tag:blogger.com,1999:blog-82857375819495279962024-03-14T05:30:30.653+00:00Pyjamas in BananasRandom musings on science, medicine, philosophy, and anything else that comes to mind.pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.comBlogger236125tag:blogger.com,1999:blog-8285737581949527996.post-69252036602484205122012-06-18T23:07:00.000+01:002012-06-18T23:07:05.312+01:00Why the worried well trump real mental illness<span style="font-family: inherit;"><a href="http://www.guardian.co.uk/society/2012/jun/18/mental-illness-people-help">Apparently</a>:</span><br />
<br />
<blockquote class="tr_bq">
<span style="font-family: inherit;"><i>"The "scandalous" scale of the NHS's neglect of mental illness has been described in a <a href="http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp" style="background-repeat: no-repeat no-repeat; border-collapse: collapse; color: #005689; margin: 0px; padding: 0px; text-decoration: none;">report</a> which suggests only a quarter of those who need treatment are getting it.</i><i>The report claims that millions of pounds are being wasted by not addressing the real cause of many people's health problems. Nearly half of all the ill-health suffered by people of working age has a psychological root and is profoundly disabling, says the report from a team of economists, psychologists, doctors and NHS managers, published by the London School of Economics.</i></span><span style="background-color: white;"> </span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: inherit;"><i></i><i>Talking therapies such as cognitive behaviour therapy relieves anxiety and depression in 40% of those treated, says the Mental Heath Policy Group led by Lord Layard. But despite government funding to train more therapists, availability is patchy with some NHS commissioners not spending the money as intended, and services for children being cut in some areas. "It is a real scandal that we have 6 million people with depression or crippling anxiety conditions and 700,000 children with problem behaviours, anxiety or depression," says the report. "Yet three quarters of each group get no treatment."</i></span></blockquote>
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<a href="http://www.guardian.co.uk/commentisfree/2012/jun/18/inexcusable-mental-health-treatments-underfunded"><span style="font-family: inherit;">And:</span></a></div>
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</div>
<blockquote class="tr_bq" style="color: #333333; line-height: 18px;">
<i><span style="font-family: inherit;">"IAPT has created a revolution in mental health by establishing a national competency framework for therapists, by training them to a high standard and by carefully monitoring their outcomes. Many readers will be amazed to hear that 10 years ago only 11% of British psychiatrists regularly administered any objective measure of mood when treating depression. Now all IAPT workers do so and the results, which are available on the <a href="http://www.ic.nhs.uk/" style="border-collapse: collapse; color: #005689; margin: 0px; padding: 0px; text-decoration: none;" title="">NHS Information Centre website</a>, are in line with the assumptions of the economic case. Latest figures show that 44% of people who have some form of treatment in IAPT recover. Many more (around 65%) show worthwhile improvements. In addition, the number of people who have moved off sick pay and benefits exceeds expectation.</span></i><span style="background-color: white;"> </span></blockquote>
<blockquote class="tr_bq" style="color: #333333; line-height: 18px;">
<i><span style="font-family: inherit;">...The same story emerges with service budgets. IAPT is expected to offer treatment to a modest 15% of people with depression and anxiety by 2014. On average services currently provide for around two thirds of that. However, instead of expanding, there are signs that cash-strapped commissioners are cutting back. For example, one well-performing London IAPT service recently had its budget cut by 30%. Such cuts make no economic or humanitarian sense. As evidence-based psychological treatments save the NHS more than they cost, we should be doing more, not less, in tight economic times."</span></i></blockquote>
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Well bollocks to that. IAPT (Improving Access to Psychological Therapy) provides a few sessions of crappy telephone or group based therapy 'inspired' by CBT and delivered by minimally trained therapists to people with mild symptoms of life stresses who barely meet criteria if at all) for mental illness.</div>
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Meanwhile people with significant mental illness are excluded by their services and sent to secondary psychiatric care where the same old waiting lists for CBT and other therapies exist as they did before IAPT was invented. All because they're too 'risky' or 'complicated' to be dealt with by IAPT (read that as 'actually mentally ill'). <span style="background-color: white;">Of course 40% of people get better, most would have got better anyway!</span></div>
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<span style="background-color: white;">Patients hate it, clinicians think it is a joke. So inevitably more and more money will be diverted in its direction, probably at the expense of people who know what they're doing.</span></div>
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<span style="background-color: white;"><span style="color: #333333; font-family: arial, sans-serif;"><span style="font-size: 14px; line-height: 18px;">The report itself is a magnificent example of eliding different definitions of depression and other mental illness -pretending that those in community prevalence estimates of depression are the same as those in morbidity studies of depression are the same as those on </span></span><a href="http://pyjamasinbananas.blogspot.co.uk/2008/11/mental-health-and-incapacity-benefit.html" style="color: #333333; font-family: arial, sans-serif; font-size: 14px; line-height: 18px;">incapacity benefit for 'mental health problems</a>'<span style="color: #333333; font-family: arial, sans-serif;"><span style="font-size: 14px; line-height: 18px;"> are the same people as those in clinical trials of depression in order to make breathtakingly speculative claims about how CBT can save the economy millions.</span></span></span></div>
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<span style="background-color: white;"><span style="color: #333333; font-family: arial, sans-serif;"><span style="font-size: 14px; line-height: 18px;">Yes, fund mental health better, no, don't piss millions more away treating mild unhappiness at the expense of real illness.</span></span></span></div>
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<br />pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com2tag:blogger.com,1999:blog-8285737581949527996.post-83967848392502263172012-02-21T22:33:00.001+00:002012-02-21T22:33:36.255+00:00All too predictableFrom <a href="http://www.guardian.co.uk/society/2012/feb/21/doctor-nhs-reforms-disciplinary-action">the Guardian</a>:<br />
<blockquote class="tr_bq">
"Doctor who criticised NHS reforms is threatened with disciplinary action...<br />
... </blockquote>
<blockquote class="tr_bq">
Prof John Ashton, county medical officer for Cumbria, received a letter
from his PCT last week after he joined 22 other signatories to a letter
in a national newspaper criticising Lansley's health and social care
bill. The letter read: "You are bound by the NHS code of conduct and as
such it is inappropriate for individuals to raise their personal
concerns about the proposed government reforms." Ashton will have to
"explain and account" for his actions at the hearing."</blockquote>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com1tag:blogger.com,1999:blog-8285737581949527996.post-35732414073707023782011-11-12T18:04:00.000+00:002011-11-12T18:04:09.150+00:00Score one for SertralineOn the basis of some accumulating evidence of dose dependent QT prolongation with <i>citalopram</i> the manufacturer Lundbeck has<a href="http://www.mhra.gov.uk/home/groups/pl-p/documents/websiteresources/con134754.pdf"> issued new guidance</a> on its use. The long and the short of it is that they advise the maximum dose is now 40mg (20mg in the elderly), that it shouldn't be used concomitantly with drugs that also prolong the QT interval (e.g. <i>methadone</i>, tricyclic antidepressants, <i>amiodarone</i> and <i>sotalol</i>), and that it should only be used with caution in those at risk of Torsade de Pointes (CCF, recent MI, bradyarrhythmias, predisposition to hypokalaemia or hpomagnesaemia, including due to medication). This risk also likely applies to <i>escitalopram</i>.<br />
<br />
<i>Citalopram</i> is probably the first-line antidepressant in medical practice, partly due to the lower rates of interactions, but give recent evidence that<i> </i><a href="http://pyjamasinbananas.blogspot.com/2009/03/are-new-antidepressants-any-better.html"><i>sertraline</i> is more effective</a>, at least compared with straight <i>citalopram</i> (rather than <i>escitalopram</i>), I think <i>sertraline</i> is going to become the go to SSRI of choice now, particularly in the elderly (the maximum dose of 20mg is also the minimum therapeutic dose - so not much scope for increasing it).pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com0tag:blogger.com,1999:blog-8285737581949527996.post-64596655982755603542011-11-04T19:57:00.002+00:002011-11-04T20:44:35.163+00:00Yet more tales of woe from the medical Gestapo<a href="http://www.bailii.org/ew/cases/EWHC/Admin/2011/2885.html">Another affair</a> where the GMC demonstrates how it pisses away the hundreds of pounds in fees paid by doctors to hound those self-same doctors for minor mistakes (highlights below, my emphasis in bold):<br />
<blockquote class="tr_bq">The appellant...submitted an application on 8<sup>th</sup> December 2005 for the post of specialist registrar in plastic surgery in the Oxford and Wessex Deanery. Candidates were required to complete an application form in full.<br />
<br />
On 17<sup>th</sup> May 2011 the panel found that the application form submitted in December 2005 contained <b>seven inaccurate statements which were both dishonest and misleading</b>; that <b>her fitness to practise was therefore impaired</b>; and that she should be <b>suspended from practice for 12 months</b>. She appeals against those findings and the sanction.<br />
<br />
Section 6 of the application form required the candidate to list her postgraduate medical qualifications. One of the bullet points states "if you are in the process of working towards a higher degree please say so, indicating expected completion date". [She]..."<b>MD; Leeds University Medical School, UK, Thesis and Viva</b>"; and then, in the final column, which is headed "date passed": <br />
<blockquote>"TO BE AWARDED</blockquote><blockquote><b>VIVA AWAITED</b></blockquote><blockquote><b>Completion January 2006</b>"</blockquote> the panel's finding was as follows: <br />
<blockquote><b>"</b>...<b>The truth was that far from a VIVA being awaited, your thesis had not even been completed. To imply that is was, applying the test in <i>Ghosh</i>, the Panel is satisfied was dishonest</b>. In reaching its decision the Panel took account of the seriousness of the allegation and your good character. The Panel did not accept your evidence that it could have been worded better. The Panel was satisfied that it was worded in such a way to convey to the reader that your VIVA was expected and by inference your thesis completed and submitted"</blockquote>Section 7 of the form required the candidate to state what relevant medical or professional courses other than those leading to a post graduate degree or qualification she had attended. [She] listed seven of these. The first was <b>ATLS (advanced trauma life support)</b>, which she stated had been attained at the Mayday Hospital, Croydon. <b>Under the heading "date certificate attained" she wrote "2001 C [ie completed] (recertification booked)</b>".<br />
<br />
...<b>had in fact successfully completed a 3 day ATLS course at the Mayday Hospital from 13-15 September 2000</b>. The certificate states that it expires on 15 September 2004, that is to say on the fourth anniversary of the last day of the course.<br />
<br />
The panel found: <br />
<ol><blockquote>"...<b>The Panel is satisfied that it was untrue to say that you completed your ATLS course in 2001</b>. In the context of an important job application, truthfulness is expected. You knew this to be untrue. The Panel did not accept your evidence that this was a mistake. This was a certificate relevant to the application. <b>Your application form implied that it was current when it was not. Applying the test in <i>Ghosh</i>, the Panel is satisfied that this was dishonest.</b>"</blockquote></ol><a href="http://www.blogger.com/post-create.g?blogID=8285737581949527996" name="para37"></a>The last entry stated that <b>from August 2004 to December 2005, a period of 17 months, she had worked at Pinderfields Hospital, Wakefield in the speciality of plastic, reconstructive, hand and burns surgery as a "Research Registrar" funded by Action on Plastic Surgery</b>....Section 9 is a single line reading "time in full-time research" and seeking an answer in years and months. The answer [she] gave was 1 year, 5 months. Section 11 asks about "time in plastic surgery (do not include research)". [She] answered that she had spent 24 months as an SHO and 17 months as a registrar. In oral evidence (Day 8, page 378) she said that during this period she spent 50 hours per week on research and her clinical hours were between 40 and 90 per week.<br />
<br />
The panel found: <br />
<ol><blockquote>"...<b>The Panel determined that it was not true that you spent 17 months in a full time research post and spent 17 months in a full time clinical post. </b>That is what your application form conveys to the reader. The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. <b>Applying the test in <i>Ghosh</i>, the Panel is satisfied that this was dishonest.</b>"</blockquote></ol>Paragraph 3(g) of the list of allegations made by the GMC against [her] referred to <b>a statement in the application form "that, during your research project, you had (1) produced 11 publications, (2) produced 21 national and international presentations</b>". This was alleged to be dishonest and misleading. The findings of the panel were as follows [emphasis added]: <br />
<ol><blockquote>"The period of your research was from August 2004 to December 2005. <b>There were fewer than 11 publications <i>related to your research</i> within that time frame</b>...There were fewer than 21 national and international presentations <i>related to your research </i>within that time frame...The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. <b>Applying the test in <i>Ghosh </i>the Panel is satisfied that this was dishonest.</b>"</blockquote></ol>In a narrative section headed "Other achievements" in the "additional information" section of the application form there were 8 sentences, the fifth of which was "I have produced medical video packages for television which was broadcast internationally on CNN". The charge in relation to this was that it was a dishonest and misleading claim.<br />
<br />
The Panel had before it a letter from CNN dated 29<sup>th</sup> October 2010 which confirmed that [she] "worked as an intern in the medical news department at CNN Atlanta in 1998 and <b>was involved in writing, production and editing of medical news packages produced for CNN Health which were broadcast nationally and internationally." </b><br />
<br />
In their findings after referring to this letter and the application form the Panel went on: </blockquote><ol></ol><blockquote><blockquote>"...The Panel determined that it was not true that you had produced medical video packages for television that were broadcast internationally on CNN. <b>It was not true that you were <i>solely </i>responsible for the production of these packages. </b>You were involved in the production with others as part of your internship. The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. <b>Applying the test in <i>Ghosh</i> the Panel is satisfied that this was dishonest.</b>" [emphasis added] </blockquote></blockquote>The findings of the appeal judge were a little more reasonable:<br />
<blockquote class="tr_bq">The above paragraphs of the judgment were circulated to the parties in draft on 1 November 2011. Counsel are agreed that in the light of their contents there would be no reasonable prospect, in the event of remission of the case to the GMC, of a Panel finding that her fitness to practise is impaired, nor of a warning being issued under section 35D(3) of the Medical Act. Accordingly the finding of impairment, the sanction of suspension and the direction for immediate suspension pursuant to section 38(1) of the Act will also be quashed. <b>The GMC must pay the appellant's costs of the appeal, which have been agreed in the sum of £22,000</b>. </blockquote>What a farce. "Protect, promote and maintain the health and safety of the public" my arse - it's a self-perpetuating and self-interested quango which acts as a tool of the medical and NHS bureaucracy to keep the footsoldiers in line.<br />
<br />
And yet, <a href="http://www.getwokingham.co.uk/news/s/2100153_doctor_back_at_work_despite_breach_of_trust">compare</a>:<br />
<blockquote class="tr_bq">A GUILDFORD doctor who was suspended from medical practice for misconduct last year will be allowed to practise from next month following a case review by the General Medical Council.<br />
Last year, the GMC found that between 1995 and 2003, Stephen Carr-Bains entered into sexual relationships with two of his patients - both of whom were vulnerable and suffering from mental health problems.<br />
<br />
Dr Carr-Bains, who worked for the Guildowns Group Practice at the University of Surrey, got one of his patients pregnant and then helped her to arrange a termination.<br />
Following the abortion, the doctor did not put a letter from the British Pregnancy Advisory Service into the woman's records, failed to make any record of the abortion and did not refer her for post-termination counselling.<br />
<br />
Several years later, in 2005 and 2006, the doctor pressurised the woman not to reveal her relationship with him to her counsellor.<br />
<br />
The 56-year-old GP had sex with the other woman while ‘staying over’ at her university accommodation.</blockquote><a href="http://www.gmc-uk.org/static/documents/content/Bains.pdf">And contrast</a>:<br />
<blockquote class="tr_bq"><br />
The Panel is of the view that you have shown contrition for, and insight into, your actions...the original misconduct took place several years ago in the context of an otherwise unblemished record. Taking into account these matters and all of the public interests at stake, it has, therefore, determined that your fitness to practise is no longer impaired by reason of your misconduct.</blockquote><br />
I will leave a comparison of age and ethnicity to the reader. The GMC is <a href="http://pyjamasinbananas.blogspot.com/2011/05/gmc-is-not-fit-for-purpose.html">not fit for purpose</a>.pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com2tag:blogger.com,1999:blog-8285737581949527996.post-64538476062913081072011-09-29T20:33:00.001+01:002011-09-29T20:33:46.924+01:00Medical students 1 Grumpy old GP 0Lovely <a href="http://www.dailymail.co.uk/health/article-2042184/Theyre-caring-young-GPs-diagnose-toffee.html">rant in the Daily Mail</a> about how these new fangled young doctors 'can't diagnose for toffee'. It contains this gem about tactile vocal fremitus:<br />
<blockquote>If they had pneumonia, and therefore fluid on the lungs, the voice would sound high-pitched, and the vibrations would be reduced. Maybe not infallible, but pretty slick, right</blockquote><br />
Oh dear, we'll leave aside that vocal resonance is a better test, and that you wouldn't test for vocal fremitus if the rest of examination was normal anyway, no, the point here is that the vibrations would be <i>increased</i> in pneumonia!* I'd expect my medical students to know this, let alone a GP. What a clown.<br />
<br />
<br />
<br />
<span style="font-size: x-small;">* Don't give me any obfuscatory crap about a parapneumonic effusion - if that's what he meant that's what he'd have said.</span>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com1tag:blogger.com,1999:blog-8285737581949527996.post-18949848668044775582011-09-27T19:47:00.000+01:002011-09-27T19:47:46.751+01:00Don't trust the mediaWords fail me:<br />
<a href="http://www.pcgamer.com/2011/09/27/itv-documentary-cant-tell-the-difference-between-gaming-and-reality-mistakes-arma-2-for-secret-ira-film/">ITV documentary can’t tell the difference between gaming and reality; mistakes Arma 2 for secret IRA film</a>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com2tag:blogger.com,1999:blog-8285737581949527996.post-9067553566170381892011-08-03T22:03:00.000+01:002011-08-03T22:03:52.947+01:00If wishes were horses...I've talked about animal experimentation before (e.g. <a href="http://pyjamasinbananas.blogspot.com/2007/07/ethics-of-animal-research.html">here</a> and <a href="http://pyjamasinbananas.blogspot.com/2007/08/replacing-animal-experiments.html">here</a>) but I was pointed to <a href="http://www.guardian.co.uk/commentisfree/2011/jul/29/primate-testing-monkeys">this discussion</a> on the Guardian website:<br />
<br />
Dr Sebastien Farnaud of the <a href="http://www.drhadwentrust.org/" title="">Dr Hadwen Trust</a> and Prof Roger Lemon of <a href="http://www.ucl.ac.uk/" title="">UCL</a> debate the ethics and uses of tests on monkeys<br />
<br />
The opening piece by Dr Farnaud contained so many anti-vivisection tropes I was moved to repeat it here (with my comments):<br />
<blockquote>"I thank you very much for giving me the opportunity to start this discussion about a very controversial matter, the validity of the use of non-human primates in medical research, a subject in which, as a medical research charity, the <a href="http://www.drhadwentrust.org/" title="Dr Hadwen Trust">Dr Hadwen Trust</a> is particularly interested."</blockquote>No, the Dr Hadwen Trust was set up <a href="http://www.drhadwentrust.org/about-us/who-we-are">specifically</a> to oppose animal research. <br />
<blockquote>"The first thing to consider is the aim of the <a href="http://www.guardian.co.uk/science/2011/jul/27/research-projects-monkeys-benefit" title="Guardian: One in ten research projects using monkeys has no benefit, finds review">Bateson report</a>, which has just been published, its standpoint and who wrote it.<br />
This report is an independent review commissioned by all the major research funders in the UK, to assess the quality, outputs and impacts of research carried out on non-human primates, and their benefits to human health. This review follows the publication in 2006 of the Weatherall report by a working group chaired by Sir David Weatherall that recommended that the major funding organisations should undertake a systematic review of the outcome of all their research using non-human primates (NHPs) supported over the last decade.<br />
Interestingly, whereas the Weatherall report was unambiguously in favour of the use of NHP in medical research, the Bateson report adopts a more challenging position. Professor Bateson, who is emeritus professor of ethology at Cambridge University and president of the Zoological Society of London, is very well respected within the scientific community.<br />
It is therefore very important that statements in his report, indicating that almost one in 10 research projects that used monkeys in the UK result in no scientific or medical benefit, are not ignored. He also states that the justification for some projects carried out over a 10-year period from 1996 was "inadequate or insufficient" and that future projects involving non-human primates that could not demonstrate plausible medical or social benefits should not be funded."</blockquote><br />
I think only 1:10 experiments showing no scientific or medical benefit is a surprisingly high proportion showing benefit. I'd imagine most scientific research is of minimal use, even medical research, and a figure as high as 90% showing benefit is amazing. Justification for most experiments, when considered outside the narrow question of what people in a particular scientific field think is interesting, is generally poor anyway. So again, I see little to criticise primate experiments over any other area of science.<br />
<blockquote>"The reviewers also reported the unnecessary and unjustified repetition of work published a decade earlier."</blockquote>To be fair, there are plenty of reasons to repeat experiments done a decade earlier, including replicating a study to show that the effect is robust and repeatable, and verifying that you are performing a particular technique correctly by reproducing a know effect so you can then go on to develop that further.<br />
<blockquote>"These points underline that the issue is not simply an ethical issue but also a scientific one. This simply questions the scientific validity of NHP use in medicine."</blockquote><br />
No it doesn't. 10% does not equal 100%.<br />
<blockquote>"The report recommends the promotion and development of alternatives to the use of NHP in research."</blockquote>Well, duh! I imagine 'mom and apple pie' also get a mention.<br />
<blockquote> "Since most diseases studied in NHP are human diseases that do not naturally occur in NHPs, it seems logical to try to develop models which are from the start human-relevant. Here we have to make clear that nobody is proposing we use invasive methods on human subjects. On the other hand, advanced techniques, which were barely mentioned in the Weatherall report, are highlighted in the Bateson report.. These techniques include, for example, magnetoencephalography (MEG) and transcranial magnetic stimulation (TMS), non-invasive imaging techniques that are already in use to help us understand diseases and the needs of patients who suffer from neurological disorders. Organisations such as the Dr Hadwen Trust have promoted and funded these techniques for over a decade."</blockquote><br />
Yeah, because if fMRI doesn't have the anatomical resolution then MEG or TMS are going to do the trick. If wishes were horses... <br />
<blockquote>"One very important point that the report makes concerns regulation. It emphasises the importance of and the need for a robust system of regulation for animal experiments, at a time when the Home Office is preparing the implementation of the new EU directive for the protection of animals used for scientific purposes."</blockquote>Good job UK regulation is the tightest in he world (which is not to say it doesn't focus excessively on process and paperwork rather than welfare). <br />
<blockquote>"To conclude I would say that although this report will not please everybody, I like to believe that it is a first step towards major changes, a different attitude that will challenge the use of NHPs in medical research."</blockquote>Indeed.pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com1tag:blogger.com,1999:blog-8285737581949527996.post-38553476899220343222011-06-01T22:00:00.001+01:002011-06-01T22:17:24.462+01:00FIFA fail<a href="http://www.guardian.co.uk/football/2011/jun/01/fifa-presidential-election-live-blog">Ha ha</a>:<br />
<blockquote>'the head of the Argentinian FA, <a href="http://www.guardian.co.uk/football/2009/oct/18/said-and-done-julio-grondona">Julio Grondona</a>.</blockquote><blockquote>"We always have attacks from England which are mostly lies with the support of journalism which is more busy lying than telling the truth. This upsets and disturbs the FIFA family..." </blockquote><blockquote>In an interview with a German press agency yesterday, Grondona called England "pirates" and added: </blockquote><blockquote>"Yes, I voted for Qatar, because a vote for the US would be like a vote for England. And that is not possible. "But with the English bid I said: Let us be brief. If you give back the Falkland Islands, which belong to us, you will get my vote. They then became sad and left."' </blockquote>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com0tag:blogger.com,1999:blog-8285737581949527996.post-56692087136825528812011-05-31T22:14:00.002+01:002011-05-31T23:00:09.821+01:00Undercover Care: The Abuse ExposedWatch <a href="http://www.bbc.co.uk/news/uk-13548222">this</a> on the BBC: <a href="http://www.bbc.co.uk/programmes/b011pwt6">"Undercover Care: The Abuse Exposed"</a>. And then reflect on the failings of the Care Quality Commission in this case* and whether they could detect or act to investigate any similar case in the future**:<br />
<blockquote>"A specialist residential hospital in Bristol is being investigated by police after secret filming by BBC Panorama found a pattern of serious abuse.<br />
<br />
"During five weeks spent filming undercover, Panorama's reporter captured footage of some of the hospital's most vulnerable patients being repeatedly pinned down, slapped, dragged into showers while fully clothed, taunted and teased.<br />
<br />
"The programme decided to secret film after being approached by a former senior nurse at the hospital who was deeply concerned about the behaviour of some of the support workers caring for patients.<br />
<br />
"Mr Bryan reported his concerns to both management at Winterbourne View and to the government regulator, the Care Quality Commission (CQC) but his complaint was not taken up. <br />
Ian Biggs, regional direction of the CQC for the southwest, said an opportunity to prevent abuse was missed when Mr Bryan's complaints were not investigated."</blockquote><span style="font-size: x-small;">* Headed by the former chief executive of West Midlands strategic health authority (SHA) who <a href="http://pyjamasinbananas.blogspot.com/2011/04/heads-i-win-tails-you-lose.html">presided over</a> the <a href="http://www.hospitaldr.co.uk/features/doctors-and-managers-must-not-forget-the-lessons-of-stafford">Mid Staffordshire scandal</a> lest we forget, so she has relevant expertise in this area!</span><br />
<br />
<span style="font-size: x-small;">** Still, at least the unit concerned probably had policies for <a href="http://northern-doc.blogspot.com/2011/05/bank-holidays-dogs-dentists-and-coming.html">dealing with dog mess</a>, so it can't have been all bad as far as the CQC are concerned. </span>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com2tag:blogger.com,1999:blog-8285737581949527996.post-74145944492663837072011-05-20T19:52:00.001+01:002011-05-20T19:57:19.705+01:00Some free advice on achieving 'world class NHS productivity' McKinsey styleFollowing on from my <a href="http://pyjamasinbananas.blogspot.com/2011/05/mckinsey-save-nhs.html">previous post</a> on McKinsey's recommendations to save money in the NHS, I don't think they've been ambitious enough - where's that blue sky thinking we've come to expect from the cream of Oxford's 20-something PPE graduates?<br />
<br />
As I mentioned before, McKinsey's approach is to list every institution in order of cost/efficiency/whatever and claim that lots of money could be saved if all those 'poor performers' performed at the level of the median. I think this technique can be taken even further, and I'll offer my advice for free!<br />
<br />
The UK spends phenomenal amounts of money per capita on healthcare compared to most countries in the world - using some figures I had leftover from <a href="http://pyjamasinbananas.blogspot.com/2010/10/levelling-spirit-pt-1.html">this</a> <a href="http://pyjamasinbananas.blogspot.com/2010/10/levelling-spirit-pt-15.html">set</a> <a href="http://pyjamasinbananas.blogspot.com/2010/10/levelling-spirit-pt-175.html">of</a> <a href="http://pyjamasinbananas.blogspot.com/2010/10/levelling-spirit-pt-2.html">posts</a> on 'The Spirit Level' - we can see that in 2006 the UK spent some $2.5k per capita on healthcare compared to a world median of around $200! That's a potential saving of over £80bn! <br />
<br />
What is that you say, other countries don't necessarily have great healthcare from that $200? Well McKinsey don't deal in trifles like cost-effectiveness and health outcomes, but I suppose I can stretch to looking at that if you insist - I like to think all those years at university were good for something. Using that leftover data I was talking about above we can see what sort of return you get for $200 versus $2.5k. Below is a figure plotting data for life expectancy (in 2007) versus health expenditure per capita (in 2006):<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-ioez1hHKsGA/TdawQWzpj9I/AAAAAAAAAQo/9MkoeFCbvwU/s1600/healthexp.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="357" src="http://3.bp.blogspot.com/-ioez1hHKsGA/TdawQWzpj9I/AAAAAAAAAQo/9MkoeFCbvwU/s400/healthexp.jpg" width="400" /></a></div>I've fitted a regression line (which is logarithmic to better reflect the shape of the data). At $2434 the UK gets a life expectancy of 79yrs (versus the predicted 81yrs) while the median spend of $218 would predict a life expectancy of 69yrs (versus a median world life expectancy of 72yrs) - countries spending around $200 include Venezuala (74yrs), Malaysia (74yrs), Kazakhstan (65yrs), Thailand (69yrs), Tunisia (74yrs), Tonga (72yrs), Gabon (60yrs), Fiji (69yrs), Guyana (67yrs), Equatorial Guinea (50yrs), Namibia (60yrs), and Swaziland (45yrs).<br />
<br />
So there you go, save £80bn and 'cut the deficit' or bail out the banks, and it'll only cost you a predicted loss of 10yrs in life expectancy - good value I'm sure you'll agree. No? Maybe that's a bit too radical for you, but there's another approach we could take - look at that figure above again, doesn't seem like you get much of a return for you investment when your expenditure goes past around $1.5k per capita (where the graph flattens out) does it? If we cut our expenditure to $1.5k per capita we would predict a life expectancy of 78yrs and save £36n - thats a reduction of life expectancy of 1-3yrs for billions saved, an absolute billy bargain!.*<br />
<br />
So basically I cannot see how nearly halving UK health expenditure could possibly have any down sides - I've proved it with numbers and graphs and everything! I wonder if McKinsey are recruiting? <br />
<br />
<br />
<span style="font-size: x-small;"><br />
</span><br />
<span style="font-size: x-small;">* If you think this proposal is a joke, consider that it is the natural consequence of the putatively 'progressive' reasoning used in 'The Spirit Level' that increased health expenditure has no beneficial effect on health outcomes like life expectancy for richer countries such as the UK (<a href="http://pyjamasinbananas.blogspot.com/2010/10/levelling-spirit-pt-1.html">I disagree</a>) - no wonder David Cameron <a href="http://www.conservatives.com/News/Speeches/2009/11/David_Cameron_The_Big_Society.aspx">likes it</a>.</span>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com5tag:blogger.com,1999:blog-8285737581949527996.post-22821871807902631792011-05-19T21:32:00.002+01:002011-05-19T21:42:15.012+01:00McKinsey save the NHS<b><span style="font-size: large;">McKinsey in shock discovery that if you put things in numerical order half of them will fall below the median. What tautology will they demonstrate next?</span></b><br />
<br />
Via DNUK again - here's a <a href="http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_116521.pdf">terrifying presentation</a> from McKinsey*:<br />
<blockquote><br />
In February 2009 McKinsey was instructed by the Department to provide advice on how<br />
commissioners might achieve world class NHS productivity to inform the second year of the<br />
world class commissioning assurance system and future commissioner development. The<br />
advice from McKinsey, in the form of the following slides, was provided in March 2009.</blockquote><br />
I recommend having a detailed read to see what a bunch of 20-something Oxford graduates with no experience of the health service can come up with. Basically if everything was done cheaper and more efficiently it'd all be fine - who'd have thought?<br />
<br />
In slide 17 we see how if we just reduced all clinical staffing levels to the median we could save a few billion - no mention of whether staffing levels have an effect on <i>quality</i> of care (another <a href="http://pyjamasinbananas.blogspot.com/2011/01/care-clusters-race-to-bottom.html">race to the bottom</a>) - indeed they later go on to argue against any attempts to ensure minimum staffing ratios:<br />
<blockquote>"Some Royal Colleges are recommending introduction of mandatory staffing ratios on safety<br />
grounds that will lead to increases in staff required above the activity growth e.g ratio of<br />
1/28 per midwife </blockquote><blockquote><br />
Certain service reviews are also recommending more staff is required e.g. stroke, children"</blockquote><br />
But they argue we should "Limit introduction of mandatory staffing ratios" to save money - they can't be arguing for minimum staffing ratios for any reason, I'm sure it'll all be fine.<br />
<br />
Highlights include slide 28 where they show how you could cut 'bed days' by 10% in mental health if only length of stay could be reduced to the median in the poor performers. I wonder whether those trusts with longer lengths of stays admit more severe patients and don't admit less severe patients, perhaps managing them in the community, and thus have already saved money over the other providers who are admitting less severe patients but getting lower average lengths of stay? Well I'm afraid McKinsey can't tell us because they are analysing data in the same way you would expect someone who has no idea of the context and a money-making axe to grind to do.<br />
<br />
Presumably we could save money by abolishing all those specialist tertiary and quaternary hospitals with their high risk procedures because DGHs get better results for the same procedures. If only these specialist centres could be as good as those small local hospitals, the difference in performance couldn't possibly be because all the really difficult ones get sent to the specialist centres - how are we supposed to show that on our pie charts? <br />
<br />
On slide 53 we can see some of the "procedures with limited clinical benefit" which are "relatively ineffective" or "potentially cosmetic" that we can 'de-commission' to save nearly £1 billion. Femoral hernia repair for instance, as someone on DNUK points out, the risk of strangulation is 45% at 21months in a femoral hernia, this is not a 'cosmetic' procedure!<br />
<br />
A particular highlight is slide 60 where we find out that US physicians who do imaging (e.g. x-rays) in their offices do more investigations than those who need to refer to a radiologist. Presumably this means that we are going to massively increase the training places and consultant jobs for radiologists so we can save a few quid on chest x-rays by running each request past a radiologist first?<br />
<br />
On slide 64 we can see that as digoxin in heart failure doesn't increase life expectancy only improve symptoms we shouldn't fund it at all. Move over NICE and the controversial QALY, if it doesn't stop you dying it isn't worth a penny.<br />
<br />
As someone on DNUK points out, all their reasoning is based on using publicly available data to rank everyone, and then claim that £X million can be saved by making the 'worst performers' as good as the best performers. Conceptually difficult ideas such as figuring out if the factors making worse performers are actually amenable to intervention (e.g. you aren't going to make the people in rural areas all close together and nice and efficient for home visits like in a city however many graphs you draw) are just so much irrelevant detail.<br />
<br />
I wonder how much we could have saved by getting some people who know what they're talking about to do a review instead of McKinsey and their one-size-fits-all Panglossian musings? <br />
<br />
<span style="font-size: x-small;">* This isn't new, for instance, the Ferret Fancier <a href="http://ferretfancier.blogspot.com/2010/08/mckinsey-extremely-expensive-rubbish.html">reported on it last year</a>, but I think it is timely to revisit what facile idea people like this (yes Lansley, I'm looking at you)have about 'reforming' the NHS.</span>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com4tag:blogger.com,1999:blog-8285737581949527996.post-88430742010834819492011-05-08T15:39:00.001+01:002011-05-08T15:44:33.416+01:00NostalgiaFrom BBC 4 - <i><a href="http://www.bbc.co.uk/i/b010w8t0/">'Movin' On Up: Pop Hits from 1991'</a></i> - a look at the early nineties Indie/Dance crossover scene. I have a particular weakness for 'Can You Dig It?' by the Mock Turtles.pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com0tag:blogger.com,1999:blog-8285737581949527996.post-76301016944728071132011-05-06T12:56:00.001+01:002011-05-07T00:47:21.829+01:00The GMC is not fit for purposeVia Doctors.net.uk (DNUK, the site where doctors go to bitch) I came across <a href="http://www.dailyecho.co.uk/news/8675714.Doctor__tried_to_sell_parking_permit_/">this story</a>: <br />
<blockquote>"A YOUNG doctor who tried to sell her staff pass for free hospital parking can only work as a medic again under strict conditions, watchdogs have ruled.</blockquote><blockquote>"...a foundation year doctor, put her free permit to park at Southampton General Hospital up for sale for £5 on the website Gumtree, the Fitness to Practise Panel of the General Medical Council (GMC) was told. </blockquote><blockquote>NHS fraud investigators found out she later claimed a senior colleague made a sexual advance in exchange for ''looking more favourably'' on the problem.</blockquote><blockquote>"During the meeting, on October 14, 2008, Dr White alleged she was firstly warned she could get the sack by her employers, the Southampton University Hospital NHS Trust. <br />
<br />
"But the more senior colleague is then alleged to have gone on to say: ''I can ensure that the trust looks on your case more favourably'' and put his hand on her knee before adding: ''What will you do for me?'' </blockquote><blockquote>But Brian McCluggage, counsel for the GMC, told the hearing in Manchester the allegation had ''no basis'' and was a ''defence mechanism'' to counteract her difficulty over the parking permit. <br />
The doctor, who is in her 20s and qualified after completing her medical degree at the University of London in 2007, was not present or legally represented at the hearing. </blockquote><blockquote>She was also accused of breaking a ban on her entering the hospital and failing to attend an examination by a psychiatrist as requested by the GMC." </blockquote>Now obviously what she did was naughty - you shouldn't be selling your free parking permit, even for just £5, but this is a trivial matter that should have been dealt with between employee and employer with a slap on the wrist. This is the consensus amongst the DNUK commenters.<br />
<br />
So what are we to make of her claim that she was sexually propositioned by her educational supervisor? Most of the senior doctors on DNUK think this is highly unlikely and agree with the GMC that this is probably a "defence mechanism". Well I am not so sure. Medicine is stuck in some kind of 1950s time warp where casual racism, sexism, and sexual innuendo are commonplace. Many female junior doctors of my acquaintance have been sexually propositioned by senior doctors (usually their clinical or educational supervisors) and several have been offered inducements (e.g. authorship on publications or attendance at conferences). Even I've been questioned about my sexuality by a consultant on a ward round in front of patients. <br />
<br />
The GMC is commonly used as a tool by hospital trusts and senior doctors to keep juniors in line (paying over £400/yr for the privilege) - how many employees making an allegation of sexual harassment against a senior work colleague are required to to attend a psychiatric evaluation? It wouldn't be possible if this was a simple employer-employee industrial dispute where this kind of punitive action would be illegal, but is just fine when it becomes a 'fitness to practice' issue. <br />
<br />
But <a href="http://www.liverpooldailypost.co.uk/liverpool-news/regional-news/2009/06/11/doctor-with-child-porn-conviction-working-at-chester-hospital-92534-23841759/">compare and contrast</a>:<br />
<blockquote>"...had all restrictions lifted on his ability to practise after a General Medical Council panel reviewed his case.<br />
<br />
"The former Royal Navy surgeon was convicted at Manchester Crown Court in 2003 of making indecent photographs of children, ordered to sign the sex offenders’ register for five years and given an 18-month community rehabilitation order."</blockquote>Or <a href="http://www.shropshirestar.com/news/2010/05/07/tears-as-doctor-is-cleared/">here</a>:<br />
<blockquote>"...admitted making inaccurate records after the operation and was slammed by the GMC panel yesterday for “significant departures from good medical practice”. </blockquote><blockquote><br />
The panel cleared him, however, of serious misconduct and found that his fitness to practise was not impaired. </blockquote><blockquote>The panel also decided against issuing the surgeon with a warning."</blockquote>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com5tag:blogger.com,1999:blog-8285737581949527996.post-43945089245012121042011-04-29T19:57:00.001+01:002011-04-29T19:59:52.212+01:00Liar, liar, pants on fire!Via <a href="http://drgrumble.blogspot.com/2011/04/grumble-and-cameron-are-as-one.html">Dr Grumble</a>:<br />
<br />
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<br />
Addressing the Royal College of Nursing conference in 2009 <a href="http://www.newstatesman.com/blogs/the-staggers/2011/04/royal-college-opposition">according to the New Statesman</a>.pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com1tag:blogger.com,1999:blog-8285737581949527996.post-35982159774808804482011-04-20T21:10:00.000+01:002011-04-20T21:10:09.982+01:00'Efficiency' is in the eye of the beholder<a href="http://www.guardian.co.uk/healthcare-network/2011/apr/20/long-term-condtions-nhs-threat-john-oldham">From the Guardian</a>:<br />
<blockquote>One of the big debates around the NHS is whether its budget should be allowed to grow in line with "healthcare inflation", a rate above the national standard that factors in people living longer and demanding more from the service. But Sir John Oldham, the Department of Health's national clinical lead on quality and productivity, has little time for the argument.<br />
"It's a cop out, is my response," he says. "The challenge we face is one we can't face by doing things as we do now. <br />
"When people give that challenge to me in a room of clinicians, I ask them each to write down, if they can, one or two things in the last week, in their personal day-to-day <a href="http://www.guardian.co.uk/public-leaders-network/front-line" title="More from guardian.co.uk on Frontline">frontline</a> experience, with a waste. And I have never walked out of a room without everybody being able to put something down."<br />
This view is popular with government ministers, who are increasing <a href="http://www.guardian.co.uk/healthcare-network/england" title="More from guardian.co.uk on England">England</a>'s NHS budget by normal inflation and trying to obtain £20bn of annual savings through the Quality, Innovation, Productivity and Prevention (Qipp) programme. It is less popular with many staff and unions, who believe that Qipp means cuts. </blockquote>Unfortunately it isn't these frontline clinicians who get to make the savings, its the managers and bureaucrats and the only way they know to save money is to sack people, they have no idea what is going on at the frontline. This is the absolutely best part of the article:<br />
<blockquote>All of this would add up to a shift in care for long term conditions equivalent to that which started in <a href="http://www.guardian.co.uk/healthcare-network/mental-health" title="More from guardian.co.uk on Mental health">mental health</a> a quarter of a century ago, when patients went from institutions to care in the community. He says there are already examples of the openness to change required, <a href="http://www.tewv.nhs.uk/Trust-News/News/National-recognition-for-mental-health-trust/">such as Tyne, Wear and Esk Valleys mental health foundation trust, which has trained nearly 50 of its staff in use of the Kaizen method for continuous improvement</a>. This involves often simple changes, but made promptly: for example, <b>after staff noticed that nurses were clustering at a station rather than walking around their wards, the trust removed the station the same night.</b><i> (my emphasis)</i><b><br />
</b></blockquote>Hah, as a doctor I've already had my office taken away (an office for some six doctors or more) and given to one modern matron to twiddle her thumbs and drink her coffee in (I now have to use the nurses' station), so I'm well aware what a massive time wasting pain in the arse it is to have some moron take away your desk space which you need to complete the tedious reams of paperwork the NHS now requires. Nice efficiency saving geniuses, maybe you could ask why they were all clustering at the nurses' station, probably all filling out the mandatory risk assessment and care plans that are now required for all patients.pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com0tag:blogger.com,1999:blog-8285737581949527996.post-72715860834686077222011-04-18T19:54:00.000+01:002011-04-18T19:54:13.969+01:00Heads I win, tails you loseI just learned today that the head of the Care Quality Commission (the health and social care services regulator) is the <a href="http://www.guardian.co.uk/society/2009/apr/01/health-social-care-regulator-bower">former chief executive of West Midlands strategic health authority (SHA)</a> on whose watch the Mid Staffordshire affair occurred.<br />
<br />
I suppose you can look at that in two ways, either it is a tacit admission that regulatory authorities cannot be expected to know what is really going on in the organisation they supervise and so bear no culpability for their failings, or, it shows how catastrophic failure is absolutely no bar to career progression for NHS bureaucrats because they take no responsibility for the direct clinical failings of their administrative decisions - heaping all the responsibility onto the front line staff because they can always hide behind the claim that ultimately everything is a 'clinical decision'*.<br />
<br />
<br />
<span style="font-size: x-small;">* I'll reproduce a comment I made on <a href="http://neuroskeptic.blogspot.com/2011/04/bbc-something-happened-for-some-reason.html">Neuroskeptic's blog</a>:</span><br />
<br />
<span style="font-size: x-small;">"I love <a href="http://www.bbc.co.uk/news/business-13016936">this quote</a>:<br />
<br />
<i>"The Department of Health insists that although Primary Care Trusts can issue guidelines on the amount of drugs GPs prescribe, it is up to the individual GP whether he or she wants to follow them.<br />
<br />
"Hazel's Primary Care Trust, NHS Enfield, admits it changed its guidance to GPs in January but insists doctors were not obliged to follow it."</i><br />
<br />
Classic administrator response - they will relentlessly hound the GPs who don't follow their guidance to reduce script length yet when they're called out on the negative consequences of their decision they basically say it is all down to the GP and not their fault.<br />
<br />
I'm seeing this behaviour more and more in the NHS - bean counters and other non-clinical staff make decisions that directly affect patient care, usually without any clinical input, and then when the shit hits the fan they blame the clinicians because, after all, they're the ones with clinical responsibility (but no power).<br />
<br />
Heads I win, tails you lose." </span>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com2tag:blogger.com,1999:blog-8285737581949527996.post-15108061591706211762011-04-18T19:36:00.000+01:002011-04-18T19:36:23.568+01:00Not the best doctor in the worldNow I may not be the best doctor in the world, but I'm pretty sure I can distinguish PEA from VF - you'd think a forensic pathologist would be able to if they're going to <a href="http://www.guardian.co.uk/uk/blog/2011/apr/18/ian-tomlinson-live-updates">declare VF arrest the cause of death</a>:<br />
<br />
<blockquote>"<strong>Dr Freddy Patel, the first to conduct a post mortem on Tomlinson's body, said the 47-year-old died of a spontaneous arrhythmic heart attack.</strong> <br />
Patel reached that conclusion through a "process of elimination" after being unable to find the source of internal bleeding into Tomlinson's abdomen.<br />
</blockquote><blockquote>"When Tomlinson collapsed,<a href="http://www.guardian.co.uk/uk/blog/2011/apr/14/ian-tomlinson-inquest-live-updates#block-10"> paramedics and, later, an ambulance worker, connected him to a defibrillator</a>. This gave ECG (electrocardiogram) readings (picture the zigzag lines you see on a beeping heartbeat screen).<br />
Patel's view was that Tomlinson died of an spontaneous arrhythmic heart attack, caused by "ventricular fibrillation" (a fast, irregular wobble of the heart). <br />
Patel conceded that he was not an expert, but said the ECG readings showed at times "chaotic" activity in the heart, which he said supported his theory. <br />
The paramedic ECG charts showed Tomlinson had something called "pulseless electrical activity" – meaning electrical activity in the heart, with no pulse and no beating heart[*].<br />
Another expert, <strong>Professor Kevin Channer</strong>, from the Royal Hallamshire Hospital in Sheffield, has produced a report on Tomlinson's ECG chart readings.<br />
<strong>He found the ECG readings showed normal activity. Crucially though, Channer said that pulseless electrical activity was inconsistent with ventricular fibrillation (the type of heart attack Tomlinson was said to have died from)</strong>."</blockquote><br />
<span style="font-size: x-small;">* This isn't true, PEA means there is 'normal' electrical activity and no pulse - the heart may still be beating but not pumping around enough blood to give a pulse, this could be due, for example, to loss of blood from massive internal bleeding.</span>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com2tag:blogger.com,1999:blog-8285737581949527996.post-79400517411272622422011-04-13T21:54:00.001+01:002011-04-13T21:59:50.085+01:00Nurses have more balls than doctorsThe RCN is usually a pretty spineless union but<a href="http://www.rcn.org.uk/newsevents/congress/congress_2011/congress_2011_agenda/27e._nhs_reforms"> they've shown more balls</a> than <a href="http://www.pulsetoday.co.uk/story.asp?storycode=4128846">the BMA</a>:<br />
<blockquote><h3>...this meeting of the RCN Congress, in the light of Anne Milton's Congress address, has no confidence in Andrew Lansley's management of this Coalition Government's NHS reforms</h3><h3>Result</h3>For: 98.76% (478)<br />
Against: 1.24% (6)<br />
Abstain: (13)</blockquote><h3></h3>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com1tag:blogger.com,1999:blog-8285737581949527996.post-61053495613489912582011-04-12T11:16:00.000+01:002011-04-12T11:16:08.750+01:00Scaring women - easy, profitable, and fun<a href="http://www.telegraph.co.uk/health/healthnews/8441176/Glass-or-two-of-wine-a-week-could-damage-baby.html">According to the Telegraph</a>:<br />
<blockquote>"Researchers say there might be no safe limit for the amount of alcohol a pregnant woman can drink without endangering her unborn child<br />
<br />
"However, now researchers in Ireland have found evidence that women who drink up to five units a week, equivalent to two 175ml glasses of red wine, could be putting their children at risk of fetal alcohol syndrome.<br />
<br />
"The study found three cases of fetal alcohol syndrome "one each in the low, moderate and high consumption groups". The fact there was one in the low alcohol consumption group led the researchers to question the theory that light drinking had no effect on a baby's health."</blockquote><br />
Well <a href="http://www.biomedcentral.com/1471-2393/11/27/abstract">this is the paper</a>, in <i>BMC Pregnancy and Childbirth</i>, the abstract sums it up pretty well:<br />
<blockquote>"A cohort study of 61,241 women who booked for antenatal care and delivered in a large urban maternity hospital between 2000 and 2007. Self-reported alcohol consumption at the booking visit was categorised as low (0-5 units per week), moderate (6-20 units per week) and high (> 20 units per week).<br />
<br />
"Of the 81% of women who reported alcohol consumption during the peri-conceptional period, 71% reported low intake, 9.9% moderate intake and 0.2% high intake.<br />
<br />
"High consumption was associated with very preterm birth (< 32 weeks gestation) even after controlling for socio-demographic factors adjusted OR 3.15 (95% CI 1.26-7.88). Only three cases of Fetal Alcohol Syndrome were recorded (0.05 per 1000 total births), one each in the low, moderate and high consumption groups."</blockquote>If we assume all births were single babies (since most will be, and the twins and higher number births will not affect the numbers much) that's rates of foetal alcohol syndrome (FAS) of .0023%, .016%, and .82% in the low, moderate, and high risk groups respectively. That gives a relative risk of FAS in the high alcohol consumption group of over 300x the low consumption group.<br />
<br />
Interestingly the overall FAS rate in the study is 1/10th of the usual estimated rate, probably because this was only those infants detected in the baby check in hospital. So, in conclusion, there were only 3 cases of FAS in this study which is both very low, and also too small to really draw too many conclusions. Any claim about low alcohol consumption causing FAS is basically a case report of one child that occurred with a rate of .0023%.<br />
<br />
Importantly, we have to remember that FAS is believed to be due to heavy drinking throughout pregnancy, and the study did not record this, only alcohol consumption early in pregnancy. If the mother of the FAS child in the low alcohol group was under-reporting her alcohol consumption or went on to drink more heavily throughout pregnancy we have no evidence for a risk of FAS in low alcohol consumption in this study.<br />
<br />
So did the authors really cause such an unnecessary scare by claiming that low alcohol consumption causes FAS as the Telegraph reports? Well here they are in the paper:<br />
<blockquote>"This suggests that the mothers of the first two infants [the low and moderate alcohol consumption cases of FAS] may have under-reported their alcohol intake at the time of booking as <b>FAS is unlikely to occur at lower levels of alcohol intake</b>" [my emphasis]</blockquote>Apparently not. So just another PR/journalist manufactured scare because worrying women about pregnancy, childbirth, and child rearing is easy, profitable, and fun.pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com3tag:blogger.com,1999:blog-8285737581949527996.post-30012489715740994572011-04-10T12:53:00.000+01:002011-04-10T12:53:35.803+01:00Read: 'The Plot Against the NHS'Read <a href="http://www.opendemocracy.net/ourkingdom/colin-leys/plot-against-nhs"><i>The Plot Against the NHS</i></a> which rather nicely details the progressive and deliberate destruction of the NHS under Labour and now the Tories:<br />
<blockquote>Prices will rise. On the one hand, the cross-subsidisation that is practised inside NHS hospitals will come to an end as the less costly activities are taken out of them, forcing them to charge more for what remains. On the other hand, Monitor will have to ensure that prices are set so that all providers make a profit. To keep the NHS budget down, what is covered by the NHS will decrease. More and more treatments will be ‘decommissioned’ and will become ‘extras’, which you can have if pay for them. This is already happening in one particular way, thanks to another New Labour measure – personal budgets, or lump sums given to patients with chronic illnesses to buy their own care with. If you want more care than the lump sum will cover you can pay for more, if you can afford it. Inequality in health care will be restored. </blockquote>If you were to ask me how I thought the NHS could be improved one of the things I would emphasise is that a <a href="http://pyjamasinbananas.blogspot.com/2011/03/fundamental-priority-of-national-health.html">fundamental priority</a> is to ensure that people brought into hospital as emergencies are treated quickly and effectively - and this means moving away from a 9-5 culture (plus massively scaled down 'on-call' emergency staffing) towards 24hr care where consultant review and radiological investigations don't keep office hours.<br />
<br />
However, government has never been very interested in emergency care, preferring to focus on the 9-5 routine elective operations because they are easy to count and put a price on - paying hospitals fixed tariffs for these. This emphasis has been such that most general hospitals are subsidising their emergency care with routine work like elective surgery or outpatient clinics. After all, it takes a huge number of doctors, nurses, and allied staff to provide even the scaled down 24hr emergency care we have now - getting some money back from this necessary excess capacity by providing elective care is paramount to make ends meet when the remuneration for the emergency care itself doesn't cover the costs.<br />
<br />
Unfortunately the new model of health care, initiated under Labour, and now brought forward by the Tories, envisages that everything will be broken down into its constituent parts and tendered for by various private providers. The <i>Independent Sector Treatment Centres</i> were the start of this - and since elective work is subsidising the huge fixed costs of emergency care there is obviously profit to be made for those who agree to take the routine elective work but don't have the same emergency care commitments. If your patients get complications after your elective surgery and you can just ship them to an NHS hospital ITU without having to cover the cost of that care from the fixed tariff paid for that operation how can you fail to be making a profit over and above the NHS?<br />
<br />
But providing A+E services and receiving unselected acutely ill patients needs more than just A+E staff, it needs the back up of general medics, general surgeons, orthopaedic surgeons, anaesthetists, paediatricians, gynaecologists, radiologists, physiotherapists, ward nurses etc so that once A&E have stabilised and triaged them someone else can actually treat them. That means, at a minimum, all the services of your average District General Hospital - you cannot hive off A&E as an isolated service.<br />
<br />
So what will happen as the DGH revenue streams begin to dry up as more and more of the easy and profitable work is taken over by the private sector? Well since every hospital will now be part of a Foundation Trust they will either have to save money or go bust. Saving money entails cutting services below the already bare bones one we have now - probably a return to the trolleys-in-corridors NHS of the last Tory government - and the rationalisation of services to fewer and fewer centres*.<br />
<br />
Competition isn't going to improve emergency medical care because there can be no market in it - already it is run at a loss because NHS hospitals can cross-subsidise from other revenue streams - they do this because they aren't run to make a profit, they are still, despite <i>Payment By Results</i> and other market 'reforms', trying to deliver good healthcare to the local population. When the NHS becomes just a franchise for private companies to compete for provision it will remain a monopoly provider of local emergency care (if you can't financially sustain one local A+E you're hardly going to open a competing one) so the best the market can deliver is a private company taking over the running of that A+E. But since they won't be able to cross-subsidise emergency care anymore - because other companies will already have cherry-picked the profitable elective work - there will be less money available and standards will have to fall.<br />
<br />
We are moving inevitably to a two-tier NHS where private companies cream off large profits from over inflated centrally determined tariffs for simple elective services like outpatient work and routine operations while complex and difficult or emergency care is provided by an under-resourced remnant of the old public system.<br />
<br />
<br />
<span style="font-size: x-small;">* For some services, like complex poly-trauma, a rationalisation to fewer centres would improve outcomes as more specialist teams have better results - but this would only be a fortuitous unintended consequence under the Tory plans, and for many other conditions which require less super-specialist provision the extra travel time is likely to prove detrimental.</span>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com2tag:blogger.com,1999:blog-8285737581949527996.post-21979970064894165232011-04-08T19:54:00.000+01:002011-04-08T19:54:00.406+01:00More illness = Good practice<span id="PostList">I have had my attention drawn to <a href="http://www.pulsetoday.co.uk/Journals/Medical/Pulse/2011_April_06/attachments/Appendix%201%20Pan%20London%20Outcome%20Standards%20and%20Technical%20Guidance.pdf">this remarkable document</a> distributed to all GP practices in London:</span><br />
<br />
<i><span id="PostList">An Introduction to a Pan London Approach to Improve Quality, Access and Patient Experience in General Practice</span></i><br />
<span id="PostList"><br />
</span><span id="PostList"></span><br />
<span id="PostList">It includes all manner of cunning wheezes to improve General Practice in London. On particular piece of genius includes using predicted* versus the actual GP reported prevalence of various diseases as <i>"an indicator of general practice performance"</i>:</span><br />
<blockquote><span id="PostList">Organisations in the top quartile ranking within London are examples of good practice. Monitoring, intervention and support would be required for those organisations within the bottom quartile ranking in London. Monitoring and support would be beneficial for those organisations within the mid quartiles within London.</span></blockquote><span id="PostList"></span><span id="PostList">That's right. If you are fortunate enough to have a population with a lower than predicted rate of an illness then you will be judged to be an example of <i>bad practice</i> and <i>failing</i>. But if you happen to have higher rates of illness for some reason, then well done you, you're an example of <i>"good practice"</i>!</span><br />
<span id="PostList"><br />
</span><br />
<span id="PostList">Now I'm no epidemiologist but population level models like this cannot be used to accurately predict the prevalence of disease at a local level** - to tell you what the <i>real</i> burden of disease is that those crappy GPs are failing to detect. A five variable* regression model does not capture all the variation in human disease however much you want it to. </span><span id="PostList">The tail is wagging the dog here.</span><br />
<span id="PostList"><br />
</span><br />
<span id="PostList"></span><br />
<br />
<span style="font-size: x-small;"><span id="PostList">* "Expected prevalence data are derived using expected prevalence rates provided by ERPHO which take account of age, sex, ethnicity, smoking status and deprivation score at practice level."</span></span><br />
<br />
<span style="font-size: x-small;"><span id="PostList">** They are based, of course, on taking all that local level data and then finding a best fit line between all the real data points - you can't then go back and say that those data points that don't lie on the line are now <i>wrong</i>. What kind of statistically illiterate fool came up with this idea? </span></span>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com0tag:blogger.com,1999:blog-8285737581949527996.post-19577474071613545142011-04-07T21:34:00.000+01:002011-04-07T21:34:14.677+01:00Administrators take over the asylumI went to visit one of the low level administrators in my trust today. For reasons that are not entirely clear to me she has swipe card access to all clinical areas of the trust including secure units and happily uses it to turn up at inopportune times to bother people (much to the chagrin of the nurses).<br />
<br />
I went to visit her today for a dull administrative reason, turns out trust policy states that doctors aren't allowed access to the administration corridor - we have to ring the person we're visiting and have them let us in.<br />
<br />
Somehow I'm trusted with access to all clinical areas in the local general medical trust (who I don't even work for) such that I could just stroll into the ITU or paediatric ward, yet my own trust won't even let me in to see the woman who arranges leave. They truly have taken over the asylum.pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com1tag:blogger.com,1999:blog-8285737581949527996.post-53691493570512215092011-04-03T11:28:00.000+01:002011-04-03T11:28:00.309+01:00Hyperinjunctions - because not talking about something makes it disappearAs <a href="http://www.telegraph.co.uk/news/uknews/law-and-order/8394566/Hyper-injunction-stops-you-talking-to-MP.html">explained in the Telegraph</a> - our wonderful legal system has a new concept - the hyperinjunction - not the superinjunction where a story can not only not be reported but also the fact that there is an injunction cannot be reported either - this is the next step:<br />
<blockquote><div class="thirdPar"> ...John Hemming, a Liberal Democrat MP, disclosed details of one on the floor of the Commons last week. </div></blockquote><blockquote><div class="thirdPar"> <br />
The hyper-injunction goes a step further. Mr Hemming told the Commons that the order, which was obtained at the High Court in 2006, prevents an individual from saying that paint used in water tanks on passenger ships could break down and release potentially toxic chemicals. </div></blockquote><blockquote><div class="fourthPar"> It specifically bars the person from discussing the case with "members of Parliament, journalists and lawyers", along with the US coastguard and any ship owners, and also forbids any speculation linking chemicals in the paint with the illness of any individuals. </div></blockquote><div class="fifthPar"> <blockquote> It says: "The defendant must not communicate to the third parties any speculation that the illness of any individual (including without limitation the collapse of H) was, has been or will be brought out by the chemical composition or the chemicals present in the coating of the potable water tanks." </blockquote><blockquote>According to Mr Hemming, the individual was given a two-week suspended sentence after talking to a lawyer about whether he would take up the case on a no-win, no-fee basis. Mr Hemming said: "What we have, therefore, is passenger vessels trundling around the world with potentially toxic substances being released into the tanks. One of those who worked on the tanks collapsed as a result. </blockquote>Now it may well not be true a true allegation about the paint - but I'm not sure that judges are the ones who should be quashing these things without any public scrutiny - and they certainly shouldn't be able to prevent people getting legal advice after they're granted.</div>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com0tag:blogger.com,1999:blog-8285737581949527996.post-74504290903482792722011-04-02T15:05:00.002+01:002011-04-02T15:07:59.986+01:00Herbal medicines - because the government thinks you're stupidDavid Colquhoun asks <a href="http://www.dcscience.net/?p=4269">"Why does the MHRA refuse to label herbal products honestly?" </a><br />
<br />
Basically the EU regulations state that you must have the following on the label of a herbal remedy:<br />
<blockquote>"Traditional herbal medicinal product for use in [insert baseless medical claim here] exclusively based upon long-standing use."</blockquote><br />
And you also get a lovely little kitemark to show that the MHRA has approved your drug:<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-EFGOx1Dd6Bw/TZcq6eIaXEI/AAAAAAAAAQk/jLvyM9tgb7g/s1600/thr.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="196" src="http://2.bp.blogspot.com/-EFGOx1Dd6Bw/TZcq6eIaXEI/AAAAAAAAAQk/jLvyM9tgb7g/s200/thr.jpg" width="200" /></a></div><br />
They might be broadly safe and manufactured to certain minimum standards but the MHRA refuse to have any requirement to mention on the label that there isn't actually any evidence that this or that herbal remedy can do what the label claims, or even to mention that the evidence shows that it doesn't work at all. And then they boast about how:<br />
<blockquote>"The growth of the THR scheme means that consumers will have access to a wide choice of over-the-counter herbal medicines made to assured standards.<br />
<br />
"The current signs are that the market will be lively and competitive. The key difference for consumers is that in future they will be in the driving seat and <b><span style="font-weight: normal;">able to make an informed choice</span> </b>when they wish to use these medicines."</blockquote>This government (and the last one) and the MHRA think you're stupid. They don't want you to know that these herbal drugs don't work because then you might not buy them. And that would upset their friends in the multibillion pound herbal supplement industry. Because ensuring a 'lively and competitive' market in useless drugs is more important than having a <i>real</i> informed choice. It's just the same story at home as selling useless <a href="http://pyjamasinbananas.blogspot.com/2011/01/britain-leading-world-in-fake-explosive.html">dowsing rods as explosive detectors abroad</a>. <br />
<blockquote></blockquote>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com2tag:blogger.com,1999:blog-8285737581949527996.post-36227152263691380182011-03-29T20:07:00.000+01:002011-03-29T20:07:32.826+01:00NHS reform mythsRichard Blogger of the <a href="http://torylies.blogspot.com/">torylies blog</a> has a good site addressing some of the <a href="https://sites.google.com/site/nhsfuture/Home/debunking-the-myths">'myths'</a> around the 'reform' of the NHS, here's an excerpt from <a href="https://sites.google.com/site/nhsfuture/Home/debunking-the-myths/myth-10"><i>Myth 10: Private providers will just cherry-pick the easiest cases, undercutting the NHS</i></a>: <br />
<blockquote><b>The Government's Claim:</b><br />
<br />
<br />
<div style="border: 1.5pt solid windowtext; padding: 1pt 4pt;">The less complex the procedure, the less someone – including in the private sector – will be paid. Unlike Labour, we will not rig the market in favour of the private sector.</div><br />
<b>The Rebuttal</b><br />
<div><i> </i></div><div><i>"The less complex the procedure, the less someone – including in the private sector – will be paid"</i></div><div><br />
</div>This shows a stunning lack of understanding about how <i>Payment by Results</i> works. Each procedure, for example, cataract removal, is paid at the same rate (the tariff). However, not every patient is the same. There will be some cases that are more difficult than others even though they are covered by the same tariff. There is plenty of evidence where this has happened with last government's Independent Sector Treatment Centre programme (ISTC). </blockquote><blockquote><b>...</b> </blockquote><blockquote>The problem with the ISTC programme is that the provider was paid for referral, not for treatment. The government says that providers will be paid for treatment, but they do not say that once referred the provider <i>must</i> treat the patient, since there is no such provision in the Health Bill it means that once a private hospital receives a more complicated case they may refer the patient back to the NHS. The NHS has a responsibility to treat patients, private providers will never have this responsibility because they know that the NHS is always there for the more difficult cases. </blockquote><blockquote><b>...</b> </blockquote><blockquote>This means that if the private providers are cherry picking we <i>will not know</i> about it because such data will be "<i>commercially confidential</i>". There is nothing in the Health Bill to prevent this, indeed, the Health Bill enables private providers to be even more secretive and apply "<i>commercially confidentiality</i>" clauses to their contracts with the NHS.<br />
<div><br />
</div><div style="border: 1.5pt solid windowtext; padding: 1pt 4pt;">The Health Bill will not prevent private providers cherry picking because it does not mandate that once referred the provider must treat the patient. The Health Bill also strengthens the use of commercially confidentiality and so the public will not know whether the private sector are cherry-picking.</div></blockquote>pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.com0