Don’t bank on it being a good idea…

The run-up to the 2017 General Election has begun, with interesting promises already being made (or in some cases, not being made) by the politicians.

Notable among the pledges is Labour’s proposal to have four new Bank Holidays.  Labour has already trumpeted its commitment to the lower-paid by suggesting an increase in the minimum wage to £10 an hour (which may mean that businesses will lay people off) but let’s look at the economics of these extra holidays…

  • Those workers paid hourly, but working an 8 hour day they will lose four days of pay, or £320.  Thus those with the owrst employment arrangements will be worse off.
  • Those businesses paying a salary will lose four days of production but still have to pay their workers the same.

Have I missed something here, or is this an oxymoronic plan?  What is the point of a holiday you end up paying for, but have to take whether you like it or not?  Of course there is, on top of this, the disruption that will occur in the NHS, which Labour pledges to protect.  Bank Holidays are already a nightmare.  All non-emergency services shut down; no cold surgery, no outpatients.  There will be a rapid increase in waits.  Think about it.  Senior doctors have six weeks leave and two weeks of study leave, which means that at most they work a 44 week year.  Those who have commitments on Mondays lose six this year to Bank Holidays (in England) so are now down to 36 weeks.  Another two weekdays go for Christmas.  Then we are to lose another four days – which is nearly another whole week (OK, they won’t all be Mondays but a week is a week).

Would you trust the originators of this madcap scheme with your money?  Leave aside that they will take even more of it to fund all their other crackpot plans.

I have a rule for plans.  Look at an idea, and work out whether there is anything that could possibly go wrong with it.  Look at every angle; assess the pros, but search for the cons.  In this case it is one big con, in every sense of the word.

 

Saying sorry

In medicine people don’t say sorry enough.  Every month there is a new press report of some disaster where there has been a cover-up, a failure of communication, an attempt to move blame, a guilty silence accompanied by a shifting of feet.  It is stupid because it aggravates the situation and leaves those affected more distressed an angry than they would have been otherwise.  A quick and appropriate apology cools the situation as people respect honesty.  The most potent example I have of this is a patient whose sight was severely affected by a prescription change in my department which I (and the patient’s GP) failed to notice.  When the problem came to light she asked what she should do, and I not only apologised but told her to consult a lawyer.  Rather diffidently she asked that, if she did and there was a case, would I continue to see her.  This was trust based on honesty.  Although there was a bit of an argy-bargy over responsibility there was none over liability, and she eventually received a six-figure settlement.  And I continued to see her.

How different Hillsborough would have been if the police had not tried to cover their backs, but admitted their failings.  On an international basis the same rules should apply.  If a civilian airliner is by mistake brought down by a missile, and all aboard perish, and there is incontrovertible evidence of the perpetrator, then that perpetrator will only be despised if they try to dodge the blame, not least if they change their story all the time.  Likewise, if nerve gas is dropped on a civilian target, and there is indisputable evidence of who did it, and equally indisputable evidence of an attempt at a cover-up (with attempted changes of story to try and adjust to emerging facts) no-one could ever trust them again.  So why do they do it?  Holding up your hands may be very painful, but there then is an end to it instead of continuing recriminations which poison things indefinitely.

So, in fact, medicine mirrors the rest of society.  What a pity.

Why have we forgotten the past?

February 21st 2017 and another report emerges in the press suggesting that the NHS provider sector can only be saved by closing hospitals.  True, the potential to develop centres of excellence is enhanced by having larger centres.  However, given the impossible-to-cope-with levels of bed occupancy (85% is considered the maximum sustainable, while it is currently running at 95% in many places) cutting the numbers of hospitals will only work if the numbers of beds in each is increased, and this does not appear to be on anyone’s agenda.  Despite the fact that the UK has fewer hospital beds per head of population than anywhere in Europe people seem to believe that simply speeding discharges into enhanced social care facilities, or even “step-down” hospitals, will solve the bed crisis.  Would it not also be possible, it is argued, for such facilities to take in those who do not really need an acute hospital bed, but something somewhat less acute, thus reducing the load on A&E departments?

There are several flaws in this.  First, the pressure to discharge patients in haste will not be reduced, because fewer A&E departments admitting the same numbers of patients keeps up the pressure on the front door.  Too soon a discharge leads to patients bouncing back.  Second, “Care in the community” is not cheap.  Third, it seems counter-intuitive to reduce costs by concentrating resources in larger units (otherwise known as economies of scale) while at the same time promoting the establishment of small ones.

And this is where the past comes in.  When the NHS began it assimilated voluntary hospital (which were largely broke) local authority hospitals and a vast network of small cottage hospitals.  During the 1970s and 1980s it became increasingly obvious that these small unites, with disproportionate overheads, were unaffordable.  So they were shut, or if bits such as outpatients somehow survived, the beds were close.  In my own area a thriving cottage hospital in Erith, taking GP admissions and step-down patients and even doing major surgery, fell foul of this and the need to meet ever more stringent health and safety rules.  The hip replacements done there were displaced to the district hospital.  In Greenwich, when I arrived there in 1983, the hospital stock included Greenwich District Hospital, the Brook Hospital, Woolwich, St Nicholas’ Plumstead, the Memorial Hospital on Shooters Hill, Eltham Hospital, the British Home for Mothers and Babies and the Dreadnought Seamen’s Hospital.  Well before I retired from the NHS in 2011 all were shut, and services confined to the Queen Elizabeth Hospital, which had started life as a military hospital but took civilian patients.  So eight went into one.

Why were they closed?  They were unaffordable. But all the people who agonised over those decisions are retired, or dead.  There is no institutional memory.  Instead the new ones on the block reinvent the wheel.  Medical advances have meant we can do more (which costs more), and keep people alive longer into frail old age when medical problems compound themselves.  But the basic financial rules underpinning it all have not changed.  Lots of small units accrue more costs than few, larger ones.  Domiciliary care requires more staff to cover the same workload, and travelling times make it inefficient in comparison to care in institutions.  You cannot close a hospital with 300 beds and expect to do the same amount of inpatient work in the one next door of the same size without increasing the bed numbers and staff there; keeping people out, using low-key facilities, may be just as expensive as keeping two hospitals open.

And did closing all those hospitals in Greenwich solve the financial problems?  A question to which the answer is no.  It is interesting to see the Sustainability and Transformation Plans being developed now.  My reading of most of them is

  • This is what we want to do
  • This is how much it will cost to do it
  • Oops!  We can’t

In the early 1980s when I was a clinical manager we did something very similar to an STP in one of my hospitals – except it was called a zero-based budgeting exercise.  Guess what? Exactly the same thing transpired.  The past seems to be a long-forgotten place…

Rather than fiddle with an increasingly broken system we need to grasp the nettle and go back to the drawing board.   I wonder whether, in 50 years’ time, people will wonder why it took so long to do that.  The NHS needs to cater for medicine of the 21st Century, not that of 1948.

New government department to be established

Today (Friday 13th January 2017)  “The Times” published my letter in response to their article describing how the government had decided to attack the head of the NHS, Simon Stevens, and blame him for all its failings.  In the edit a little bit was lost, so I quote the whole thing here:

“For the government to blame Simon Stevens for the crisis engulfing the NHS is akin to the Dutch public of old attempting to blame the little boy who stuck his finger in the dyke.  As for not following the government’s “direction of travel” – well, there isn’t one.  All credit therefore to Mr Stevens for trying to find it.  The government may not like what he says, but at least he is thinking outside the box which, as thinking inside it has manifestly failed to sort things out over the last 30 years, can only be a sensible thing.  That said, it doesn’t matter how brilliant a manager is if the business he is trying to run is terminally bankrupt.  The NHS as constituted cannot work and it is time to seek radical alternatives.”

I trust that Mr Stevens, should he read the letter, take some comfort from my support. Doctors traditionally bash managers; managers refer to the control of doctors as like herding cats.  But successive governments have spent untold time, and money, trying to “fix” the NHS almost from its beginning, and yet successive quotes in newspapers from the 1950s onwards have wanred of impending or exisiting crisis.

Things are very different from 1948.  Then, infectious diseases still killed thousands; heart attacks were untreatable, gastric and duodenal ulcers were rife, investigations were primitive and cheap; cancer simply killed.  Now antibiotics have saved thousands, heart attacks are treatable, if not always preventable; drugs have almost eliminated stomach ulcers and cancer can be treated.  All of this comes at a cost.  Investigations that are now routine, such as CT and MRI scanning, are not cheap and drugs that limit disease and extend life are exorbitant.  People live longer as they don’t die early from the aforementioned conditions, but live into old age with multiple, life-threatening pathology and often dementia on top.  Take such a person and admit them and it will cost thousands.If it’s a different set of health issues then I argue it needs a service designed to fit it.

Tinkering has failed us.  We labour under the illusion that the NHS is a business.  We have a so-called purchaser-provider system where the purchaser’s outlay is limited because it is constrained by what it gets from government, and the provider side limited because government sets the pay rates for procedures.  How such an arrangement can provide, or be expected to provide a surplus is beyond economic comprehension.  If government gives too much money to an organisation, all it has done is just that; if it gives too little then the organisation will be in so-called deficit.  To make savings it then has to make cuts in service, so it then gets even less money and the spiral continues.

Phillip Collins in “The Times” today argues that the age of the general hospital is over, suggesting that orthopaedic surgery can safely be conducted in small (and he presumes cheaper) units. He is completely wrong because he has looked only at one side of the argument.  A small unit may be cheaper (though there is a vast pool of evidence to suggest the opposite) but to divorce specialties from each other runs the risk of serious clinical failure.  If there is some unforeseen problem, where is the physician to solve the coronary episode or pulmonary embolus, the sudden loss of diabetic control, the acute hot joint?  Where is the vascular surgeon to deal with the postoperative unstoppable haemorrhage?  Where are the opportunities to exchange cross-specialty experience, or to train trainees in complication management? What is the cost of providing small intensive care units to rescue the patient who suddenly collapses and requires ventilation?  It is the availability of multiple specialties that maintains the safety of medicine. Collins hadn’t thought of that.

This all leads me to the expected announcement that the government will change its planning processes.  As well as coming up with ideas it will also test them to destruction in a new departmental analysis system.  In the NHS and elsewhere we have been belaboured and bewitched by policy initiatives that have fallen over because no-one has looked at the possible bad outcomes of change alongside the good ones.  Take Jeremy Corbyn’s recent idea to limit top wages.  Sounds great – economic madness and probably impossible to implement (and top earners will leave the country – pay peanuts, get monkeys, not a good idea.  So watch out for the new Department of Alternative Orthodoxy, which will contain a new committee called OfWhat (the Office of “What if?” or the Null Hypothesis Office). All plans would pass through a scrutiny committee whose only role would be to find something that would make the scheme fail.  Then there would be no egg on face when some smartass like me pointed out post-hoc why it wouldn’t work, and no need for the enthusiasts to slink away, red-faced with embarrassment at their simple and stupid errors of omission.

Let me give another example.  Some years back the NHS became intensely interested in the American system of Health Maintenance Organisations (HMOs).  My hospital was approached to consider the system.  It was decided that a working group of managers and consultants should go to the States for a week to see the system first hand.  There was great excitement.  There was no doubt that such a trip would be a good learning exercise and would help us to make a decision on whether an HMO system might work fir us, but I pointed out that if the public got to learn of it, given the parlous financial situation at the time, there would be the most frightful reaction and those that went would be pilloried for wasting resources by going on an expensive junket.  The press would have a field day.  Somehow no-one had thought of that. They had all looked at the plus side of the equation alone.  The proposal was abandoned.

Actually no such department will be established because it is too bold a step.  It would tacitly acknowledge the recurrent failures in the present system and no politician would be prepared to do that.  Would they?

Oxymorons and unintended consequences

I receive a daily digest of articles from the HSJ, or Health Service Journal in full. Today there are two headlines:

More trusts considered for ‘financial special measures’

All trusts given new targets to achieve provider sector surplus

Now Trusts considered for special measures are, basically, in financial trouble, in other words in deficit.  Many such Trusts have been unable to solve their deficit problem, and have had a succession of managers who have come and gone as the impossibility of balancing the books and maintaining safe clinical services becomes apparent.  As I have commented before, reducing deficits means cutting services, while maintaining these with adequate staff means increasing the deficits; there is a limit to how long the pips can squeak for.  The disastrous failure of clinical safety in Stafford will almost certainly be accepted to have been due to the cutting of corners, but the Care Quality Commission can put a Trust into special measures if its finances are wrong (even if its clinical services are fine) or if its clinical services are wrong (but its finances are fine). Heads I win, tails you lose.

To achieve a provider sector surplus requires Trusts to save more money still.  If they cannot do it now, how will they possible do it tomorrow? And what will be the effect on their clinical services if they succeed?

So these two juxtaposed headlines are, effectively, mutually exclusive.  The irony of the juxtaposition appears to have escaped the HSJ.  However there is another ingredient to this toxic mix. Jeremy Hunt,  the Rachman landlord of the NHS, has spoken at the Conservative party conference to announce that he intends to force trainees to stay in the country after qualification for four years, because too many are leaving and abandoning patients to foreign doctors who can’t speak good English.  He also intends to increase medical school entry to make it less necessary to recruit NHS medics from abroad, but also fill the unfilled posts currently washing around the system.

But herein lies a problem.  If Trusts are bust then how will they be able to employ more doctors?  It won’t help the provider sector surplus, will it? Cutting deficits means shedding staff, not employing more.

Of course what Mr head-in-the-sand Hunt has failed to realise, or chooses to ignore if he has realised, is that doctors are voting with their feet because life as an NHS doctor employee is becoming intolerable.  He won’t fill medical school places when all the prospective students are being put off by their medical friends, parents and relatives.  So before trying to induct more people into this uncomfortable and failing system he should first address the concerns of doctors over workloads, continuing education, regulation and bullying (viz the attempt to enforce a new contract).  Then we might get somewhere.  But he will never produce results from a sullen and rebellious workforce.

 

Cardiovascular risk, Cholesterol and NSAIDs

The complexity of the inflammatory response continues to puzzle the medical world.  Arterial plaque in the coronary vessels predisposes to heart disease, but why does it develop? Is it due to high cholesterol levels (seeing as cholesterol is present in them) or primarily due to intimal inflammation? Non-steroidal anti-inflammatory drugs (NSAIDs) reduce inflammation but increase cardiac risk.  Treating an “inflammatory” disease such as rheumatoid arthritis (RA) with a disease-modifying drug – and RA has a high cardiac risk – appears to diminish that risk, but using an NSAID increases it.  If inflammation is a single entity these facts conflict.

The answer to what causes the increased cardiovascular (CV) risk from NSAIDs appears to lie in the cyclooxygenase pathway and I am grateful to Fred Kummerow of THINCS for my Damascene moment[1].  The enzymes COX-1 and COX-2 (primarily COX-2) are principal agents in the genesis of prostacyclin, which is a vasodilator, and of platelet aggregation inhibition.  Thus suppressing them leads to a reduction of prostacyclin and an increase in platelet aggregation, and suppression of COX-2 will produce a greater effect than suppression of COX-1.  Arterial plaque is irregular and platelets will stick to it – which will trigger aggregation.  So although the COX enzyme by-products are inflammatory, inhibiting them will increase the risk of platelets sticking to plaque, and the reduction of prostacyclin will mean the vessels, plaque or no, will be narrower than they would otherwise.

That explains not only the increased risk, but also the reason why COX-2 inhibitors have a worse effect on cardiovascular disease than COX-1 inhibitors.  Of course, research into RA has shown that the inflammatory cascade is unbelievably complex, with the interaction of T- and B-lymphocytes, tumour necrosis factor, interleukins (and we number them in dozens), complement, autoantibodies, immunoglobulins and other immune mediators.  Of interest is that nitric oxide, which plays a part in vascular integrity, may also be important in RA.

There does not appear to be any evidence supporting a hypothesis that cholesterol plays any part in altering COX enzyme levels.  There is, however, evidence that exposure to trans fats does.  These are found in partially hydrogenated oils, and ingestion of these produces substantial reductions in prostacyclin release.  The belief that trans fats were no different from other fats has been upset both by this finding and by the chemical analysis of them showing that there are subtle differences in molecular structure with the production of isomers that do not occur in nature. These are recognised as foreign by the body and provoke an inflammatory reaction. There is also good evidence to show that the increase in CV mortality during the last years of the 20th century has a direct relationship with trans fat intake, and likewise the removal of trans fat from consumables has been mirrored by a reduction in mortality.

Plaque generation per se is not related to lipid levels either.  The fact that cholesterol is found in plaques is simply an expression of what happens when intimal damage is followed by an attempted repair process.  Reducing cholesterol will not reduce the risk of plaque formation, as it is not the cause of the initial intimal damage.  Neither will reduction alter vascular calibre or interfere with surface platelet aggregation on an arterial plaque. There is now too much evidence and too many “Black Swans” that contradict a direct link between cholesterol and vascular disease for this link to be acceptable.  There is plenty of evidence to explain both the causes and mechanisms of vascular disease, but I hope to see an understanding that statins are, population-wise, a costly mistake.  There is good reason to suppose that aspirin, which is a potent inhibitor of platelet aggregation, is of more use in CV protection that cholesterol-lowering drugs.  I have a personal reason to suppose this is true.  I have suffered from migraine from the age of 12 (when it might reasonably be supposed that my blood vessels were clear of cholesterol-laden plaque despite my high blood levels).  Migraine is a condition in which an aura, is followed by a typical headache.  It was hypothesised many years ago in an article in “The Lancet” that the cause of the aura was ischaemia as a result of localised platelet aggregation, which with the subsequent release of prostacyclin as a response resulted in vasodilatation which caused the headache.  I began taking aspirin and my attacks, which were severe and occurring monthly or more often, stopped completely.  After five or six years of symptom-free life I stopped the aspirin without ill effect, but after a decade the attacks re-started, interestingly with the same intensity of aura but a much reduced subsequent headache.  I began taking aspirin once more and my auras vanished again.  While I accept that I am treating a condition on the basis of a hypothesis I have been unable to find another sensible explanation of the aspirin effect.

[1] Kummerow FA. In Fat and Cholesterol Don’t Cause Heart Attacks and Statins are Not the Solution (Ed Paul J Rosch) 2016: Chapter 4, pp65-71.

What part of “No” do you not understand?

My son taught me this response and very useful it has been in defusing my internal tensions.  However they are building up again as I read that the acute sector of the NHS is to undergo a “reset”.  A reset would be fine if it delivered.  It won’t.

The acute sector is in crisis. Two-thirds of acute Trusts are in serious deficit.  A “reset” would work if (1) it wrote all the deficits off and (2) it ensured that they would not come back.  This requires a lot of money which isn’t there.

Large numbers of Trusts (all of them in my part of England, without exception) are in “special measures”.  This means they are not performing to the required standard, whether in financial or clinical terms.  If it’s the financial state that is the problem, see the above paragraph.  If it’s a clinical problem it is almost certainly due to a lack of staff.  Fixing this requires a lot of money which isn’t there, not least if a Trust needs to cover gaps with agency locums, which cost even more lots of money.

Bust Trusts are often burdened with serious debt from Private Finance Initiative (PFI) funding, as many projects are based on long repayment terms at crippling rate of interest, which sucks a lot of money out of real healthcare.

Many Accident and Emergency departments are working at full capacity despite being short of staff, burdened further by bed shortages (or blocking because patients well enough to leave hospital but with no system to get them out).  To fix this problem requires lots of money – either to increase acute beds, or to upgrade social services support, or both – which isn’t there.

Many Commissioning Groups, or CCGs, which buy acute services, are facing severe financial difficulties and are trying to reduce costs, in one instance by the quite extraordinary suggestions that GPs stop referring any non-urgent patients to hospital.

So (I put that in because it now appears essential to preface a response from anyone in research) acute services, which are commissioned by CCGs, are bust and/or judged to be failing clinically.  To be less bust they need to cut staff, and to stop failing clinically they need to employ more staff.  This is an oxymoron. Of course, failing units could shut.  After all that’s what failed businesses do.  However that then reduces the already perilously low bed numbers and shifts the problem elsewhere – and given that every hospital is in the same boat will cause chaos.  Of course, the hospitals that remain open, requiring vastly more beds to cope with the displaced patients, could always expand, but would have to do so by adding to their PFI burden with a rebuild.

Meanwhile the government is merrily and on the basis of misinterpretation of data pushing on the concept of a seven-day service, which requires even more lots of money to cover rotas, overtime etc. It also appears to be indifferent to the scandal of generic drugs manufacturers escalating their prices without any apparent justification.  And the public still expects, in this Kafka-esque situation, everything to be completely free.  This is not a case of trying to fit a quart into a pint pot, but trying to fit Kielder Water reservoir into a test tube.  The purchasers cannot purchase, the providers cannot provide and yet everyone sits round thinking up yet another reorganisation or “reset” to add to the list of failed solutions since the 1950s.

These have never worked.  Some were devised by highly sensible and intelligent people. If they haven’t fixed it after all this time, what makes anyone think that it can actually be fixed at all?  I feel a sense of deja vu creeping up.  I have said all this before, and while it gets steadily worse, and deficits pile up in yet more places, “Nero” Hunt fiddles as Rome burns.  And, of course, makes things even worse by slagging off the doctors.

All right, you say, you have identified problems, and irreconcilable ones at that, but what are your solutions?  I suggest some or all of the following.

  1. Abandon PFI or refinance very PFI project to reduce historic and ridiculous interest rates to today’s levels
  2. Sort out the scandal of drug overcharging
  3. Stop some free prescriptions.  If someone needs thyroid replacement let it be free, but not the multitude of other drugs that are also prescribed but have nothing to do with replacement.
  4. Stop doing some expensive and marginal things. For example, is there any reasonable point in administering anti-cancer drugs at £30,000 a pop to gain six weeks of life?  And likewise is there any justification for resuscitating, or indeed treating, elderly mentally frail people in intensive care units when the quality of life when they leave the unit is awful?  This is of course contentious, but we must face the reality that the NHS as currently working is unaffordable.
  5. Stop statins (bee in bonnet here, but the costs are astronomical).
  6. Abandon any idea of seven day working until finances are demonstrably stable.  Which may be forever.
  7. Run the NHS either as a fully subsidised state monopoly enterprise, or as a business, but don’t pretend that it’s possible for it to be both.  And if it’s a business, then close bits when they go bust.  A true market will soon work out what works and what cannot.  That will focus the mind wonderfully!