Correspondence

I think the government has set out a clear vision for PGME reform

6

I feel I have been engaged in the deliberation of PGME reform

38

15

I think the staff in my organisation understand PGME reform well

42

17

Strongly disagree

Disagree

16

34

15

0

18

22

31

8

23

18

40

I believe my organisation is ready for 3 the implementation of PGME reform I feel in the long run patients will benefit from PGME reform

31

44 25

50 Responses (%)

Neither agree nor disagree

7

6

27

6

25

8

75 Agree

3

100 Strongly agree

Figure: Medical education leaders’ perceptions of the PGME reform Distribution of responses (%) by the extent of agreement with the proposed statements. PGME=postgraduate medical education and training.

Government signalling its intention to introduce a regional levy,1 most respondents believed it was the least effective way to raise PGME funding. Likewise, most respondents believed that regional provider-led LETBs should have greater responsibilities than central government agencies, but Health Education England has recently launched a consultation to centralise LETBs.4 A substantial proportion of respondents (18%) who provided anonymous open-ended comments, did not grant permission to cite them. We hypothesise they were wary of disagreeing with the Government while being part of the Government-run health system. This questions the usefulness of government top-down consultations in their present open-ended, non-representative, and nonanonymised form. We surmise that while there is no consensus on PGME reform among medical education leaders, the Government is able to force top-down reforms that might have short-term benefits for politicians or administrators, but no long-term benefits for patients or the medical profession. We therefore advocate a bottom-up debate among PGME stakeholders with a view to building a national consensus on future policy options. www.thelancet.com Vol 384 July 26, 2014

We thank the medical education leaders who participated in the survey. AMB is a member of the UK Medical Schools Council and a fellow of the UK Academy of Medical Sciences. PVO and CJ declare no competing interests.

Pavel V Ovseiko, Crispin Jenkinson, *Alastair M Buchan [email protected] Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK (PVO, AMB); and Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK (CJ) 1

2

3

4

Department of Health. Liberating the NHS: developing the healthcare workforce. A consultation on proposals. London, 2010. http:// webarchive.nationalarchives.gov.uk/+/www. dh.gov.uk/en/consultations/liveconsultations/ dh_122590 (accessed July 14, 2014). Ovseiko PV, Buchan AM. Postgraduate medical education in England: 100 years of solitude. Lancet 2011; 378: 1984–85. Department of Health. Liberating the NHS: Developing the healthcare workforce. From design to delivery. London, 2012. https://www. gov.uk/government/uploads/system/uploads/ attachment_data/file/216421/dh_132087.pdf (accessed July 14, 2014). Health Education England. A sustainable future for Health Education England—realising our potential. London, 2014. http://hee.nhs. uk/2014/07/04/a-sustainable-future-for-heerealising-our-potential/ (accessed July 14, 2014).

Keeping pace with population growth July 11 marks World Population Day, calling attention to the crucial part that population growth plays in meeting the health needs of a global population projected to reach 7·3 billion people in 2015 when the Millennium

Development Goals (MDGs) come to an end.1 The region of sub-Saharan Africa faces particular challenges, where the population is projected to nearly double from 510 million people in 1990 to 989 million in 2015, driven mainly by high fertility and large cohorts of women of reproductive age. When compared to other regions, sub-Saharan Africa is often described as lagging behind in terms of MDG progress on reproductive health. Looking at the absolute numbers of people reached, however, reveals unrecognised efforts made by countries in the region. For example, the percentage of women who received at least four antenatal care visits during pregnancy from skilled health personnel increased minimally over the past two decades, from 48% in 1990 to 50% in 2012 (figure).2 However, the estimated number of births for which mothers had received four antenatal visits increased by 61%. Moderate progress in increasing coverage of skilled attendance at birth (from 40% in 1990 to 53% in 2012) also masks a substantial increase in the absolute number of births attended by a skilled health provider, doubling from an estimated 9 million births in 1990 to 18 million births in 2012. Moreover, contraceptive prevalence among women of reproductive age (aged 15–49 years) who are married or who are in a consensual union doubled in the region (figure), whereas the absolute number of married or inunion women using contraceptives more than tripled over the same period, from 10 million in 1990 to 34 million in 2012.3 These examples indicate both the considerable challenges posed by population growth for efforts to deliver basic health services to all as well as real progress in the region, although not fast enough to keep pace with everincreasing numbers of people in need of those services. Population growth will continue to have a serious effect on the ability of countries in sub-Saharan Africa to provide the necessary health services

Published Online July 11, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61130-2

307

Correspondence

11 million births 17 million births

At least four antenatal care visits

48% 50%

9 million births

Skilled birth attendance

40% 18 million births

Contraceptive prevalence among MWRA

53%

10 million women

13% 34 million women

0

5

10 15 20 25 30 People receiving a health service (millions)

35

40

26% 0

20 40 60 80 Population receiving a health service (%)

1990 2012 100

Figure: Population receiving selected health services in sub-Saharan Africa in 1990 and 2012 Sub-Saharan Africa includes all of Africa except northern Africa; Sudan is included in sub-Saharan Africa. Data are from references 2 and 3 and author calculations based on reference 1. MWRA=married or in-union women of reproductive age.

unless programmes and resources are significantly expanded. While the development goals and targets that the world will adopt following 2015 are still unspecified, it is timely to take into account the powerful force that population numbers will play in achieving these goals and targets. The views expressed are those of the authors and do not necessarily reflect the views of the UN. We declare no competing interests.

Vladimíra Kantorová, *Ann Biddlecom, Holly Newby [email protected] United Nations Population Division, Department of Economic and Social Affairs, New York, NY 10017, USA (VK, AB); and Division of Policy and Strategy, United Nations Children’s Fund (UNICEF), New York, NY 10017, USA (HN) Published Online June 23, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61001-1

1

2

3

United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2012 Revision. http://esa.un.org/unpd/wpp/index.htm (accessed July 3, 2014). United Nations. The Millennium Development Goals Report 2014. http://mdgs.un.org/unsd/ mdg/Default.aspx (accessed July 7, 2014). United Nations, Department of Economic and Social Affairs, Population Division. Model-based Estimates and Projections of Family Planning Indicators 2014. New York: United Nations. http://www.un.org/en/development/desa/ population/theme/family-planning/cp_model. shtml (accessed July 7, 2014).

news highlights how lives could be saved if the UK adopted a similar approach. Despite evidence for the effectiveness2 and cost-effectiveness3 of the lay administration of naloxone, supported by strong recommendations from both Advisory Council on the Misuse of Drugs4 and the UN,5 it is not widely or equitably available to opiate users in England. This year Tower Hamlets became one of the first London boroughs to implement universal access to take-home naloxone to people at risk of accidental opiate overdose. This builds on the experience of the national programmes in Scotland6 and Wales. 7 However, coverage across England remains sparse. Local authorities, clinical commissioning groups, and drugs services need to come together to organise take-home naloxone programmes to reduce the 1000 annual opiate-related deaths in England and Wales.8 We declare no competing interests.

*Tim Crocker-Buque, Chris Lovitt [email protected] Tower Hamlets Local Authority, London, UK 1

Time for universal provision of take-home naloxone It is encouraging to read about the further use of naloxone in the USA to reduce the number of deaths related to opiate overdose,1 and this 308

2

3

4

Alcorn T. America embraces treatment for opioid drug overdose. Lancet 2014; 383: 1957–58. Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med 2014; 8: 153–63. Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med 2013; 158: 1–9. Advisory Council on the Misuse of Drugs. Consideration of naloxone. 2012. https:// www.gov.uk/government/publications/ naloxone-a-review (accessed July 14, 2014).

5

6

7

8

UN Office on Drugs and Crime and WHO. Opioid overdose: preventing and reducing opioid overdose mortality. 2013. http://www. unodc.org/docs/treatment/overdose.pdf (accessed July 14, 2014). McAuley A, Best D, Taylor A, Hunter C, Robertson R. From evidence to policy: the Scottish national naloxone programme. Drugs Educ Prev Policy 2012; 19: 309–19. Bennett T, Holloway K. The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the THN Project in Wales. Drugs Educ Prev Policy 2012; 19: 320–28. Office for National Statistics. Deaths related to drug poisoning in England and Wales, 2012. http://www.ons.gov.uk/ons/ dcp171778_320841.pdf (accessed July 14, 2014).

Department of Error Bhutta Z, Das J, Bahl R, et al, for The Lancet Every Newborn Study Group. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384: 347–70—In this Series paper, the author “Jeeva M Sankar” should have read “M Jeeva Sankar”. Also, the second sentence of the summary should have read “To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035…”. Additionally, the fifth sentence of the Introduction should read “Achievement of the proposed Every Newborn targets of ten or fewer neonatal deaths…”. These corrections have been made to the online version as of June 23, 2014, and to the printed paper. Devos P, Haeffner-Cavaillon N, Ledoux S, Balandier C, Ménard J. Assessing the French Alzheimer plan. Lancet 2014; 383: 1805—In this Correspondence (May 24), the declaration of interests should have read: “JM was involved in the design of the plan. JM has received personal fees from Actelion and Sanofi outside the submitted work. The other authors declare no competing interests”. This correction has been made to the online version as of July 25, 2014.

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Keeping pace with population growth.

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