Saturday 7 January 2006
BMJ
The BMJ is evolving
We want it to be a great magazine as well as a great journal
T
he BMJ is evolving, and with this first issue of
2006 you will see some changes. The most
obvious of these are some new section
headings, but wider changes are afoot which will
culminate in a redesign of the journal in July.
The changes stem from a series of conversations we
have had with doctors, healthcare researchers, and
policy makers in the UK and overseas. These have told
us a lot about how people use information and what
they look for in the BMJ. They confirmed what we know
to be the BMJs strengthsbroad appeal across medicine
and health care, reputation for courage and integrity,
mix of serious science and analysis with practically
useful material, readability, hard hitting journalism, and
entertaining comment. But they also told us that readers
are confused about what the BMJ is and who it is for. Is it
mainly for general practitioners (the hospital doctors
thought so) or mainly for hospital doctors (as the
general practitioners thought)? Is it about clinical medi-
cine or public health? And is it a journal or a magazine?
Confusion is not necessarily a bad thing. It is often
the springboard to creativity and innovation. In this case
we think it tells a success story. The BMJs strength as a
general medical journal is that it can remind doctors
that they are still all part of one commuity. The BMJ has
broken the mould of traditional medical journals. It
reaches beyond a single group of doctors. It is one of the
few journals that can bridge the gap between primary
and secondary care and between research and practice.
It bridges other gaps too: between doctors and other
health professionals, between doctors and patients,
between younger and older practitioners, and between
treating individuals and populations.
It has also become more than just a journal.
Journals were defined by our focus groups as being
carriers exclusively of peer reviewed research and in
depth clinical reviews; they saw them as factual, dry,
and to be archived for future reference (often without
being read). But neither is the BMJ simply a magazine
carrying only news, updates, and comment. A
magazine was defined by our focus groups as being
tabloid, opinionated, humorous, colourful, and to be
thrown away after being read, or even before. Many of
those we spoke to want us to choose between these
stark extremes, but we think that making a choice
would mean going backwards.
We think the BMJ can be both a journal and a maga-
zine. After all, one of the worlds most respected science
journals, Nature, is exactly that. But to fully achieve this
BMJ 2006;332:12 alchemy, we know we have to take a step up in both
BMJ VOLUME 332 7 JANUARY 2006 bmj.com
directions. To be a great journal we aim to further
strengthen the research and reviews that we publish and
experiment with new ways of presenting them to
readers. To be a great magazine we will develop the
BMJs look and feel, further increasing its readability and
providing an even greater variety of content.
Strengthening the research we publish means
doing what all good journals are doing to attract the
best research in their field. We aim to focus on research
that will help doctors make better decisions. We aim to
provide a great service to authors, offering speed, use-
ful critique, and courtesy, and context setting if your
work is published. And we need to shout a little more
about our unique selling points for authors: our broad
international readership in paper and online; our high
standards of peer review and publication ethics; and
our ability to give you as much space as you need on
bmj.com while also providing a shorter, more readable,
version of your work online and in print. In addition,
uniquely among the five major general medical
journals, we provide open access to all of our original
research articles with free full text available online
from the day of publication (although with the business
models for scientific publishing in flux, we are keeping
these policies under review). We also feed these articles
straight to PubMed Central, the most prominent open
access archive.
The new Research section pulls together all our
original research. This brings an end to the separate
Papers and Primary Care sections in the BMJ. The Pri-
mary Care section was originally launched in 1981 as
Practice observed to raise the visibility of general
practice and encourage practice based research. It has
more than done its job, to the extent that many now
find the division unhelpful. The research most relevant
to todays health care has implications across settings.
We remain committed to encouraging research in pri-
mary care as part of our mission to publish the very
best practice based and health services research.
The other new section headings show our
continued commitment to providing practical and pro-
vocative material for readers and to leading the debate
about the future of health care. The Clinical Review
section remains, and will carry up to date, evidence
based reviews on diagnosing and treating important
conditions in primary and secondary care. These
reviews will cover the 100 topics most frequently
requested by users of bmj.com, and we will aim to revisit
these every two to three years. A new section, Practice,
will provide practical information to help doctors and
1
Editorials
researchers in their work and professional develop-
ment. Finally, Analysis and Comment replaces Educa-
tion and Debate. The name change was partly just that,
but it also reflects a shift to more commissioned
material and greater variety of article types.
Two occasional sections, Learning in Practice and
Information in Practice, have disappeared. Again, this
is not because we think these areas unimportantthey
are clearly central to the future of health care. For this
reason, the research and commentaries that used to
appear in these sections will now appear in Research,
Epilepsy and supplementary nurse prescribing
The NHS needs advanced nurse prescribers
T
he scarcity of health professionals for managing
epilepsy results in uncontrolled seizures, drug
side effects, and psychosocial and physical mor-
bidity.1 2 Of the more than 1000 deaths related to
epilepsy in the United Kingdom each year, up to half
might have been prevented by optimal treatment.3
Recently, NICE (the National Institute for Health and
Clinical Excellence) recommended that specialists
should diagnose and manage refractory epilepsy and
that patients should have access to epilepsy nurse
specialists. Moreover, the government has offered
general practitioners incentive payments to conduct
annual reviews for epilepsy.
In the UK there are more than 350 000 people with
epilepsy, and the NHS employs around 350 neurolo-
gists and 100 epilepsy nurse specialists. Access to nurse
specialists improves patients management and reduces
the need for appointments at hospital clinics, with spe-
cialists, and with general practitioners,4 but variations in
the quality of services throughout the country make
these outcomes unreliable. Less than half of all epilepsy
nurse specialists have postgraduate qualifications
relevant to managing epilepsy, provide nurse-led
clinics, or take responsibility for managing the
condition. This throws doubt on the use of titles such as
specialist nurse and may have implications for patients
safety. In response the Nursing and Midwifery Council
has proposed that nurses with advanced level skills are
recognised by a protected title and registered as such.5
The proposed education and competencies of an
advanced nurse practitioner include a masters degree
and the ability to undertake case management, make dif-
ferential diagnoses, and prescribe medicines. The
masters degree, however, may be generic rather than
clinically focused, which would allow nurses with qualifi-
cations unrelated to epilepsy to register as advanced
nurse practitioners in epilepsy care andafter complet-
ing a course on supplementary prescribingto prescribe
antiepileptic drugs. To manage epilepsy and prescribe
antiepileptic drugs requires knowledge of the semiology
(presentation) of seizures and classification of syndromes,
and of differential diagnosis, medical and surgical
treatment, pharmacology, neurophysiology, neuroimag-
ing, neuropsychology, and psychosocial aspects of
epilepsy. These subjects are usually taught only in
specialist training with the main focus on epilepsy.
2 BMJ VOLUME 332
Practice, or Analysis and Comment. Some sections
have not been changedEditorials, News, Reviews,
Obituaries, and Minervabecause our readers tell us
these are thriving. But all of these, and the new
sections, will look different and carry new features as
part of the redesign later this year. We will be consult-
ing readers and authors as we go.
Fiona Godlee editor
(fgodlee@bmj.com)
BMJ, London WC1H 9JR
Around 28 000 nurses are currently registered in
the UK as independent prescribers and 4000 as
supplementary nurse prescribers. The aims of nurse
prescribing include improving access to drugs and
better use of nurses skills. Supplementary prescribing
enables nurses to prescribe most of the appropriate
drugs in the British National Formulary for a chronic ill-
ness, following a clinical management plan.6 From
spring 2006, qualified nurse prescribers will be able to
prescribe any licensed medicine for any medical condi-
tion (with the exception of controlled drugs).7
To ensure that the NICE recommendations and
incentives for general practitioners on managing
epilepsy are effective, suitably qualified epilepsy nurse
specialists should register as advanced nurse practi-
tioners. They would practise in consultation with
specialists, accept direct referrals from general
practitioners, and provide unrestricted advice on treat-
ment to general practitioners and patients. To provide
advanced level care for 350 000 patients, a minimum
of 350 advanced nurse practitioners are needed; they
would have caseloads of 1000 patients, roughly the
same number as are managed by consultants who spe-
cialise in epilepsy. In the NHS there are now, however,
only around 25 nurse specialists who would qualify as
advanced nurse practitioners in epilepsy.
Patricia G Hosking epilepsy nurse specialist
(phosk@hotmail.com)
University College London Hospitals Trust, National Hospital for
Neurology and Neurosurgery, London WC1N 3BG
Competing interests: None declared.
1 Clinical Standards Advisory Group. Services for people with epilepsy.
London: HMSO, 1999.
2 Hanna NJ, Black M, Sander JW, Smithson WH, Appleton R, Brown S, et
al. National sentinel clinical audit of epilepsy-related death: epilepsydeath in the
shadows. London: HMSO, 2002.
3 Cockerell OC, Johnson A, Sander JW, Hart YM, Goodridge DM, Shorvon
SD. Mortality from epilepsy: results from a perspective population-based
study. Lancet 1994;344:918-21.
4 Hosking P. The specialist nurse role in the treatment of refractory
epilepsy. Seizure 2004;13:303-7.
5 Nursing and Midwifery Council. Consultation on a framework for the stand-
ard for post-registration nursing. 2005. www.nmc-uk.org/(spzpnh55
bbetagu5rgrh0c55)/aArticle.aspx?ArticleID = 82 (accessed 1 Dec 2005).
6 Department of Health. Nurse prescribing training and preparation: extended
formulary nurse prescribing. 4 Jun 2004. www.dh.gov.uk/PolicyAnd
Guidance/MedicinesPharmacyAndIndustry/Prescriptions/
NonmedicalPrescribing/NursePrescribing/NursePrescribingArticle/fs/
en?CONTENT_ID = 4123001&chk = 2KTZRP (accessed 8 Jun 2005).
7 Department of Health. Nurse and pharmacist prescribing powers extended.
10 Nov 2005. www.dh.gov.uk/PublicationsAndStatistics/PressReleases/Press
ReleasesNotices/fs/en?CONTENT_ID = 4122999&chk = Mjc1MS (accessed
15 Dec 2005). BMJ 2006;332:2
7 JANUARY 2006 bmj.com