Politics of healthcare

Help the Aged have released details of a survey today. They conclude that 1.4m older people in the UK feel socially isolated and that 1.25m are often or always lonely.

I am often dubious about the way in which surveys are interpreted. However, the findings of this survey do bear out many of the sadder observations made in general practice. 

I have long thought that social cohesion is one of the best things for both quality and quantity of life. The current approach to improving health in older people seems to be focused on prescribing more drugs to treat blood pressure, cholesterol and depression. I would much rather see one’s cardiovascular risk factors and mood addressed through meaningful activity, pleasurable and varied diet, and companionship.

Here is Sir Michael Marmot (author of The Status Syndrome, among others) on neighbourhood effects on health: “Rates of mortality and illness differ markedly between areas…Cities all over the world have variations in health by area according to socio-economic level to a greater or lesser extent…Evidence suggests that neighbourhood characteristics such as social cohesion are crucial.”

A systematic meta-analysis published earlier this year  exploring how psychosocial factors relate to health found evidence that favorable psychosocial environments “go hand in hand with better health”.

A couple of years ago in Iceland, I was deeply impressed at the convivial atmosphere after work when whole neighbourhoods seemed to gather every evening – regardless of age or sex – in cheap, local hot spas. The conversation and welcome was fabulous, old people and young people all welcome alike. There was not much exercise going on: mainly people just sat around and chatted. Icelanders have a famously long lifespan. I suspect social cohesion has something to do with it.

The dirty semi-secret that GPs get paid per item of what they do – for example, immunisations, cervical smears, blood pressure checks – has been making me uncomfortable for years. I still do not know what the best way of paying GPs is. The Sunday papers this weekend are full of stories about GPs being paid not to send people to hospital. This is only the tip of an unpleasant iceberg. Professional medicine should be about doing the right thing for patients. And while doctors should have an eye on the cost effectiveness of potential interventions, and should not be wasting public money, there should be no personal financial gain involved.

What would be a better way? On one hand, the ‘independent contractor’ model (where GPs contract services to the NHS) at least has the chance to try and negotiate a decent professional contract. On the other hand, this hasn’t been achieved; would a standard contract actually allow professional values to flourish? Maybe a flat pounds-per-hour would be better; good practice could be audited by peer review and patient feedback. Not to mention a proper assessment of prescribing practices and referral rates.

The Lancet has a great editorial today. It’s about the need for guidance for doctors who are asked to assess prisoners who are hunger strikers. They say that doctors should recognise that hunger strike may be the sole method of protest a prisoner has. People who are starving, however, may become confused and disorientated; the difficulty then is to decide whether the person is competent, with medical capacity to decline intervention. Intervention has and is used in this situation, for example in Guantanamo Bay, where prisoners have been, and are, force fed. However, says the Lancet, force feeding has no place in high quality medical care. Independent physicans are required to explain the risks to life that the striker is taking. However, advance directives written by a competent person should mean that if confusion afflicts a prisoner due to a chosen hunger strike, their preordained wishes should be followed.  

Force feeding is not nice. Dr David Nicoll, a neurologist in England, has done a huge amount to highlight this issue (correspondence between him and a previous commander of the Guantanamo military hospital is available here.) The picture of the ‘restraint chair’ that is used is especially harrowing. The bottom line is that individuals with mental capacity have the right to choose what medical care they want – and don’t want. Doctors have to respect that right.

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.  

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.

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.

There is an interesting and worrying piece in the New York Times about dermatologists in the US. The charge is that patients attending with medical skin complaints are treated as second class compared with those patients seeking cosmetic interventions. The latter make more money for the MDs. The insurance company payout for seeing people with ’ordinary’ medical skin complaints is low, say some dermatologists in defence.

There are lots of reasons why I find this disturbing. The ultimate outcome of demand-based medicine means that the largest dollar shouts loudest. But this does not match who is in need of most medical care. Why on earth should patients with serious skin complaints be dealt with less quickly than those who want a few wrinkles pressed out? Medical magazines in the UK frequently offer courses for doctors or nurses wanting to do a bit of cosmetic botox. Dentists, too, are getting in on the act. Is this really a good use of time and training? 

The other thing that bothers me is our apparant obsession with being wrinkle free. What kind of society is it that proclaims itself to think ageism a terrible thing  – but then spends vast amounts of time and money trying to superficially avoid the signs of maturity?

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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