Politics of healthcare

Antibiotics don’t work on most colds, flu or sore throats. This is old news, but the Department of Health is re-launching their Antibiotic Awareness Campaign to remind us. Indeed, the more antibiotics are used, the bigger the problem resistance becomes. So I’d like to know what the sense is in making antibiotics prescribable by more healthcare workers, in reducing the amount of pharmacology taught in the medical undergraduate curriculum, and in plans to make certain antibiotics available over the counter.

The snow falls, public transport grinds to a halt, schools are closed, and the Met Office issues “severe weather” warnings.

And death rates go up: as the temperatures drop, so-called “excess winter mortality” kicks in. This phenomenon has been noted in many other countries, too, but why does it happen? A reasonable suggestion is that fuel poverty and cold living conditions cause people to become unwell and a proportion to die. A large study published in the BMJ a few years ago, found that for people aged over 75, being female or having respiratory illness were risk factors for increased mortality. But there was no relationship found between increased mortality and either having trouble heating the house or suffering financial difficulties. In other words, providing winter fuel allowances – which the UK does - was not, according to this study, going to be enough to protect people from excess winter mortality. Interestingly, a study trying to find risk factors for excess winter mortality in New Zealand concluded that there was a ‘surprising’ lack of relationship to commonly supposed risk factors – making it difficult, of course, to know what to do to protect people from it.

In Siberia, there is only excess winter mortality when the temperature dips below 0 degrees C, unlike in Europe where the excess mortality starts above this. So what do they do differently in Siberia? In an interview study of 1,000 Russians, published in the BMJ in 1998, the researchers noted their ability to keep their homes cosy even when outside temperatures dipped below -25 degrees C,  and the admirable amount of clothing they wore. The average number of items of clothing was 16, with the average layers of clothing worn being 3.7. This reflects another study published by the Lancet in 1997 which concluded that fewer clothes, less activity and colder homes across Europe were all related to higher mortality.

It is therefore quite nice to not only feel justified in my rather large collection of assorted hats, gloves, scarves, coats, boots and various other apparel which I  can now not only consider essential, but can also heartily recommend to others.

The EU Medicines Directive has decided that Orlistat, a weight-loss drug, can go on sale over the counter. You’ll be able to buy it without a prescription from pharmacies, and online. The difference between the over-the-counter version and the prescription variety will be the dose: the usual prescription strength is 120mg three times a day – the OTC product will be 60mg.

Is patient choice and increased availability a good thing? All drugs have side effects, and Orlistat – or Alli as the OTC version is to be called – is no exception. The side effects are mainly to do with bowels and incontinence – I will spare you any more detail. Still, it seems to suit some people, and there is evidence of benefit. How much benefit? The majority of studies on Orlistat have used the 120mg dose. Most trials also involved people being given stringent dietary and exercise advice. In trials, people taking Orlistat – with these provisos in place – have lost about 2kg-5kg more than people taking a placebo.

The problem is that we won’t know if this OTC development will work or not. As far as I can see, no one is looking into whether it will make a measurable and effective difference to people’s weight under these lower-dose and real-world conditions.

The other problem is fragmentation of care. The fact that more people are becoming involved with a patient’s healthcare without shared notes makes me concerned that we are creating problems-in-waiting. Shouldn’t we get this sorted out before even more drugs obtain an OTC licence?

I am dismayed to note that complementary therapists are now able to register with the CHNC. Ben Bradshaw, the health minister who is also so keen on the non-evidence based ‘iwantgreatcare.org’ doctor-rating website, is reported as saying:  ”I welcome the opening of the Complementary and Natural Healthcare Council (CNHC) register…which the public can turn to for help. Members of the public who use these therapies will be able to check whether the practitioner they’re seeing is registered with the CNHC. If they are, they have the reassurance of knowing that they have had to meet minimum standards of qualification … Practitioners too will benefit by increased public confidence. Public safety is paramount. Registration, whether voluntary or statutory, is about protecting patients, and I am pleased to see this important milestone in voluntary registration.”

This is nonsense. What about protecting the public from ineffective interventions? Or false hope, wasted time and effort or indeed, potential harm? What is the point of improving “public confidence” in things that don’t work? (And “alternative” therapies which do work are taken up into orthodox medicine.)  Bradshaw would be serving the public far better by advising them to be cautious when engaging with healthcare interventions which have not been proven to work. Isn’t that the best way to “protect” patients? And, incidentally, Bradshaw’s signing off line — “People should always seek their GP’s advice to ensure that any other therapy they use does not conflict with orthodox treatment” – is the epitome of weasel words: how can a GP ethically end up taking responsiblity for things he or she doesn’t prescribe or suggest?

There have been stories recently about how much the NHS are paying agency staff to work shifts. These kind of locum shifts are usually contracted at short notice or include unsocial hours. But it’s madness – £188 for an hour’s work? I have heard worse recently: a GP paid £200 an hour for working at New Year, and an anaesthetist paid almost the same for working at Christmas.

This is one outcome of allowing market forces to dictate NHS spending. There was a time when the NHS made people work “emergency”, unfeasible or dangerous hours for pennies in order to save money, but the pendulum has now swung too far. The problems started when out-of-hours work began to be counted up by a government who had decided to start contracting for it, hoping to save money. They did not believe the hours that they were told were being worked and then they badly underestimated them. It ended up being far more expensive than had been planned for. “Medical professionalism” started to erode: every little thing  is expected to be costed and accounted for. In turn, it is easy for healthcare workers to refuse to do things – even important things – that have not been contracted for, and then blame the contract as the reason why. Professionalism in healthcare is desperately needed, but I am not convinced we will realise this until the NHS is on its knees and the doctors have all clocked out. 

Sir Richard recently gave an interview to the BBC  when he said, amongst other things, that the healthcare industry could learn from the airline industry; and that all healthcare workers should be screened for MRSA and treated for it because it “is far better than having people dying from unnecessary diseases, and all the misery and pain that that causes, and the cost to the NHS which is enormous.”

Sir Richard is now vice-chair of the Patients Association. If he wanted to go and talk to the scientists who actually do know about MRSA then he would find out all kinds of things; for example, in many outbreaks of MRSA, staff strains are different from those that patients are colonised by. And that MRSA is on places that may not routinely get cleaned; and that it is a bit daft to be so concerned about cleaning bedposts if there is only one commode being shared by a whole ward. Now, if Sir Richard was proposing research to find out what the most cost-effective ways are of reducing MRSA (and other hospital aquired pathogens) transmission and disease resulting from it are, I would be entirely supportive. But presuming that one knows the answers when it is clear that this is a complex area where randomised controlled trials are few – is dangerous.

As for the airline/healthcare analogy, well…

If a pilot thinks it’s unsafe to fly due to risk factors, for example poor weather, then they don’t. They stay, rightly, grounded. If a doctor thinks that surgery will be high risk, they don’t always have the choice of staying ‘grounded’ and not operating: the illness may well be the reason why the operation needs to be done. In other words, the airline industry has much more choice about the risks it is prepared to take on.

And. Airlines fly routes that are profitable and readily possible. Healthcare has to deal with things that may be neither. Neither can the identification of ‘near misses’ in air travel be used as a reason to compare it with safety in healthcare – in any case there seems to be justified concern that pilots don’t always ‘fess up.

This isn’t to diminish the huge responsibility which airline pilots take on and have. Aviaton and healthcare systems may have some similarities but they are limited. Here is one comparision it might be worth making. A pilot has a co-pilot and a standard number of crew without whom he cannot fly. The healthcare vogue is for promoting less qualified team members to diagnose and treat conditions. This is analogous to the pilot remaining at the airport but taking responsibility for the cabin crew flying the aircraft and dealing with any problems. It may be cheaper to do so but it isn’t necessarily desirable or effective. This is something which competitors to NHS primary healthcare may wish to note.

Yep. In this week’s BMJ, is an advert for a ‘vacancy for a member’ for the Herbal Medicines Advisory Committee , which advises the Medicines and Healthcare Regulatory Agency on the ‘safety, quality and efficacy of herbal medicinal products for human use.’ Of further concern to me is that they wish their newly appointed member to have recent experience in paediatrics.

Herbal medicines are, if they work, nothing special – St John’s Wort, aspirin (willow extract), vincristine, a chemotherapy drug, which is derived from plants….they all have side effects and interactions with other drugs. In fact, one could say that herbal medicines which work are in fact just medicines, to be used with the same provisos as any other medicines.

These leaves the ‘other’ herbal medicines as the ones which don’t work. And which, by definition, we should be ensuring either aren’t used, or are properly researched so that we know whether they should be or not.

What is gained by having a Herbal Medicines Advisory Committee? Obfuscation, and the danger of having a different set of standards for one set of chemicals compared to another, I suggest.

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?

“GlaxoSmithKline is to make public the level of advisory fees it offers to doctors and medical academics, and will strictly cap the payments they can receive in the US to $150,000 (£88,000) a year each. Andrew Witty, chief executive of the UK-based pharmaceutical company, said he was introducing tougher new rules to impose a cap “without exception” on such payments and promised to publish the amounts.”

I’m catching up with my reading. Andrew Jack interviewed Andrew Witty, the chief exec of GSK, in the FT a week or two ago. That’s the first paragraph of a very interesting piece. 

Now, publishing the amounts GSK pay doctors is very good, but, er, 88K a year? For a couple of lectures and lending one’s name to a bit of ghost-writing? GSK, please save your cash and don’t pay any doctors not wholly employed by you for any advisory anythings. Last year the kickbacks received by orthopaedic surgeons – some up to $1m worth – in the US were revealed after a federal investigation showed just how closely doctors and the orthopaedic industry were “working”.  There is still cash being thrown at doctors in the UK. I am tired of throwing out all the invitations I get to hearing the latest on cardiac risk factors/obesity management/urinary incontience over dinner at very nice restaurants courtesy of pharmaceutical reps.

Would you want the advice of a doctor who has just been eating canapes courtesy of the latest anti-inflammatory rep? Would you take the recommendation for your type of hip replacements from someone who has just spent a few five star days giving “consultancy” to the manufacturers?

I hope not. Medicine is difficult enough without having one’s judgment impaired by biased interpretations of the evidence. There is lots of dialogue to be had between doctors and both the pharmaceutical and medical device industries. But this should be done without personal gain. 

That should be obvious. Professionals should not be technicians who can be puppeteered at the whim of the sponsor; they should be acting for the best interests of those they serve with 20/20 clarity. That’s surely the bare minimum we should expect as patients, from doctors?

Every time I have written about this I have had emails from doctors who tell me that I am a fool. You can have nice dinners and lux conference stays and still be a pro, they say, I can’t be bought! But of course you can. Anyone can. The point of being a professional is surely that you choose not to be.

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?

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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