NHS

Alan Johnson, the Health Secretary, has announced that patients will now be allowed to buy and be treated with medicines not available on the NHS – but without affecting that person’s entitlement to NHS care. Previously, the rule had been that if a patient was having additional treatment in the private sector, they lost their NHS entitlements. This has become a cause celebre, especially in the case of some recently licensed cancer drugs.

At first glance this strategy might seem fairer – i.e no one should be denied NHS care. That is the heart of the meaning of what the national health service is – free, and available to all in need. Except of course, it’s not completely ‘free’ – many people pay prescription charges, or dental fees.

The reasons why I’m concerned are several. First, this is a green light for even more hype about new cancer drugs. I have not been convinced of either the wider media or even some researchers or doctors to present results of new research findings consisently in an unbiased way. I am afraid of the effects of overselling of benefits and the underselling of harms, or the lack of effect, to this group of patients and their friends and family.

Second, if a treatment is cost-effective, it should be available to all via the NHS. What makes something cost effective depends on how much we are willing to spend, and how much the intervention costs. The intervention may be too expensive for the limited benefit it provides. Or, of course, we could spend more on interventions, even less cost-effective ones, and there are expensive and ineffective white NHS elephants (Connecting for Health, PFI hospitals, Independent Treatment Sectors) which should be got rid of and the funds diverted usefully elsewhere.

But last, the other issue is that of the patient-doctor relationship. Fragmenting care into provision of some treatment in the private sector and the rest in the NHS is far from ideal. How will it be decided which are the ‘top-up’ private treatments and which are not (for example, follow up scans and blood tests which may be required as part of a treatment?) And how are patients going to feel if they are recommended to have a treatment which is too expensive to afford? Will they feel pressed to spend time, emotion and money on something which may not, in the end, be that useful to them?

The Healthcare Commission have published a report today about the state of the NHS.

On Radio 4′s Today programme this morning, they had Dr Michael Dixon speaking. He is a GP and chair of the NHS Alliance, as well as being a Trustee of Prince’s Foundation for Integrated Health. Dr Dixon took issue with the charge that hospitals were not sending out discharge summaries quickly enough. He was asked why this was; he said the cause was “arrogance”.

There is no doubt that discharge summaries are important. But to accuse hospitals of “arrogance” as a cause of slow receipt of them by GPs? It is not uncommon for hospital doctors to phone GPs like me to discuss difficult cases or to flag up potential problems as a patient comes home. This is rather helpful. Not at all “arrogant”.

It is also common for patients to come to the surgery, or to deliver in, a hand written discharge summary with a note of the most important problems or changes to treatment. This isn’t “arrogant” either.

I know for a fact that many hospital doctors stay late or go back in when they are not supposedly working to get through the paperwork; I also know that hospital secretaries, who are paid appallingly, work long and hard to get discharge letters typed quickly. I also know that most secretaries could earn more money for an easier job elsewhere. Most secretaries do not just type letters but act as PAs and organisers for patients, smoothing paths and sorting problems. I have not met an “arrogant” secretary yet.

This kind of comment damages morale and does not recognise the real resources that the NHS relies on. Goodwill and vocation is what keeps the NHS afloat.

Hospital acquired MRSA infections in the UK have apparently fallen by a third in the last year according to the Health Protection Agenc y. Gordon Brown is writing to all NHS staff to say well done.

I foresee problems. There have been a couple of political drives on MRSA recently which have been non-evidence based; the ‘deep clean’ of all hospitals and a ban on long sleeves for staff (even though the Department of Health itself said this was non evidence based.) In fact, the nonsense spoken by the DoH demonstrates the absurdity of how MRSA is being dealt with. On one hand the Uniforms and Workwear policy they have produced keeps saying how important it is to look professional (no untied long hair, not ‘too many’ badges) because this could ‘send the wrong messages’ to patients about ‘professional pride’. At the same time, while acknowledging there is no evidence for it, the policy bans neck ties.  I know of hospitals expending considerable energy into banning cufflinks while doing precious little about their commodes being shared. There is no evidence that any of the government’s ideas have had anything to do with a decreased rate of MRSA infections. The danger is that the government believes its own hype and that its policies have made the difference.

I wrote about microbiological concern about MRSA transmission last year here. The things that do seem to make a difference to MRSA infections are antibiotic prescribing, the cleaning of all surfaces, especially the less obvious ones, and decreased bed occupancy rates. Banning neck ties is not only non evidence based but it is not the surface most able to come into contact with most patients either. What about blood pressure cuffs, stethoscopes, curtains around beds, and visitors?

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.

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.

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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.

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.

The National Institute for Clinical Excellence is proposing that four drugs licensed for the treatment of renal cancer are not to be funded; they are not, we are told, ‘cost effective’. Charities, doctors groups and patients are reported today as condemning the situation with strong criticism of NICE. However, there are surely other criticisms due. If the pharmaceutical companies manufacturing these drugs wanted to make them ‘cost effective’ then they could reduce the cost until they are.

I consider morale to be a rather important in the smooth workings of the NHS. True, some things in the NHS are done badly, and some things definitely need to improve. But we hear a lot more within the media about NHS failings rather than successes. This doesn’t just affect morale within the NHS. It can also give a skewed view to people who are trying to decide whether or not to accept NHS care.

I am handing over to Emeritus Professor Joe Lamb who has emailed and who is keen for his experience of the NHS to be heard.

A total knee replacement in a Scottish NHS hospital On Monday 23/06/08 at lunch time I entered the Golden Jubilee National Hospital in Clydebank and, like all other patients, was allocated a single room with en-suite facilities, TV, phone etc and then was seen by the surgeon and registrar, the anaesthetist and various other staff. Next day at 8am I was given a spinal anaesthetic & sedative (my choice) into my arm. I woke at 11am, had a normal lunch at 12-30pm and was up on a zimmer by 4pm.

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