The healthmatters blog; commentary, observation and review
The European Parliament has strongly backed moves to make smoking less attractive to young people but has rejected the health commissioner’s call to have electronic cigarettes (e-cigarettes) classified as medicines. The MEPs vote on Tuesday, 8th October came after months of lobbying by major tobacco manufacturers to try to water down and delay the European Union’s attempts to strengthen the existing legislation on tobacco products.
MEPs agreed that in future clear health warnings should cover at least 65% of both sides of a pack of cigarettes and packs of fewer than 20 cigarettes would be banned. Flavourings such as vanilla, strawberry and menthol, designed to mask the taste of tobacco and make products attractive to young people would also be banned but only after the legislation had come into force.
However, the commissioner failed in his attempt to have e-cigarettes classified as medicines with all the regulation that this designation would impose. British Liberal Democrat and Conservative MEPs successfully opposed the move which they said, would have increased the cost of e-cigarettes and reduced their availability.
An interesting development which demonstrates the power of the tobacco industry in lobbying in its own interests. The industry is clearly an anti-health force to be reckoned with. But, looking at the bigger picture, smoking e-cigarettes is much safer than smoking normal ones and for some nicotine addicts is a more acceptable way of obtaining nicotine gratification than through patches or chewing gum. So, on balance, I think the European parliament made the right decision.
Over 70% of prescriptions for antipsychotic medications are given to those without a record of severe mental illness.
The proportion of people with intellectual disability in the UK who have been treated with psychotropic drugs far exceeds the proportion with recorded mental illness, finds a study published by The BMJ today.
This suggests that, in some cases, these drugs are being used to manage other presentations, such as challenging behaviour,rather than for mental illness, say the researchers. They call for changes in the prescribing of psychotropic drugs for people with intellectual disability as well as more evidence on their safety in this group.
People with intellectual disability develop severe mental illness at higher rates than do the general population and may show challenging behaviour.
Concern has existed for many years that psychotropic drugs in general – and antipsychotics in particular (mainly used to treat schizophrenia and bipolar disorder) – are overused in people with intellectual disability, but accurate estimates have been difficult to obtain.
So a team of researchers based at University College London set out to describe rates of recorded mental illness, challenging behaviour, and use of psychotropic drugs in people with intellectual disability in UK primary care.
They analysed data from 571 UK general practices using the The Health Improvement Network (THIN), a large database of electronic health records, and identified 33,016 people with a record of intellectual disability. Average age at study entry was 36 years and average follow-up was five and a half years.
Of 9,135 participants treated with antipsychotic drugs by the end of the study period, 6,503 (71%) did not have a record of severe mental illness.
Of the 11,915 with a record of challenging behaviour, 5,562 (47%) had received antipsychotic drugs, whereas only 1,561 (13%) had a record of severe mental illness.
And of those with a record of prescription of antipsychotics, 26% did not have a record of severe mental illness or challenging behaviour.
New prescriptions for antipsychotics were significantly more common in older people and in those with a record of challenging behaviour, autism, dementia, and epilepsy, as well as mental illness.
People with a record of challenging behaviour were more than twice as likely to receive a prescription for antipsychotics compared with those without a record of challenging behaviour, say the authors.
Prescription of antipsychotic drugs is disproportionate to the level of recorded severe mental illness and is associated with the presence of challenging behaviour, older age, and diagnoses of autism and dementia, they add.
“Inappropriate use of drug treatment has implications for the individual and for healthcare systems,” they warn. “These findings highlight the need for an improved evidence base for use of drugs and optimisation of drug treatment in people with intellectual disability.”
The Health & Social Care Information Centre’s recent report on Written Complaints in the NHS – 2014-15 makes interesting reading apart from the repeated disclaimer: ” We are unable to provide comparisons with previous years”. In response to the report the NHS Federation (representing senior managers) said: “A higher number of patient complaints may be received by Trusts as we see an even greater open dialogue between the NHS and patients.” Maybe, but how could we tell from HSCIC data? How are we to make any sense of this kind of information without seeing the trend over time? It makes Health Matters wonder why the report was released at all.
There is a shortage of nurses in general practice, so when a South London group practice found one, they employed her immediately. She had been a district nurse, then a practice nurse, before taking a break. The practice wanted to deploy her to start the annual ‘flu vaccination campaign, but the CCG demanded evidence that she could give intra-muscular injections. Wasn’t her career to date enough evidence, said the practice innocently. No said the CCG, evidence of past skills was not evidence of current ones, she must go on a refresher course and get a certificate. There is a waiting list for the course, so the practice must wait. Being entrepreneurial the practice is teaching senior medical students how to give flu jabs, as part of their clinical training. The CCG cannot interfere with professional education, yet.
Talking of CCGs, a North London example is having its governance procedures reviewed after a whistle-blower piped up about the shambolic running of the organisation, its autocratic leadership and the sense of intimidation in the area. Health Matters will keep you informed.
The ‘preferred provider’ is making a comeback, if the HSJ is to be believed (26th August 2015). Monitor had announced that “Northern, Eastern and Western Devon Clinical Commissioning Group did not break procurement regulations when it selected a preferred provider for a £100m community services contract without going to tender”. The competition was between Royal Devon and Exeter Foundation Trust (the challenger) and the current provider, Northern Devon Healthcare Trust. Allegations of conflicted interest and opacity were made, but Monitor approved the process, creating a precedent for not going out to tender. Do we now have a loophole for CCGs to keep the private sector out? We shall see.
The HSJ reported (28th August 2015) that more than 2,100 mental health patients needing hospital admission were placed in-patient beds out of their area in May of this year. Not a happy state of affairs, but Health Matters notes that on Wednesday 26th August there were no forensic psychiatric beds available in either the NHS or the private sector in the South of England. That’s mentally ill people with a history of violence we are talking about.
Volunteers are important people for the NHS, as for all of civil society, but recruiting and retaining them is not easy – some say it is getting harder. A recently published study shows that whilst big centralised command-control charities (like RNIB) can successfully grow and sustain intervention programmes at scale, there are a number of factors which mean local franchises of devolved-model charities are unlikely to be able to do so. This is useful information for anyone who believes that large-scale public services can’t be replaced by volunteer provision. Check out: http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0019/131176/FullReport-phr02070.pdf
Sir Robert Naylor is leaving University College London Hospital Trust. He helped develop the Foundation Trust model as part of Labour health secretary Alan Milburn’s strategy team in the mid noughties. Now he says Foundation Trust’s have to go, and the NHS needs a dose of “co-operative and collaborative skills.”(HSJ September 1st) He added: “The whole tariff situation is no longer fit for purpose, and that’s been compounded by the fact you’ve got all these hospitals making a deficit and they’ve been given handouts,” “It’s hardly surprising that trusts now are aiming to make a deficit because if you make a surplus, then what would happen? They’d take the money away from us, so what’s the point?” Oh dear, trouble in the managed market.
Commenting on the Health & Social Care Information Centre’s figures today (26 August 2015) on patient complaints, Helen Birtwhistle, Director of External Affairs at the NHS Confederation, said:
“The safety of patients is of paramount importance to the NHS and patient feedback is essential for improving care. Our 2015 Challenge Manifesto champions the needs of patients. This in itself can lead to a higher number of patient complaints received by trusts as we see an even greater open dialogue between the NHS and patients today.
“There is a ‘golden thread’ to handle complaints effectively which involves apologising, explaining what happened, and describing why it won’t happen again. Managers and clinicians work hard to ensure patients receive safe and timely care but we need to always make sure that we are learning from patients and saying sorry, while we continue to take robust action to solve problems that occur.”
It is often said, probably correctly, that the biggest health gains have come through public health not through medicine. Things like immunization, clean water, adequate sewerage, decent housing and even decent education all contribute to improving health and increasing life expectancy. Increasingly we learn from political geographers like Danny Dowling that life expectancy and poor health can be predicted from post code at birth just as educational attainment, crime rates, and teenage pregnancy rates. We all have the equal opportunity to climb as high as our “parent’s” income permits.
Fixing the positioning and role of public health as a public sector function has been complicated by the establishment of the NHS as the only major personal public service completely outside any democratic control and thus as an island with its own culture, run in the interests of a loose coalition of vested interests. Responsibility for public health has moved around between health bodies and local government.
It appears everyone agrees we have to move more around education and prevention and to tackle the causes of ill health, not just treat the poor health when it happens. Making people healthier has to be achieved by an integrated approach guided by clear policy and driven by inspirational public leadership; the kind of leadership which cleared the slums. Instead, we have fragmentation, an unstable policy base and In the NHS public leadership is vested in the PCTs which are led by people who are unelected and unaccountable and if the ConDems are to be believed – incompetent.
To many this appears that Local Government must have a much greater role, even though they don’t want it, they have the power to do pretty much anything so long as they can argue that it improves the “well being” of the community they served.
The link between well being to public health is obvious and powerful and the White Paper, in one of its better portions, makes the links and states how local authorities will have explicit functions around public health (with funds attached) as well as having some vague and ill defined role of “promoting” integrated commissioning of care. Health and Wellbeing Boards are to be set up, but not as a formal Council Committees and without a Portfolio Holder/Cabinet Member responsible.
Local authorities will have greater responsibility in four areas:
· leading joint strategic needs assessments to ensure coherent and co-coordinated commissioning strategies;
· supporting local voice, and the exercise of patient choice;
· promoting joined up commissioning of local NHS services, social care and health improvement;
· leading on local health improvement and prevention activity.
The recent letter to Directors of Public Health from Professor Dame Sally Davies – Chief Medical Officer (Interim – does this make her a Management Consultant?) tells of the development of a National Public Health Service (PHS) within the DH – good centralising move, but sheds little real light on what is expected locally. The claim is of an exciting vision for an integrated service but with both the DH and the local authorities still in the mix this is a false hope. More is promised later in the year.
You are left with the feeling that the proposals don’t actually join up. Local authorities have a role but not the responsibility or even the authority to make things happen. The GP Consortia Commissioners have the authority to commission the health services and are accountable to the DH (sorry Commissioning Board), but they have some sort of responsibility to take part in the Health and Wellbeing Board – Councillors meet GPs!
The only sensible path to integration is to give all the responsibility and authority to the local authorities for all aspects of care as well as public health. For many aspects of commissioning, especially of health services, the responsibility might be delegated to other bodies (such as with Practice Based Commissioning) and it would have to be informed by working with health professionals, and patient groups. The Strategic Needs Assessments which local authorities have to carry out could be the driving force for integrated commissioning in a way that just has not happened so far.
That gives a real platform to drive integration but also saves a great deal of bureaucracy and management cost as local authorities already have in place much of what will have to be duplicated to create the governance and performance management infrastructure for the GP Consortia. And, the health of the public will benefit.
Socialist Health Association
The small business model of general practice in the UK has “served its time” and should be remoulded, with primary, secondary and community care integrated in single local organisations, the outgoing chairwoman of the Royal College of General Practitioners has said.
In a recent interview Dr Clare Gerada questioned whether GPs’ independent contractor status was still fit for purpose and challenged the profession to adapt to new ways of working. She called for GPs to lead multidisciplinary teams that incorporate acute, mental health, community health, and social care services in the community with all staff employed by the NHS.
The independent contractor status status served us well, she stated, but since 1948 what hasn’t changed is the way general practice is organised and hospitals are organised. “We need to protect what is best about generalism but move closer to our hospital and community colleagues so that we become one organisation and one service. I would challenge whether we need the independent contractor status. I would question whether it actually means anything anymore when we’re actually salaried to the State anyway.”
Dr Gerada called for the model proposed by the former health minister, Ara Darzi, which proposed the historical separation between primary and secondary care to be broken down, to be revisited.
BMJ 2013; 347:f5922
Integration of primary, secondary and community care is an important goal which is long overdue. However, one has to ask whether general practitioners becoming salaried employees is the only way to achieve this. As someone who was a salaried employee of the NHS for the whole of my career I used to think that the independent contractor status of general practice was an outdated model which owed its continued existence purely to political expediency; and that a salaried service would be much more appropriate. Now I am not so sure. The salaried nature of much of the public sector including the NHS has resulted in a grossly inefficient use of resources and to a remarkable lack of innovation. The small business entrepreneurial model can, I believe, deliver a more efficient and creative service. Perhaps the way forward requires a middle way involving salaried staff including general practitioners working for a social enterprise or cooperative independent organisation contracted to deliver comprehensive health and social care to a defined population.
Benenden National Health Report 2015 reveals public perceptions about the cost of NHS care.
The UK public routinely underestimates the costs of many common NHS procedures and habitually prioritises its own needs when it comes to treatment, the National Health Report 2015 reveals.
The report, compiled by mutual health and wellbeing provider Benenden, questioned 4,000 people across the UK asking them to put a cost to some common procedures and treatments – ranging from natural child birth to liver transplants, while at the same time enquiring if they believe some of those treatments should be funded, at least in part, by the individuals on the receiving end. It also explored attitudes surrounding the public’s prerogative to those same NHS treatments, revealing disproportionality between what people believe others are entitled to and their own entitlement.
When it came to judging the cost of procedures and treatments, liver transplants were estimated to cost £12,279 per operation, when in fact the true cost is £70,000; abdominal hernia surgery, of which 7,489 low risk ones were carried out last year, were thought to cost £1,609 rather than the £2,281 in reality; almost half (48%) of respondents thought less than 2,500 gastric bands, gastric by-passes and gastric balloons procedures were carried out by the NHS each year, far shy of the real figure, which is double that at 5,443, costing the NHS in excess of £25m in 2014.
IVF comes low on the list of NHS priorities as far as the public is concerned, with more than three-quarters of those questioned stating that people should either contribute towards the cost of IVF or foot the bill entirely, with only 22% of recipients believing it is a treatment that the NHS should offer. One round of IVF treatment on the NHS costs between £1,287 and £6,000, with women under 30 years of age being offered up to three rounds, and women over 40 given just one round on the NHS. The younger the recipient, the more likely they are to believe that IVF should be funded by public money: 28% of 25-34 year olds think the NHS should pay in entirety for the treatments, while only 15% of 65-74 think the same.
Keeping to the topic of pregnancy, it is apparent that the public is naive when it comes to the cost childbirth, with almost half of people (47%) thinking it costs less than £500 for women to have a natural birth in hospital, without any complications. Even taking all survey respondents into account, the average cost of a natural birth is estimated to be £1,288 by our respondents, which is more than £500 short of the true figure of £1,824.
Commenting on the findings of the report, Medical Director of Benenden, Dr John Giles, said: “The issues surrounding NHS funding is an extremely contentious subject and disparity between the actual and perceived costs of treatments on the NHS needs to be addressed. As a nation we have lost touch with the role we should play in our own health and wellbeing, with a large proportion of the population relying on the NHS to maintain our health even if our own lifestyles are detrimental. This has led to a damaging culture whereby we are happy to point the finger when it comes to saying who doesn’t deserve treatment, but we take little responsibility on the individual impact we are all having on the NHS.”
Despite being naive when it comes to certain treatments, the public is accurate when judging the cost of cosmetic procedures on the NHS. The average cost of a ‘nose job’ is £2,498 for adults over the age of 18 and slightly more for teenagers at £2,582, which the public estimated quite accurately. The younger the respondent, the more accepting they were of cosmetic produces on the NHS to help those suffering from self-esteem issues: 38% of 16-24 year olds thought it was acceptable, while just 25% of 55-64-year olds thought cosmetic surgery courtesy of the NHS was OK, with the percentage dropping to just 18% in the 75-84-category. Shockingly, nearly one in 10 admitted to either lying to their doctor or knowing someone who’d lied about being depressed or suffering from low self-esteem in a bid to get free cosmetic surgery, with this trend much more common in the younger respondents.
The survey revealed that the public will take a hard line when it comes to treatments needed as a result of excessive lifestyle choices. The number of people who believed making poor health choices, including, obesity, drugs or alcohol, should result in not being treated by the NHS hovered around 51%-53% in each case.
Last year more than 1.4m people used NHS drug and alcohol services, including rehabilitation, at a total cost to the NHS of £136m – and Benenden’s survey respondents were unforgiving: just 15% thought treatment for alcohol abuse should be offered free-of-charge on the NHS, while 85% of respondents believed patients should either pay for their own treatment or make a contribution towards it. Similarly, one in 10 Brits think that if you need a liver transplant as a result of abusing alcohol, then the NHS shouldn’t provide it and a further 23% believe alcoholics should contribute towards the transplant. A more generous 43% thought they should get liver transplants for free providing they are alcohol free for three or more months prior to the operation.
When it came to looking at their own attitude to the NHS and what they feel they are entitled to, the public was more relaxed. Three-quarters (75%) of those questioned admitted they didn’t consider the cost of a procedure or worry that the free treatment they were receiving could be taking treatment away from someone in greater need, despite 62% expressing concerns that the NHS was under strain.
Another area where views on cost proved to split opinion is prescriptions. Currently in Scotland, Wales and Northern Ireland, prescriptions are free to all citizens. However, in England, unless you fall under certain exemptions then you are expected to pay for prescriptions. The Benenden report reveals that almost four in 10 (37%) thought the current system was unfair and that people in England should get their prescriptions for free, with an almost identical number believing it is the systems in Scotland, Wales and Northern Ireland that should change and start charging.
Dr John Giles commented: “These findings are somewhat worrying as they offer a perturbing insight into the sense of entitlement of the British public. This manifests itself in an enormous cost to the NHS, which is not helped when people abuse the system. Yet, unfortunately the burden often rests with healthcare professionals and the NHS itself.
The selfishness displayed by the public when it comes to looking at their own attitude to the NHS and what they feel they are entitled to is contributing considerably to the strain the NHS is currently under. If the public was more aware of the cost of appointments, treatments, operations and prescriptions, and really took responsibility for their own health, using the NHS only when absolutely necessary, the crisis the service finds itself in today would be significantly lessened.”
Limit alcohol to one drink a day for women and two drinks a day for men, say experts
Even light and moderate drinking (up to one drink a day for women and up to two drinks a day for men) is associated with an increased risk of certain alcohol related cancers in women and male smokers, suggests a large study published by The BMJ today.
Overall, light to moderate drinking was associated with minimally increased risk of total cancer in both men and women.
However, among women, light to moderate drinking (up to one drink per day) was associated with an increased risk of alcohol related cancer, mainly breast cancer.
Risk of alcohol related cancers was also higher among light and moderate drinking men (up to two drinks per day), but only in those who had ever smoked. No association was found in men who had never smoked.
Heavy alcohol consumption has been linked to increased risk of several cancers. However, the association between light to moderate drinking and overall cancer risk is less clear. The role of alcohol independent of smoking has also not been settled.
So a team of US researchers based at Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital in Boston, set out to determine whether light to moderate drinking is associated with an increased risk of cancer.
They used data from two large US studies that tracked the health of 88,084 women and 47,881 men for up to 30 years. They assessed risk of total cancer as well as known alcohol related cancers including cancer of the the colorectum, female breast, liver, oral cavity, pharynx, larynx and esophagus.
Light to moderate drinking was defined as up to one standard drink or 15g alcohol per day for women and up to two standard drinks or 30g alcohol per day for men. One standard drink is roughly equivalent to a small (118ml) glass of wine or a 355ml bottle of beer.
Influential factors, such as age, ethnicity, body mass index, family history of cancer, history of cancer screening, smoking, physical activity and diet were also taken into account.
During the follow-up period, a total of 19,269 and 7,571 cancers were diagnosed in women and men, respectively. The researchers found that overall, light to moderate drinking was associated with a small but non-significant increased risk of total cancer in both men and women, regardless of smoking history.
For alcohol-related cancers, risk was increased among light and moderate drinking men who had ever smoked, but not among men who never smoked. However, even in never smoking women, risk of alcohol-related cancers, mainly breast cancer, increased even within the range of up to one drink a day.
This large study sheds further light on the relationship between light to moderate drinking and cancer, says Dr Jürgen Rehm at the Centre for Addiction and Mental Health in Toronto, in an accompanying editorial.
More research is needed to explore the interaction between smoking and drinking on risk of cancer, he says. But, roughly speaking, women should not exceed one standard drink a day and men should not exceed two standard drinks a day.
Finally, people with a family history of cancer “should consider reducing their intake to below recommended limits or even abstaining altogether, given the now well established link between moderate drinking and alcohol-related cancers,” he concludes.
The NHS Confederation says that new figures released by NHS England on 13th August 2015 reflect pressure across the health service and the crucial need for a ‘whole system’ response.
Dr Johnny Marshall, policy director of the NHS Confederation, said:
“The health and care system is dealing with increasing demand in an ongoing period of change and financial restraint that stretches back over the last five years. The subsequent strain on the NHS is written all over these statistics.
“Our members and staff across the whole service are working hard to ensure that patients continue to receive world-leading care. They are running services whilst making improvements to the way they deliver care to keep up with changing demand. This is a task that will take at least five years to complete and we recognise that more needs to be done – in health, in social care and in public health and prevention.
“Organisations across the country are working on new models of care that better join up health and social care for people in the community. This is better for patients and will, in time, support hospitals in reducing demand and in discharging patients safely so they spend no longer in hospital than is necessary. The only way to achieve this is through solutions that embrace health and social care services across the whole system. Pressure felt in hospitals is often a consequence of pressures in community and social care services.
“There is a pressing need to improve the experience of care for older people. At the NHS Confederation we are working with our members and health experts to identify the best ways to improve urgent care for older people. If we can get this right we can look to improve patients’ experiences and ease the pressure facing hospitals across the country.”
Male doctors have nearly two and half times increased odds of having medico-legal action taken against them than their female counterparts, according to research published in the open access journal BMC Medicine. A better understanding of why this is the case will lead to improved support for doctors and make patient safety better.
Recent times have seen an increase in the number of medico-legal actions taken against doctors. In the US, between the years 2008 and 2012 there has been a 17 per cent increase in the number of medical licenses that have been revoked, denied or suspended. In the UK, the medical regulator, the General Medical Council, has seen a 64 per cent increase in complaints between 2010 and 2013.
Some previous studies have looked at the sex differences and medico legal action in specific countries but none have examined this globally. To investigate these differences on an international level and whether there have been changes over time researchers from University College London conducted a systematic review and meta-analysis. They identified and analyzed the results of 32 studies. This represented a population of 4,054,551, which included 40,246 cases of medico-legal action.
The results of the systematic review and meta-analysis found that male doctors were more likely to have medico-legal action taken against them compared to female doctors, with nearly two and half times the odds. This effect was found to be consistent across a number of years, different study types and across the countries included in the investigation.
The researchers divided medico legal action into six categories. These categories were disciplinary action taken against a doctor by a medical regulatory board, malpractice claims/cases, complaints received by non-regulatory bodies that investigate healthcare complaints, criminal cases and, finally, medico-legal matter with a medical defense organization. This last category relates to any studies that grouped together several medico-legal action types.
It has been previously believed by some that male doctors are more likely to experience medico-legal action as more male doctors were practicing medicine. Had this been the case the differences between sexes would have reduced over time due to the growing number of female doctors. This analysis has shown that the difference between the sexes has remained consistent for the last 15 years.
Other studies have shown that male doctors work more hours than female doctors, male doctors also have more interactions with patients. This may have an influence on the differences in the likelihood of medico-legal actions taken against male and female doctors. Further research is needed to confirm if there are any associations with these two factors.
Lead researcher, Emily Unwin, says: “Investigating complaints about doctors’ fitness to practice not only places an enormous level of stress on the doctor being investigated, but also places a resource strain on regulators, and may lead to patient concerns about the quality of care they receive.
“More research is needed to understand the reasons for why male doctors are more likely to experience a medico-legal action. The causes are likely to be complex and multi-factorial. The medical profession, along with medical regulators, and medical educationalists, now need to work together to identify and understand the underlying causal factors resulting in a sex difference in the experience of medico-legal action, with the aim of better supporting doctors in achieving the standards expected of them, and improving patient care. “
Comment. An interesting but for me not an unexpected finding. I have views about why male doctors are more prone to medico-legal action but what do you think?
Paul Walker, Co-Editor