The most direct way to improve health: more money

A new study by the Scottish Public Health Observatory has reviewed the potential effects on health of a series of interventions.  The effects on health are considered mainly in terms of mortality and the need for hospital care.  The measures in relation to incomes, cutting alcohol, tobacco or obesity, and encouraging cycling and walking to work.

Health interventions

The biggest benefits, by far, would be gained by the introduction of a living wage; the next biggest, though it is even more important for the poor, would be an increase in minimum income benefits.  Some of the measures they are being compared to seem restrained – a weight-management service rather than measures to reduce sugar, short-term interventions on alcohol rather than taxation by unit – but the size of the difference is so big that it’s unlikely to  tilt the table.

A pensioner goes walkabout

A report in the Dundee Courier this morning concerns a manhunt (or womanhunt, if you prefer) for an 86-year old  from Dunbartonshire.  When her care workers arrived at 7 am yesterday, she wasn’t there.  A search has been mounted with police dogs, a helicopter and the co-operation of the Ministry of Defence.  It’s not unusual for the police to be involved in searches for missing pensioners – in a case last year in Birmingham, they”searched the local area, made enquiries with relatives and checks with taxi firms, public transport and health care providers” – but the scale of this search raises questions about how we ought to respond.

There is nothing unusual about people with dementia going out.  People with dementia tend to do things that they’ve done throughout their adult life.  It’s often the context that makes the actions seem disturbed  – people going for a walk because they think they’d like to take a walk, cooking in the middle of the night, going to the shops when everything is shut, lighting a fire when they’re cold, deciding to visit their family while not remembering that their family don’t live where they used to.   In the bad old days, which are not that long gone, older people would routinely be incarcerated in psycho-geriatric wards, typically with locked doors.  When we committed ourselves to keeping people in their own homes, we took on a degree of risk.

What kind of response would be proportionate?  I don’t know; I don’t even begin to have an answer.   But there has to be a better way than helicopters and dogs.

The manifesto for mental health

A number of organisations dealing with mental health have issued a ‘manifesto‘, intended to influence policies in the run-up to the 2015 election.  There are several measures I’d endorse wholeheartedly, including better funding, minimum waiting times for access to support services, support for new mothers and improved physical health care for people with mental problems. 

The only point I’m not really convinced by is the idea that there should be “integrated health and employment support to people with mental health conditions who are out of work and seeking employment”.   ‘Integration’ rarely works; when everyone is expected to do everything, things don’t get done properly.   (I asked a nurse recently:  “Are you asked to treat patients holistically?” and she answered, “Oh yes, it’s just that we’ve not been trained to do that bit.”)  We can’t get different parts of the health service to communicate adequately with other parts now, and I’m not sure that adding further services to the brew is going to deliver any more effectively.  

Good news on infant mortality

Here’s some good news, for once, which I was pointed to by a report about China in the Economist.  International organisations have identified ten countries which have made exceptional progress in keeping children alive.  The basic figures are here; a report explaining what those countries have done to achieve it is here.  A substantial part of it is the improvement in the health of the mothers.

Under 5 mortality rate per 1000 live births
1990 2013
Bangladesh 144 41
Cambodia 116 40
China   54 14
Egypt   86 21
Ethiopia 204 68
Lao PDR 163 72
Nepal 142 42
Peru   79 18
Rwanda 151 55
Viet Nam   51 23


A report showing how benefits fail to support people with mental health problems

Worried Sick is a new report from the Scottish Association for Mental Health.  It reflects concerns about the way that people with mental health problems are left to negotiate the reefs of the benefit system without adequate support; in six cases SAMH workers had to help people attempting suicide because of what was happening.

The report’s sample focused on the poorest areas.  That makes it easier to find people in trouble, but it can be misleading.  Mental health problems, and benefit problems, don’t just affect the poorest people, or people who live ‘somewhere else’; they can hit anyone, anywhere.  It could happen to you.

On the problems of A & E

The winter holiday has produced the usual slew of concerns about Accident and Emergency provision.  There is too much demand; the numbers of people using the service are up again; waiting times are excessive; there are staff shortages.  Something like this happens every year.

There are two different kinds of problem here.  One is a reflection on the continuing problems of general practice.  What’s supposed to happen in principle is that everyone is supposed to have a general practitioner, and when they’re ill they will receive treatment from the GP first.  This doesn’t work as it should, because there are still large numbers of people (especially in London) who are not registered with a general practice, and because the reform of out of hours services has generated problems in its own right.  The problems are not confined to A&E.  A study of the demands made by unregistered patients in the Journal of Public Health found that the highest number of outpatient attendances were in genitourinary medicine, trauma and orthopaedics, while the highest costs were associated with trauma and orthopaedics, forensic psychiatry, mental health and general medicine. There is also some evidence that most of the people who go to A&E ‘inappropriately’ are people who are already registered with their GP, and who use their GP repeatedly – they have twice as many appointments, and make ten times as many out-of-hours phone calls as others.  (It’s difficult to be certain what is an ‘appropriate’ call, because so much depends on what other services are available: an article in Family Practice reports estimates of inappropriateness that varied from 6% to 80%.)

There is however a further problem, and that problem lies in  A&E itself.  The system was mainly developed in the 1960s as part of the general philosophy that a medical service had to have comprehensive provision for when the need arose: a centralist dream, the same kind of rationale which insisted that all children had to be born in hospital.  So we built a system that could cover general practice, casualty, unscheduled care and major trauma from a single service.  It’s exhausting to operate.  Because it has  simultaneously to be decentralised and always open, and to offer highly specialised trauma care, we can’t train or maintain enough staff to provide the cover; and it guarantees that whenever there’s an outbreak of winter vomiting, sufferers will come together in one place to spread the disease.  There are alternatives: to have a domiciliary response to minor injuries, community based hospitals for general practice and urgent attention, casualty units for accidents and major trauma centres with specialised resources for the most serious cases.  Following the Kerr report, which argued for a schematic approach to unscheduled care, that’s the pattern developing over much of Scotland.

Neither of these problems would be addressed by the silly proposal to charge people for going to A&E services.  The main people to be put off would be those who are already poorest and least well served.

A little more on why we can't trust the statistics in published articles

I’ve referred earlier this week to the work of Ioannidis, who argues that most published medical statistics are wrong. The British Medical Journal regularly uses its Xmas issue to publish some disconcerting, off-beat papers.  In a previous issue, they produced the findings of a randomised control trial which showed an apparently impossible result: praying for people whose outcomes were already decided several years ago seemed to work.  The message:  don’t trust randomised control trials, because they’re randomised.  This year, an article, “Like a virgin”, identifies 45 women in a sample of nearly 5,500 who claim to have had a virgin birth. The message: don’t believe everything people tell you in surveys.    If only medical journals applied the same rigour to some of their ‘serious’ results.

Cancer treatment: it's not just about the postcodes

In the Scottish Parliament, Labour leader Johann Lamont has raised the case of a cancer patient who is “considering moving to England to get free access to drugs she cannot be prescribed on the NHS in Scotland.” Lamont is critical of money being used to pay for paracetamol while this drug is not prescribed.

Cetuximab is a drug prescribed in certain cases of advanced cancer, principally colo-rectal or head and neck cancer; in both circumstances it’s used for a relatively short period in combination with other therapies. It’s approved for use in Scotland and England and Wales on similar terms, but the terms are highly specific. Three issues are worth noting. One is that while the treatment does lead to an improvement in life expectancy, the improvement is very small – two to four months, assuming best supportive care.   The second is that the drug is dangerous: “Cetuximab has a non-trivial safety profile and data are compatible with an increased risk of death in patients administered cetuximab as add-on to chemotherapy.” (Scottish Medicines Consortium)  The third issue, as often happens, is that the drug is also very costly – the Health Technology Assessment suggests that the manufacturers have underestimated both the duration of treatment and the cost of supportive care.

It’s not possible to tell what the basis is for the decision about the particular patient identified in the Scotsman, and I’m not going to try.   It’s not difficult to understand, however, that decisions about prescription have to be made in a specific context, for a specific person, and that different decision-making bodies may reasonably arrive at different conclusions.

Paracetamol, by contrast, is a largely beneficial drug, prescribed in well over two million cases in Scotland every year.   The idea that Scotland should stop prescribing it in order to facilitate paying for expensive drugs with very limited benefits doesn’t look like sound policy.

The Francis Report

Although the situations considered in the Francis report are shocking, the situation they describe is all too familiar. The scandalous ill-treatment of patients was a recurring problem of long-stay institutions – reflected for example in Sans Everything (1967) and a string of scandals in mental institutions, detailed at length in J Martin, Hospitals in Trouble (1984), a book cited in this inquiry report. Nearly thirty five years ago, as a student, I was given an advance copy of the Normansfield report by Brian Abel-Smith; it described how patients were restricted and neglected, and the upper echelons of NHS management did nothing about it. David Ennals explained, in Parliament: “… the report makes clear that there were many people who knew just what the position was. Some of them were in positions of authority with power to act but they failed.” In other words, we have been here before. The main difference is that this time it’s in acute care.

Unfortunately, the Francis report does not point to the way out of the problems. There are some hard-hitting passages – given the findings, there had to be – but there’s an awful lot of words in between. At nearly 1800 pages, the report is rather badly written – indiscriminate, repetitive, with some slushy, mystical twaddle about leadership (the stuff about it being a quality of the ‘spirit’ is in there twice) and an 125-page “Executive Summary” (someone should have taken the learned chairman into a corner and explained what that phrase is supposed to mean). The review of evidence in volume 1 is generally good; Volume 2 spends several hundred pages reviewing what regulatory and supervisory agencies did not do, and is interminable; the review of general issues in volume 3 is long, prescriptive and often preachy. The sheer number of words guarantees however that it won’t be read.

The stuff on leadership presents the most obvious problem. This report uses the word more than 800 times, referring to leadership haphazardly whenever it wants to think about the position of people in charge, senior management, ward management, roles in professional settings, personal qualities, motivation, or relationships with juniors. The poisonous cult of leadership, and the assumption that people in charge should energetically push others to share their values and aims, is part of what’s created this mess in the first place. What the report is really describing is systemic failure, and systemic failure cannot be responded to through on an individualistic basis without gaps being left.

Promoting GP competition

Reform Scotland has published a pamphlet arguing that since GP practices are insufficiently sensitive to patients’ needs, the answer must be to promote competition between providers. That doesn’t follow. When markets are based on ‘choice’, the choices that are made are not just the choices of consumers; they are also the choices of providers. Competition works because providers refine and select what they do. They choose who their customers are. They choose their location. Making the right choices cut costs; that is why competitive markets tend to be efficient (and why public services aims for ‘cost-effectiveness’ instead of efficiency – the aims are very different). The selective decisions of providers, within the current system, are precisely the reasons why patients do not get what they need. Which practices are going to cover people in isolated rural locations? Who is going to provide services to drug users, who use GP services at ten times the rate of other people? Who is going to provide services to very elderly people, who cost practices seven times the resource of other patients? Competition is not the way to a universal service; it is the opposite of what is called for.