Effectiveness

Margaret McCartney

Most couples are aware of the potential hazards of putting off “trying for a baby” – and rightly so. As less than 2.2 per cent of women over 43 who undergo IVF are successful, it’s not as if there is an easy solution on hand for couples who fail to conceive naturally.

But now a host of fertility tests is piggybacking on to this fear that women (and, yes, men) may be leaving it too late. The most established test measures a woman’s follicle stimulating hormone, or FSH. This fluctuates slightly through the menstrual cycle, but rises in the menopause. However, this test is not useful for everyone, as it may not give much more meaningful information beyond what a woman already knows about her body.

Continue reading “The stork knows best”

Margaret McCartney

The issue of evidence on the Breastlight breast monitoring product for women has got me thinking about how much evidence one should have before an intervention is declared to work. In an ideal world, there would be continuous monitoring of all interventions so that very late or very rare complications would show up. In the real world that doesn’t often happen and we have to make do with initial studies and then voluntary reporting of problems thereafter.

So the quality of the evidence at the start would seem important. Here’s another Boots product: advanced electronic cold sore treatment which says it ”reduces the duration of the attack and speeds up the healing time”. It’s a good concept, and certaintly cold sores are common and often unpleasant. So does it work?

Margaret McCartney

Ever bought one of these? …Its an electronic gadget claiming to be able to repel mosquitoes by emitting a low frequency noise. Tempting, I suppose, since it seems quick and easy – no tablets to remember.

However a cochrane review - Electronic mosquito repellents for preventing mosquito bites and malaria infection – have found categorically that these devices don’t work. Regardless, they have been on sale widely including on board several major airlines.

Dr Bart Knols, who edits the MalariaWorld website decided to get busy and write to the airlines expressing his concern. Success: KLM have pledged to no longer sell them from March 2010 – KLM: An airline that acts responsibly – and responses are awaited from BA and Singapore Airlines.

A victory for evidence.

Margaret McCartney

I am confused. The Robert Francis inquiry is a the response to the Healthcare Commission’s investigation into the higher than expected mortality rate at the Mid Staffordshire NHS Foundation Trust.

The enquiry says “many staff” expressed concerns, but were “ignored”. Nurses complained there were not enough beds to cope with the demands placed on the service, and that they were expected to deal with a workload far above what could be safely managed.

Pressures to meet waiting time targets compromised care – for example patients were moved out of A&E regardless of their clinical state and how much monitoring they needed.

There were not enough senior and skilled nurses.

Wards were made more mixed to contain more different types of cases, despite objections from clinical staff that it would compromise care.

Trained staff numbers were reduced in ward reorganisations which went ahead despite opposition from clinical staff.

Why were the savings being made? The hospital was in debt, and this is what drove staff cuts.

Alan Johnson, then health secretary, has said there was a ”a complete failure of management to address serious problems and monitor performance”. But management had in fact been doing an awful lot of what they had been told to do: sort out the financial problems, meet the targets.

We are now coming round to thinking that it isn’t just individual mistakes that should be seen as problems, but the system, which allowed them to occur.

Blaming the managers is an easy option. Isn’t it the case that the system that managed this Trust – the political structure that told it what ‘good outcomes’ were – is the one to blame?

Margaret McCartney

On February 22nd the UK government Science and Technology Committee published Evidence Check 2: Homeopathy and concluded that “the NHS should cease funding homeopathy”. Hurrah! 

It also noted that ”the Medicines and Healthcare products Regulatory Agency (MHRA) should not allow homeopathic product labels to make medical claims without evidence of efficacy. As they are not medicines, homeopathic products should no longer be licensed by the MHRA.” Hurrah again. 

But this is the really really interesting bit. “In the Committee’s view,
homeopathy is a placebo treatment and the government  should have a policy on prescribing placebos.”. They go on to say that placebos involve deception, and are not consistent with informed consent.

To which I say: no, no, you miss the point.

Margaret McCartney

I am ashamed at how late I run, some days, at work. I have gaps built in to my appointment times for catch up (resulting in a longer overall clinic) but it is never enough. Sometimes I try and reflect on what I could do faster, but I can’t usually come up with much that I could myself control and that I think it’d be a good idea to do.

Various studies have suggested that the average number of items a GP deals with in one appointment is 3. A ten minute appointment, then, is rather stretched.

Margaret McCartney

Part of UK NHS development has been to make some nurses specialists in their area. Some aspects of this are not new – if you keep people learning and involved in a certain area – diabetes, say, or asthma – they are going to get very familiar with management of that particular condition.

The NHS and Department of Health, though, have moved things further yet – for example, by allowing nurses to prescribe any medicine after a few weeks training. Not everyone has “done the course” however, or wants to sign their name – which means that phone calls are not unusual from, say, the pain nurse, the respiratory nurse, or the terminal care nurse asking for a patient to be given whatever drug.

Margaret McCartney

Cuts in NHS spending are looming. So we would want to be sure that the money in study budgets is being wisely and carefully spent, and with an eye on the evidence.

This course - Core Skills in Creating Excellence in Patient Experience – is not the most expensive of its type but look at how many kinds of staff it is aimed at - all administrators and lots of nurses. It could give Martin Lukes a run for his money for gobbledesense: “Lead the creation of a truly customer-centric culture of excellence … this course, designed for those taking the lead, comprehensively covers developing a patient experience excellence strategy and implementing it throughout a team, department or even a whole Trust.” All in just one day!

Margaret McCartney

Those of us who prefer Cochrane reviews for our evidence, and who know that the majority of pharmaceutical companies do not publish all of their research, will not be surprised by this publication in the BMJ today: Neuraminidase inhibitors for preventing and treating influenza in healthy adults: systematic review and meta-analysis. The lead author is Dr Tom Jefferson, who we’ve interviewed for the blog. Here’s the conclusion, about the impact of neuraminidase inhibitors oseltamivir and zanamivir :

” Neuraminidase inhibitors have modest effectiveness against the symptoms of influenza in otherwise healthy adults. The drugs are effective postexposure against laboratory confirmed influenza, but this is a small component of influenza-like illness, so for this outcome neuraminidase inhibitors are not effective. Neuraminidase inhibitors might be regarded as optional for reducing the symptoms of seasonal influenza. Paucity of good data has undermined previous findings for oseltamivir’s prevention of complications from influenza. Independent randomised trials to resolve these uncertainties are needed.”

Margaret McCartney

So what, exactly, has the private sector in the NHS done for us? The governments’ much spun “Choose and Book” scheme is alleged to offer patients greater choice in the venue of their care – including private providers – when booking hospital appointments.

It has been unpopular with GPs because the software has been slow, because it has been difficult for a GP with expert knowledge on the local patch to know as much about more far-flung equivalents and because it costs a lot to do something that there seems little clinical reason or particular desire for.

And so, to a recent BMA News report that a GP in Yorkshire had tried to access a hernia repair for one of his patients at a private hospital run by Spire Healthcare. Hernia repairs are usually one of the more straightforward operations, and are commonly performed.

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About our regular bloggers

Margaret McCartney is a Glasgow-based GP and FT Weekend columnist. She started writing for the Life and Arts section in 2005 and moved to the magazine in 2008. She also has her own blog: www.margaretmccartney.com/blog

Clive Cookson has been a science journalist for the whole of his working life. He joined the FT in 1987. Clive, the FT's science editor, picks out the research that everyone should know about. He also discusses key policy issues, from R&D funding to science education.

Andrew Jack is pharmaceuticals correspondent, covering the industry and public health issues. He has been a journalist with the FT for 19 years, based in London, Paris and Moscow

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