about it, the more they can do something about it,” she says. The professionals. practice is hard to spot, however: she warns, “Some doctors may have seen a case and not realised what it was. Like sexual abuse, Is it a crime? this practice is hidden.” Breast ironing is not specifically mentioned in UK law, but it is What impact can it have? harmful and considered to be child abuse. Morgan says this means that doctors have a duty to follow local safeguarding procedures if Breast ironing can cause pain, bruising, cysts, and scarring of the they suspect that a girl is a victim. breasts. Girls may develop asymmetrical breasts, and one or both No perpetrators have yet been prosecuted. breasts may disappear. It may result in feelings of low self esteem Francesca Robinson, freelance journalist, Hampshire and lost femininity, and victims may be reluctant to undergo [email protected] medical examination. Cite this as: BMJ 2019;365:l1790

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