Monthly Archives: August 2008

I am perturbed. The US Preventive Services Task Force, a government health body, has decided that doctors should stop offering prostate-cancer screening to men over 75.

It has made a definitive statement: “Do not screen for prostate cancer in men age 75 years or older.” But instead of happy relief at this rare outbreak of common sense, there has been outcry.

Men’s health, the accusations go, is being left out in the cold, for dead. Since I wrote a few lines on this subject on my FT blog, I have received a stream of unhappy e-mails from people distressed that they might now not be recommended to have this “life-saving blood test”. One said: “I feel like I’ve been thrown on the scrapheap.”

The remainder of this column can be read here. Please post comments below.

The World Health Organisation are presenting their findings of a three year investigation into the ‘social determinants of health’ today. The report is available here. We are all used to hearing that the latest health news is ’shocking’ and ‘appalling’, but this report is a rare exception – it does actually deserve these descriptions. Life expectancy in one part of Glasgow is falling with a 28 year disparity in one part of the city compared to another. Maternal mortality in Indonesia is 3-4 times higher in the poor compared to the rich. They say “In the United States, 886 202 deaths would have been averted between 1991 and 2000 if mortality rates between white and African Americans were equalized”.

The report is rather brave. It talks about things like ‘social justice’ as a way to tackle health inequalities; for example, the importance of good urban developments, the need for fair and decent work, comprehensive social protection, the need for quality and equity in primary health care, and the problems with ‘practices that tolerate or actually promote unfair distribution of and access to power, wealth, and other necessary social resources’.

At the moment the best we seem to be doing to reduce health inequalities is to medicate more people with statins and antihypertensives. The ‘inverse care law’ as described by Julian Tudor Hart, suggests that the more people need medical care, the less they receive it, and I think this is true today. However I do not believe that real improvements in health can be tackled by addressing just access to healthcare. There is only so much that medication can do: low aspirations, unfulfilling employment, financial distress, a lack of  control over one’s life, and little social cohesion have a huge influence on the quality of life and health. These need to be addressed holistically: ‘social justice’ is the right term for it.  

‘Health’ I understand. But ’wellness’ ?

‘Wellness’ appears in the dictionary. But it is a mushy, ill-defined, nebulous word that is inherently anti-science (as it has no clear meanings or parameters). I find it to be a very irritating word. ‘Wellness’ is a word which, I have noticed, seems to increase in use in proportion to the money that one is invited to spend on trying to obtain it.

But ‘wellness’ is subjective, and, as a goal, tempts people into new dimensions of worry not just about the absence of disease but also about the depth of exuberant positivity one should bodily and mentally expect to find. It also invites lavish consideration of preventative ‘health checks’, many of which are marginal in potential benefit and most of which come with a flip side of cons. There are drinks, work outs, food, shoes, bras, chairs,  and, of course, health clinics, which come with the promise of ‘wellness’.

Thus, I have spent years trying to dissociate myself from the curse of ’wellness’ in healthcare, and now I have a moral dilemma. I have spent several months trying to find bathroom fittings that will fit into an awkwardly shaped room. I have found the perfect fit. However, the modest fittings are defined as a ‘wellness product’. The search goes on.

It may be summer, but doctors are already ordering stocks of vaccine ready for the flu season.

The NHS pours a lot of money and effort into its annual drive to vaccinate as many people in the high-risk groups as possible, and it has a pretty decent record of doing so. So there’s a good chance that if you are over 65, live or work in a care home (or elsewhere in the health service), have a respiratory disease such as asthma or chronic bronchitis or a condition such as diabetes or heart disease, you will be offered a flu jab free of charge.

The question, however, is whether the NHS should be making such an effort to give you that jab. There have been several reports that vaccinating some of those groups classed as “high risk” does little to cut the risk of complications from flu, for example pneumonia. A paper published in The Lancet this month matched older, healthy people who had received the flu jab with others who hadn’t – and found no evidence that the vaccination reduced the risk of contracting pneumonia. Nor is this the first piece of research to sound a note of caution on the benefits of vaccinating some high risk groups.

The remainder of this column can be read here. Please post comments below.

The latest medical scandal is that dead bodies are left on hospital wards for ‘hours’ before they are taken to the hospital morgue (so says the Herald in Glasgow, the Scotsman in Edinburgh, the Telegraph, the Independent and BBC News) . I discern a distinct lack of a story here.

Dying happens, and I am glad that, as reported, staff on the wards in the hospital thought it appropriate that relatives, friends and chaplains were able to spend some time with the deceased person before the body was removed. That seems humane. While private single rooms are nice, old style Nightingale wards are what the NHS has stocks of. The issue seems to have been that a visiting relative of another (live) patient complained that, on a large ward, and despite the curtains being drawn around the bed, the dead man’s face was visible, uncovered, on a pillow.

Death is sometimes tragic, and often sad, but we do ourselves no favours by attempting to remove ourselves from all witness of it. What, really, do we think happens to our body when we die? The hospitals have apologised, which I am disappointed by; they should have said that caring well for dying people, and caring well for the recently bereaved is immensely important and they are proud of what they have done. There is nothing to apologise for. The inevitability of death is hardly the NHS’s fault.

Moan as we do about the National Institute for Clinical Excellence (NICE), which decides which drugs should be available on the NHS, the idea that there should be a rationale about rationing has been received rather differently across the Atlantic.

In the US $2,000bn is spent annually on healthcare, but only 0.1% of this is actually used to assess whether any of the money was spent wisely, the BMJ reports this week. Two Democratic senators have introduced a bill, which has been generally welcomed, to establish a NICE-like institution to evaluate what the most effective healthcare interventions are. 

The responses to the piece below about NICE’s proposal not to fund new drugs for renal cancer are, in disagreement, understandable. But the problem is that rationing healthcare interventions is inevitable. Even if we (rightly) save money by stopping inappropriate prescribing and other ineffective interventions, there are still going to be limits and hard judgment calls to make. These decisions should be made openly and as fairly as possible.

Pretty soon, it might well make more sense to ask who isn’t on statins, rather than who is.

More than three million people are estimated to take these cholesterol-lowering pills – mainly to help reduce the risk of heart disease – and recent plans to offer everyone over 40 a cardiac risk assessment could more than double the figure. Statins can be bought over the counter, and the NHS spends £500m a year on them. That makes them the biggest single item on the health service’s shopping list.

The remainder of this column can be read here. Please post comments below

Pharmacists were reportedly delighted with a new scheme, just announced, to allow for azithromycin, an antibiotic, to be made available without a doctors’ prescription. This drug is a treatment for the sexually transmitted infection Chlamydia. Since Chlamydia infection can be without symptoms, and since, if it is left untreated over time, it can lead to problems such as inflammation and infertility, the idea has been to try and treat as many infections as possible before they cause problems.

This sounds sensible. But as usual the truth is a bit more complicated. This new prescription-free service is part of the Government’s strategy on dealing with sexual infections, and it hinges on screening for Chlamydia. Crucially, testing for this no longer needs an internal examination and swab to diagnose it. Instead, Chlamydia infection can be identified on a urine sample. This means that a doctor or nurse to do an internal examination isn’t needed, and that a urine sample can be tested. If positive, the infection can be treated with the over-the-counter azithromycin, and without a doctor.

This approach increases the amount of places to get a diagnosis and access to treatment. But the problems are multiple. There is a lot of concern that in offering only testing for Chlamydia, other sexual infections will go undiagnosed. Doctors are frequently reminded that other infections, initially without symptoms, can be sexually transmitted, particularly HIV and Hepatitis B. Indeed, at least some of the problems resulting in these infections not being diagnosed as early as they could be has been because of the (sometimes understandable) reluctance of healthcare professionals to raise the issue of testing for something which carries a stigma. However, earlier diagnosis brings many benefits, and stigma may simply have been perpetuated by medical reluctance.

But the other issue is whether this scheme will result in more diagnoses of Chlamydia. The ‘approved standard testing kit’ costs £25, and the antibiotic to treat a positive result costs £20. Since testing is free, meantime, on the NHS, and the prescription for a positive result available for either cheaper or free, I am not sure that this new innovation will prove the answer for over-stretched services, as claimed. Indeed there is still considerably dubiety about the effectiveness of opportunistic Chlamydia screening in general. Health economists have pointed out that on current evidence, it does not appear to be cost effective.

This week’s BMJ carries a review I’ve written on Iona Heath’s new book ‘Matters of Life and Death: Key Writings’. Dr Heath is a GP in London and is someone whose attitude towards medicine I’ve admired for many years. This book has made me think hard about what it is that doctors are meant to do, and what makes a good life and a good death. It is a shame it’s been packaged as a medical textbook as it deserves a far wider audience. Apparently in Italy it’s been released as a general interest book which makes more sense to me.

As I was logging on to the BMJ website to get the link to the review I noticed the banner advertisement. It was not advertising pharmaceuticals or medical conferences  – the usual products seen here – but the somewhat racy lingerie chain Agent Provocateur. I’m not sure whether this is a welcome distraction from medical research or the reward for it.

It was reported today that East Lancashire Primary Care Trust have a plan to deal with overweight schoolchildren. When the children return to school after the summer holidays they are to be weighed, and, if overweight, apparently they and their families will be ‘cold-called’ by nurses, who will then encourage them to lose weight.

But how? I’m sure the intentions behind this scheme are good ones. But I can’ t help wondering how evidence based this scheme is. The Cochrane Library contains information about  interventions for reducing obesity. Essentially “there is a limited amount of quality data on the effects of programs to treat childhood obesity”. In terms of prevention, another Cochrane review says that “There is not enough evidence from trials to prove that any one particular programme can prevent obesity in children, although comprehensive strategies to address dietary and physical activity change, together with psycho-social support and environmental change may help”.

My concern is not just that I loathe pushing unsolicited medical advice. It is also that all medical interventions contain the possibility of harm. We don’t know whether children will be stigmatised or totally turned off by this kind of intervention. Additionally, the resources may be better used elsewhere to pay for decent and exciting play parks (I am always sad when the tiny patch of grass in housing estates is marked with ‘no ball games’ signs), safe road crossings to walk to school, or free good quality school lunches for all. But without considering what the evidence tells us, and trying to address these and their multiple uncertantites, we are not going to be doing anyone any favours.

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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