NHS

Independent Sector Treatment Centres (ISTCs) were part of this governments plans for the NHS. GPs were encouraged to use them: this was meant to be the epitome of ”patient choice”. But not only have many contracts been issued on a “take or pay” basis, the cost efficiencies of these units have not been hauled up for scrutiny. Professor Allyson Pollock and Graham Kirkwood obtained data under the Freedom of Information Act in Scotland – no such data has been released elsewhere in the UK – and write in this week’s British Medical Journal about what it means. Poor value for money, and much missing data, they say: “If the same patterns apply in England, up to £927m of the £1.5bn may have been paid to ISTCs for patients who did not receive treatment under the wave one ISTC contracts”.

They conclude that “Contracts should not be renewed and new contracts should not be signed until a proper independent evaluation has been published assessing referrals, actual treatments carried out, and payments made for work done along with value for money analysis. Full contract details and costs must be placed in the public domain for this assessment to take place.”

Surely that can’t be argued with?

Margaret Haywood was struck off by the Nursing and Midwifery Council last week. She had secretly filmed patients in the hospital where she worked to document the conditions, which she claimed to have previously reported. These images were subsequently broadcast on the BBC programme Panorama. There has been an outcry from nurses, as well as from some families of patients on the ward, objecting to the penalty. One has described the conditions there as appalling.

Was this fair? Yes. Patient confidentiality is sacrosanct. If you have to break it – and there are few reasons for doing so – it has to be after other avenues have been exhausted.

And lo, the government said, we must woo voters. And they had a great idea: check ups. Let’s not leave them to the private providers. Let’s put them on the NHS. Everybody loves a check up.

The Department of Health sets out its new idea in a policy paper “Putting prevention first – vascular checks: risk assessment and management”. This includes the laudable aim to prevent ‘at least’ 9,500 heart attacks and strokes in a year. It is also estimated that the program could prevent 4,000 people from developing diabetes and ‘detect at least’ 25,000 people ‘earlier’ with diabetes or kidney diseases.

I’m beginning to think that this sounds suspiciously like a screening programme. The publication goes on: the vascular risk assessment programme will enable ‘everyone between 40-74 in the population to have their vascular risk managed appropriately’. Sounds daunting. Millions of people will be need to be assessed, and an enormous amount of healthcare staff time will be diverted. In light of this, one should expect this scheme to have been tested in real world situations with real world benefits in the UK population it is targeted at. One would be interested especially in medium and long term effects. One would also hope that adverse effects and cost efficiency have been examined. Instead, most of the work examining the effects of this scheme has been done through assumptions and modelling scenarios.

Further, because most of the work is intended to be done outside of GP surgeries, medical advice is not always going to be readily available. I cannot be the first doctor to have been faced with an anxious patient concerned that a cholesterol reading performed beyond the surgery has been found to have been marginally, and inconsequentially, higher at a private providers. I would not have wasted resources in needlessly repeating a test, but this is only going to be a small part of the difficulties of this new scheme. Screening tests should be done as part of an evidence-based policy which acknowledges the possibilities of false positives, negatives, and impact of tests on peoples’ lives.

Screening tests are complicated, messy and confusing. Throwing inadequately tested tests at the problem is rarely the solution.

I have been inspired by Harry Eyres’s piece on Slow London in the FT over the weekend. So much of working in medicine feels like a sprint. Short and overbooked appointments, busy clinics, multiple bits of administrative work to be ticked, crossed, signed and dated; e-mails and correspondence to deal with, questions from patients and carers and family members; equipment to be checked, replaced… it can feel frenzied.

Yet in medicine, seriously valuable things go missing in the fast pace. A detailed case history can be time-consuming to obtain but can save so much more on the wrong or unnecessary tests or investigations. Waiting to see if a symptom or test result improves may feel like a waste of time or even laziness, but can, in certain cases, be the most diagnositically useful thing to “do”. Allowing recovery from serious illness can sometimes feel frustrating: can nothing else be done? Yet it may be that “building in time” is the purest and most effective way back to a usual lifestyle.

Imagine if we could get rid of all the time-sapping, cash-depleting vogues in the NHS – Choose and Book and the tick boxes of the GP contract, for example – and invest instead in giving doctors and patients a bit more time to have adequate consultations?

The FAST campaign wants you to call 999 if you can answer, about someone you’re with, “yes” to the question “Has their Face fallen on one side?”, “no” to “Can they raise both Arms and keep them there?”, or “yes” to “Is their Speech slurred?” The idea is to get people with strokes to hospital as quickly as possible.

Several readers have been in touch to say that they found the ads on TV frightening and guilt-inducing – had they done enough for a friend or relative who had an evolving stroke? Was it their fault that a stroke progressed as far as it did?

I hope that the effects of these adverts will be investigated, in particular to see if they have any lasting benefit to public health but also to see what the adverse effects are – like what the readers writing to me have experienced.

The Joseph Rowntree Reform Trust is today launching a report, “Database State”, which examines the rationale, security and consequences of 46 public sector databases. It is co-authored by Ross Anderson, professor of security engineering at Cambridge University, who is an outspoken critic of government databases.

The results are startling. Two databases, the NHS Detailed Care Record and the Secondary User Service (which holds summaries of treatment and is supposed to be used for administration and research) are given a “red light” rating. This means, according to the report, that they are “almost certainly illegal under human rights or data protection law and should be scrapped or substantially redesigned. The collection and sharing of sensitive personal data may be disproportionate, or done without our consent, or without a proper legal basis, or there may be other major privacy or operational problems.”

When I spoke to Prof Anderson yesterday, he had much to say on the subject, which he has been researching for almost 15 years. He told me that since about 1995, the Department of Health “has focused on driving control of medical records from doctors to government. It [the Dept of Health] has behaved as though doctors are impeding progress of the evolution of health”.

In Scotland, there has been one main supplier for computerised medical records – the General Practice Administration System for Scotland, or Gpass. Though the system is government sponsored, Ross doesn’t see this as an advantage. He believes that “it has rapidly fossilised. The only interest in upgrading the service has been to put into practice what the civil service has wanted.”

Anderson was adamant that centralised control is “going to be disastrous for medical records”. He gave me an example from Nuffield hospital in Oxford: “[They] put in the new system – and they found that records were suddenly kept on a remote server rather than locally. The server went down in Swindon, and they couldn’t access any records, and therefore couldn’t do any operations.”

But it is not the logistical minutiae of centralised records that concerns Anderson the most. He is more worried about whether they are a good idea in the first place. “In medicine, you have to make sure that the systems are responsive to needs. This is not like a McDonald’s franchise. Medicine is so complex that you can’t [have a "one size fits all" electronic medical record]. Also, when you look at hospital medicine, there are dozens of little specialities, and each wants its own best of breed system.”

Such choice is not going to be possible under the NHS’s new “Connecting for Health” plan. Anderson is also concerned about the plan’s feasibility. “You can build a system for security, or functionality or scale. If you are very good you can maybe do two out of the three. But not three. A GP centre with 10,000 records can cope with risks, maybe there will be a problem with confidentiality once in a career there. At least it is limited and local. But once you get to 50 million records with a large pool of access to them, you can’t realistically expect them to stay confidential”.

There have already been cases where NHS workers have accessed records they had no reason to look at. The few who fail to respect confidentiality will have access to more records, not less.

Connecting for Health says that it will be hugely beneficial to be able to access a person’s full medical record from anywhere in the UK. Yet you hardly ever need a full medical record in order to receive immediate treatment. If you arrive at Accident and Emergency so unwell that you can’t give your basic medical details, it’s unlikely you’d be able to give your name and date of birth either, so access to your computer health record wouldn’t be possible. The ideal may be to use something like medi-alert bracelts, where specific health information — say, about allergies or life-threatening conditions — is available no matter the state of the patient.

As is, the amount of information that the record plans to hold is so enormous that the record ceases to become clinically useful. So much of the data is simply administrative. But it also means that full — or almost full — medical records become accessible to just about anyone working in the NHS (and note, there are 1.3 million people employed in it).

The new records will be opt-out, rather than opt-in, which I think is immoral. There has there been no decent reassurance from the government that standards of confidentiality in medical records will be upheld. I think Anderson’s concerns are justified — and you can start the process of opting out of central systems by making your wishes known to your GP surgery.

The investigation into the Mid Staffordshire NHS Trust makes for harrowing reading. The mortality rate at the hospital was found to be high in patients admitted as an emergency. The first data that showed an increase in the standardised mortality ratio was in 2005. The Healthcare Commission investigation was done during last year, 2008, and is reporting now, 2009. It can be difficult and labour-intensive to interpret statistics correctly. But it is not helped if the length of time it takes to analyse the numbers approaches the life of some health policies.

The report highlights what can happen when fulfilling targets becomes the chosen marker of quality. The target of no more than a “four-hour wait” in A+E led to unsafe practices, such as triage in A+E being done by a receptionist. Similarly, money was saved by getting rid of the hospitals’ clinical staff, as highlighted in the report. The irony is that it’s not difficult to envisage situations where receptionists could be given some training, welcomed as “clinical partners” in “skill mix”, and the system declared innovative and cutting-edge. But these kinds of terms are used to make cost-savings sound palatable: the training for being able to triage is better given via nursing or medical school. Meanwhile, Mid Staffordshire was given Foundation Trust status, and “focused on promoting itself as an organisation, with considerable attention given to marketing and public relations”.

Yet the Government is reluctant to admit that the target culture will not sort out all the NHS’s problems. Nor will shiny PR polish resolve understaffing and overstretching. Should we not just ditch ineffective policies, base healthcare policy on evidence, and move on?

The concept of doctor-rating websites seems to be gathering political momentum; in fact, it’s already a reality. The NHS is being offered this data, apparently to ensure that “patient choice” is offered and “patient experience” is good. I think it’s an unproven and potentially hazardous waste of money. There’s a piece that I wrote for the BMJ here; and you can also read Neil Bacon’s opposite point of view.

As an unschooled observer of the money markets, I have been struggling in recent months to understand what anything is actually worth. In healthcare, there is a similar problem, though it makes for rather less exciting headlines. All NHS procedures have to be costed to the last penny, and reported on in “completed care episodes”. But just like financiers, healthcare professionals can’t put an exact price on everything.

Blood, for example, is a commodity given free of charge by people willing to sacrifice time and comfort in order to make a significant difference to someone else. Bone marrow is another “gift”, donated by those who know they will not be repaid financially for being inconvenienced. And then there are the gifts given in the aftermath of death: corneas, kidneys, livers, skin, hearts… all capable of transforming a stranger’s life.

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

The British Association of Plastic Reconstructive and Aesthetic Surgeons have issued the results of a questionnaire asking surgeons if they have had to give emergency treatment to people who have had cosmetic surgery abroad. Unsurprisingly, the answer was yes. This is only the tip of an iceberg – there have been reports of patients returning after “transplant tourism” abroad, where people have paid for kidney transplant operations. What are doctors to do when patients present needing drugs to prevent rejection of the organ, or if a cosmetic surgery wound is badly infected?

BAPRAS says that there is a need for clear guidance as to what doctors should do. Should patients in this situation be made to pay private fees for medical intervention – after all, these are not things that the NHS has instigated, and normally, the team responsible for follow up care are those who did the procedure in the first place. It hardly seems fair that the NHS should be made responsible instead – costing time and money that should have been available to NHS patients. The uncomfortable bit is that doctors should be treating on the basis of need, and by the time there is a complication of surgery abroad, there is usually a need for urgent care. Where is the solution? Can doctors ethically ignore patients with such complications? Or should they simply be billed for their cost to the NHS?

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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