How the NHS failed me and mine.
What it did, to the most important person
in my life and how it could happen to you unless
we do something about it!

Tuesday, 6 December 2011

The Perfidy of Politics.

Now that Osborne has cancelled Christmas, probably forever, I wanted to examine the the somewhat hypocritical, even treacherous view that 'contracts' with those providers in the Private Finance Initiative (PFI) are somehow 'different' from contracts with the employees of the State.

We have been told, interminably by those in power, that PFI under the last Government was sacrosanct as the contracts written were unable to be broken, despite the huge cost the taxpayer has had to bear, with little (no) reward. Ordure was heaped, quite rightly, upon the Labour Government for the  veritable 'bonanza' that PFI enjoyed during these years, with outfit's like Innisfree (who they?) making huge returns on contracts, and with equity capital investors enjoying unprecedented yields, all funded by the taxpayer. In addition, these same investors were also able to take advantage of refinancing the contracts and thus receiving 'windfall' profits of many millions without any consequent reduction in charges to the client.  These investors, in the main, were domiciled  for tax purposes in places like Guernsey or Jersey, where they paid no UK tax on these profits (capital gains), and yet the tax yield had been part of the assessment of cost/benefit analysis by the Treasury, that allowed PFI to be used as the major vehicle for infrastructure development in the first place!

So, large and important elements of the infrastructure of this country, including Education and the NHS, were leased from a 'cabal' of financiers and construction companies at returns that were at least double the rate of the government borrowing for up to 35 years, with maintenance contracts that extracted annual increases far in excess of those available by competitive tender. In one case a return of  60% was made by refinancing the 'mortgage' on a Hospital without a penny of the profit or any reduction in the lease cost to the NHS. All of this is down to successive governments of the 'neo-liberal' persuasion (all of them in the last 30 years then!) who have wanted to abdicate all responsibility for the cost or construction of infrastructure and keep the capital spending off the balance sheet, even if it meant huge lease costs to the taxpayer.

The recent Public Accounts Committee Report makes interesting reading (although 66 pages long), with some 30 projects worth a value of £2.1 billion being signed to March 2011 despite the rhetoric of Cameron about 'poor value'. And there are some 61 projects of a value of £7 billion in the 'pipeline'. The ConDems' will quietly agree these without demure, just as all those who went before. After all the contracts are 'off balance sheet' and no one will notice the perfidious nature of the transaction, will they?

Interesting also, is the sale of equity in the PFI's by the Construction sector, which yielded between 41% and 78%  to the 'usual' suspects (Carrilion, Serco, et al) compared to the sort of  profits seen in building of 1.5% (1998-2010). This makes the financing and also the running of the enterprise funded, somewhat more lucrative than any other area of construction (sic) and whilst it can be important to have a vibrant and profitable construction sector these are the 'fat cats', with most of the small and medium sized enterprises (SME's) in this sector struggling to survive. This is often, against a background where SME's are being squeezed on margins for the subcontracts that are let by these same companies, and payment terms extended well beyond that which is viewed as norm (30 days). But we are 'all in this together', some of course more together than others. The view that an elite group of financiers and construction 'super' companies are running and maintaining this country at the expense of  taxpayer funded contracts is difficult to believe. That they are doing so at enormous cost, but with little yield to the 'paymaster' (the taxpayer) is also a view that is inescapable. This is where the real escalation of the cost of  UK plc is founded. Not in the pensions of binmen, health care assistants and nurses.

Since 1992 a large and still growing proportion of the UK's infrastructure has in fact been 'privatised', much without our knowledge or consent. This includes, prison's, roads, incinerators, the MOD's buildings portfolio, air traffic control centres, fire and ambulance control centres, (which we have not used but are committed to pay all the charges for another 25 years), schools and colleges, police stations, together with many local and central government offices. This would not be a problem if  the outcome had been better buildings and services at reasonable cost, with a privatised workforce being provided with better management, pay, and conditions. But again this has not been so, with large parts of the legacy of the hard work and sacrifice of generations since the Second World War, being sold for a pittance. Sold despite the fact that the taxpayer owned and paid for these assets. Gas, Electricity Generation and Distribution, Water, Coal, Telecoms, Railways, and much else was virtually given away by successive administrations all bowing to the altar of marketisation and privatisation.

What do we get for allowing this to happen? Well the privilege of Innisfree being allowed to manage vast tracts of the NHS real estate portfolio at such cost as to be able to afford to remunerate David Metter, the CEO to the tune of £8.6 million (salary and dividends) despite the payroll covering less than 30 people. Apparently the average salary of all his employees is £268,000 each!

This 'PFI' construct is a 'bubble', albeit a laucrative and thus far sustained one. Sustained by the belief that NHS Trusts that cannot meet their commitments will be bailed out by successive governments, just like the Banks'.  Does that hold true for the future and anyway, should it? The current paradigm of sustainability of the NHS is being wrought asunder by a certain Mr. Lansley who may have little choice if his back is against the wall on funding for failing components of his 'grand design'. What then for PFI when its' market becomes another 'Greece'?

Thursday, 24 November 2011

Chocolate and Paracetamol.

No, it's not a new recipe for pain relief, although thinking about it may have some merit.

Chocolate has been investigated for it's efficacy as a medicine, primarily as an anti-hypertensive, but also for it's possible use in many cardiometabolic disorders. This is especially good news, for those who desire chocolate almost, if not more than sex, as a number of women have told me (although that may be a reflection of my lack of personal attraction). Hey-Ho. But yes, there is at least some statistically significant evidence that even the obese can benefit. It is important that it is dark chocolate and in my interpretation, that with the highest cocoa mass would be the one to go for, although above 85%, it does tend to be somewhat bitter, although as cocoa mass increases, sugar decreases. Always remember as sucrose intake increases, so does plasma glucose and insulin.

85% cocoa mass chocolate yields (per 100grammes);-
Protein - 9.70 g
Carbohydrates - 17.00 g
(of which sugar is 5.80 g)
Fat - 51.40 g
(of which monounsaturates is 17.90 g)

Putting aside the sugar content, for the non-diabetic that is quite small and provided consumption is kept to 25 or 50 grammes per day is unlikely to yield much harm whilst at the same time providing a healthy fat intake and of course the flavanoids that produce the improved endothelial function. The study published in the BMJ seems quite convincing although as a meta-analysis and largely observational study, it does have confounding factors and the cohorts had little heterogeneity. Nonetheless for the relatively healthy it's a somewhat better 'medicine' than most of the drugs peddled by 'Pharma' and I have myself, despite my indifference to chocolate (what you say!) started to consume 25 g per day, some time ago.

In the responses there are some detractors, mainly those who are frightened of 'fat' despite the fact that high cocoa mass fats largely comprise monounsaturates with a small polyunsaturates content which the 'mainstream' generally view as healthy. I'd prefer mine with lard to be honest, but I'll leave that for frying my egg yolks and bacon, oh and my 97% meat content, organic sausages. I'll eat my chocolate with a glass of good red wine instead.

Paracetamol (acetaminophen) was in the news recently although if you blinked you may have missed it. This is largely because even in doses that are often prescribed by Doctors in Hospitals (yes really) they can be somewhat dangerous. It does have a cumulative effect especially if taken at maximum dosage for a number of days and in some cases for weeks. The effect on the liver is quite toxic and can often be fatal, especially in those with reduced function in that organ, such as those with even mild alcoholic or non-alcoholic fatty liver disease. Even mild overdose due to timing of intake can be hazardous, and the study in the British Journal of Clinical Pharmacology warned that prolonged usage presented more problems in treatment, and risk of death than did single overdoses. It is easy to forget that no more than 4 doses (of 2x500mg) in 24 hours should be taken, when those doses are taken at 4 hour intervals.

The data is not exactly new and the phenomena well known for some time,  but most was for single excessive doses, a number of which were intentional, although I could think of better ways to end it all than the multi organ failure that often is the outcome. The important lesson, which was not very well reported, is that this is an easy trap in which to fall into. You do not have to be much outside the 'normal' dose parameters to cause fatal consequences, and that is for healthy people. The elderly, children, and underweight and malnourished recipients are particularly vulnerable and it is so easy for people to view this over the counter analgesic, as eminently benign. It isn't, it is potentially fatal at quite low levels. The antidote, N-acetylcysteine, (NAC) another OTC supplement used in some cough medicines, has to be administered pretty rapidly to save lives, although for this problem intravenously by rapid infusion. The window for saving lives is tight, generally eight hours.

Personally, I never take paracetamol, well not any more, as I have known of its dangers for many years. If I'm in any serious pain, which is usually due to arthritis, I use a topical NSAID, such as Ibuprofen gel and even then rarely. The lesson is plain. Over the counter paracetamol and its combination forms (aspirin, ibuprofen and codeine) can be lethal, just as lethal as some potent drugs.

Monday, 21 November 2011

The English Diet and Other Drivel.

Not been too well of late, so I'm having to catch up with a few things. Quite debilitating back pain was the problem; something I've had for some years due to a 'hard life' but which responds to physiotherapy relatively quickly. My thanks once more to Robin McKenzie again for his excellent protocols, they have stood me in good stead, when my back succumbs to the disc problems I am plagued with from time to time.

Posture corrected then, I can (hopefully) satisfy those who waited with breathless eager anticipation for my latest post, filled with my rapier like wit and surgical dissection of the sensible from the profoundly stupid, and there's been a lot of that recently.

The 'English Diet' came in for praise, on the back of a 'study' from Oxford University, and it's pretty much 'wibble'. Based upon the 'Dietron Model' a sort of Monte Carlo simulation (more wibble). It hypothesises, that data gleaned from self reported information from people, (that no doubt told many lies about what they ate), could be in any way be useful to a scientist in his/her pronouncements about that which might make a difference to the health of each of the nations that make up the United Kingdom. House of cards built upon quicksand is the only conclusion that I can come to. It's a corruption of a meta-analysis, that's purely self-reported and observational with a huge array of confounding factors that are ignored. Why anyone takes this sort of rubbish seriously when most, if not all of the conclusions have been proven by good scientific studies, to be untrue really makes me cringe.

It is suggested that saturated fat is taxed and that fruit and vegetables be subsidised and of course salt is restricted. All in the name of better health for the nations that border England. It continues the myth that if we all eat 'healthy food' like (highly volatile) seed oils, rice, pasta, whole grains (brown food), fruit and vegetables (full of starch and sugar) we will possibly live forever! This is of course the advice we've been given for about thirty years with no appreciable benefit thus far other than an increase in the profits of the food cartels and supermarkets, and an inexorable rise in the output of 'Big Pharma' to counteract the consequences of this blatant rubbish. I have debunked most of this before and written extensively about the dogma that masquerades as science, but so long as these 'faux' studies are given air time and media coverage without challenge, ever will it be so.

Moving swiftly on, I note that illustrious body the British Medical Association (BMA), the Doctors Union has pronounced on smoking in cars, especially with children in them. The eminent Dr. No has done a first class 'hatchet job' on the evidence, so I don't need to, except to say that the BMA would be better expending its time and its members funds on other pursuits such as protecting patients, and their membership from attacks by the GMC than involving itself in this sort of support for the Neoliberal agenda to curb personal freedom. This attempt by Vivienne Nathanson to once more proselytise, using the 'child harm' card is typical of most of the 'politicised' class of Doctor, invoking the hysteria that allows the actual evidence to be forgotten, in the face of the dogma. This is the ethos of medical ethics 'at the top'; ignore the vast harms that are perpetrated every day in health care in favour of a distraction to grab a cheap headline in the Sun or the Daily Fail Mail.

Salt, specifically sea and rock salt, is in the news and has been shown to be little different to 'normal' salt. Except of course for the additives, which they obviously didn't include in the analysis. Pretty much the same the conclusion arrived at when organic food was debunked in the media as being no different than say McDonalds'. Of course if one blasts things in a bomb calorimeter all you are doing is analysing the basic constituents and ignoring micro nutrients, which are an important constituent of the human diet that are generally lost in processed food. The same of course is true in salt.

Sea salt, is generally lower in iodine and richer in magnesium than is table salt, but the main thing is that it's natural product used by man for eons, both as preservative, condiment and ingredient, even as a means of payment ( 'sal' means salary). Iodised table salt, whilst having some advantages for thyroid function is also full of additives to make it 'free-running', and anti-caking agents so it doesn't 'stick'. My personal view is that sea or rock salt is better (rock salt is 'old' sea salt), and like many natural products you use less. As for 'low sodium' salt, well, we just put more on our food because you can't taste it! In fact the evidence still shows that sodium reduction has virtually no effect and can even be counterproductive for overall mortality.

And GlaxoSmithKline is having to dig deep to settle its dispute with the US Federal Drugs Administration (FDA). The largest payout in 'Pharma's' history. Even bigger than Pfizer's payout in 2009. It's unlikely to dent the drug giants A+ credit rating. Well there's a surprise then!

And finally  from my new friends, over at the Low Carb Diabetic; this is priceless. They have suffered greatly of late from the sort of complaints that beset bloggers and had their blog removed/blocked on occasions and had a lot of grief from the mainstream idiots aligned with, well you know who they are.

Monday, 24 October 2011

Phones, Breasts, and Vaccines.

The report on the dangers of using mobile phones has been published in the BMJ, and frankly it tells us very little. The cohort sample did not include those who use them for business, who would be the heaviest users, one would think. So not to include these users is a glaring error surely, as in most things, dose dependency would be a significant element of any dangers.  Considerable heterogeneity in the cohort sample also leads one to the belief that significant factors unrelated to mobile phone use, could be at play or simply that those with a subscription may not even use their phone or use it infrequently or with some device that moves it from their head. This study then proves little and reinforces the tenet in scientific study that 'correlation (and observation) does not prove causation', or in this case does not prove any absence of harm. My advice then, for what its worth, is to avoid prolonged conversations, use some form of earpiece to move the mobile away from your brain, and eliminate their use by young children.Oh and wait for some real evidence of any lack of harm, before you drop your guard.

Breast Cancer is again in the news with further evidence of the harms attendant on Mammography Screening. The cited study highlights the increased liklihood of 'false positives' in line with the frequency of mammograms. And the recent Swedish Study reports that screened women had a higher incidence of breast cancer than did those who were not screened and of course the study, published in the 'Lancet' has a pay wall, except for the abstract. Is it any wonder then, that women have little information of an unbiased nature available to them, when this important study is virtually hidden from view, with little or no publicity attached. So the impossibility of informed choice continues. Mette Kalager's  comment in the same journal is telling. Is it not time that the facts were presented to women so as to enable them to discern dogma from fact?

Vaccines rear their dubious benefit once more now the 'flu season is with us once more. Health Professionals (sic) are entreating all over 65, pregnant women and the vulnerable to get their 'jabs'. I have to confess that I don't do it  (there's a surprise then) because I feel it to be worthless. The vaccine offered is not comprehensive for many 'flu strains nor is it tested fully for safety, so I'll take my chances, keeping my Vitamin D3 levels high. Recent studies  have shown little effect for vaccines for the elderly or indeed for those less so.  To be frank, I would be loath to give these vaccines to anyone. They are symptomatic of the interfering nature of the state to govern our health by diktat or worse, 'nudging', without any foundation of the intervention as having value. Most are ( in my view) worthless or even dangerous.

I am capable of acting in my own best interests and I do not need the ambivalent support of the State to guide me toward the best outcome for me. So I told the GP, when he 'hounded' me, as to why I hadn't taken up their generous (and incentivised) offer of a 'flu vaccination, to read the science, and politely suggested that he was just trying to fill the quota and thus get the money. I was astounded when he actually agreed. I think that some Doctors are as much victims of the system that tries to turn citizens into a vulnerable client of the state bureaucracy of health as are we all. Not that I view that as an excuse. Just 'following orders' has never been a worthy defence, even for a Doctor (sic).

Sunday, 16 October 2011

You Want To 'Save' The NHS. Why?

As Thursdays report from the Care Quality Commission reverberates around the media, and adds to the mountain of evidence of misery, that is perpetrated upon that most 'captive' of all audiences, the Hospital Patient, is it any wonder that I question the motives or naivete of those who campaign to save our NHS?

This follows on from the  Royal College of Surgeons Report of only last week highlighting the appalling care meted out to patients who submit to emergency surgery, who or are admitted to A & E Departments at nights and weekends. The NHS is patently sick and cannot provide even the most basic standards of care, despite the vast sums of money extracted from the public to pay for it. 

It seems that the usually 'piss poor' CQC has followed Lansley's diktat and undertaken a number of unannounced 'spot' checks on Hospitals to formulate the report and found many Hospitals sadly wanting in the care of the elderly. Well once more I say 'no shit sherlock'. I could have told you that! Well more power to them, but I have to ponder as to whether they are an adequate provider of vigilance when they continue to be the 'licenser' of Health care Providers as well as it's invigilating body. They are funded by the very organisations they presume to police, which is a clear and present danger of potential bias and lack of independence. They have hardly covered themselves with any 'glory' in the past and the body itself is peopled by many 'refugees' from the PCT's and Hospital Trusts. It is highly likely that without the Health Secretary's urging that this report would have even been compiled. So I have to thank Andrew for that, although little else.

The NHS costs the taxpayer just shy of 8% of GDP in 2009/2010 (just over £100 billion) up from its initial cost in 1949/50 of less than £500 million (£11 billion at today's prices). The greatest volume increase being some £46 billion in the 'Blair' years (1997-2008). Yet we have seen very little improvement (er.. none) in the standards of care or the safety of patients despite this vast increase in expenditure. Under staffing and 'dumbing down', yes we have seen much of that. Vast increases in the apparatchiks and their enforcers and huge increases in pay for GP's and Consultants. Intensive 'marketisation' including PFI and the ISTC's, which even though some patients have been happy with (in the main due to short stays and hotel style accommodation) , does not detract from the view that a properly organised and adequately funded public health service, should be able to do better than the 'private sector', because there is no profit margin to factor into the equation. Hip replacement in the NHS, say £6000. In the 'private sector' £6000 + profit of 25% = £7500. And of course no 'backstop' in event of an adverse incident except to rush the inconsiderate sick patient to the nearest A & E of the NHS.

'Marketisation' then is likely to do little more than bankrupt many Hospital Trusts in the 'brave new world' of the HSCB with the large cohort of  'privateers' extracting ever more from an already creaking budget. But more; the growth of 'disease mongering' in the Primary Care sector will grow at an even faster pace, driven to new heights by the involvement of  'Big Pharma' in the provision of service as well as drugs. There is an already unhealthy relationship between the drug industry and many Doctors and Clinicians as Fiona Godlee stated in her recent BMJ Editorial, citing this study from the US and Canada as evidence of  'less than honest' dealings. I would cite more but the BMJ will not dispense with the 'paywall' on many occasions, thus actually adding to the censorship of that which goes on in the world of medicine, without the knowledge of those who are ultimately paying for it!

I actually find the original NHS model of universal health care as being a fine and principled concept that I supported for many years. I do not do so now, not from any perverse hatred of that concept but that it no longer ticks any of the boxes of its founders. Since 1979 it has been guided by the politics of greed and stupidity, most largely imported from USA. It has received huge increases in funding that have been 'squandered' on flights of fancy that did nothing to improve or even alter patient outcomes. The NeoLiberals gave most of it away to private sector companies who frankly would have no more idea about 'competition' than flying to the moon! Most would not survive at all but for the largess of the taxpayer, they have no other clients! Like the Banks, they have grown fat and lazy on our money, often without having to tender for anything. Like the Banks they have given us little in return, except another bill for our offspring's to pay.

What I would like to see is a new NHS. One that fulfils its original criteria without all the bureaucracy, hypocrisy and reverence afforded to Doctors and Clinicians as if they are some sort of superhero's. There are plenty of good guys out there, they just seem to have lost the ability of shouting louder than the bad one's. Instead of talking 'ball's' they need to find some.

Tuesday, 11 October 2011

"Something Rotten In The State Of Denmark".

So said Marcellus in Hamlet. The same seems to be the case today, with the imposition of a tax on the sale of foods containing saturated fat in Denmark, the home of Lurpak and Danish bacon. But, that any civilised society sees fit to 'ban' anything says quite a lot about that society, especially a foodstuff, that has figured in the human diet, since the beginning of, time, says even more.

There are many strands to this, not the least is that to ban anything needs for that ban to be right. Society's that ban things have done so often at their peril, often inculcating a desire that was only weak into one that becomes an absolute need. We only have to look to alcohol or religions see this as historically inevitable. The 'fight' against drugs is a prime example, where we have squandered billions to achieve little. So to ban 'fat' seems perverse, but of course, like most Neoliberal regimes, the ban allows taxation to be invoked which will then swell the exchequer, so despite the inherent hypocrisy of a nation whose primary exports are (poor quality) pigs and butter (laden with saturated fats) they can still make money from their people and those of other nations whilst at the same time feeling the warm glow of moral superiority.

As many that have read my words know, I'm a convinced 'low-carber' with a predilection for fat and protein and have produced a considerable body of evidence that proves it's lack of any danger, over many of my posts. I have a hatred of dogma, cant and hypocrisy. The Danes have proscribed a number of foodstuffs, in the past few years including a ban on 'transfats' (trans-isomer fatty acids) and a tax on sweets, together with products high in sugar, and I would endorse the sentiment but I'm sorry, I can't endorse the legislation. If any society is to ban anything, it has to do so from a viewpoint of absolute morale integrity based upon complete and unequivocal evidence that considerable danger is invoked by indulgence in the item(s) or protocols involved. It is clear to me that Denmark is unable to do this; the evidence denies it. Yet nonetheless they have. Chris Masterjohn has an interesting and somewhat philosophical viewpoint about the Danish 'fat tax', it's worth a read. He is somewhat more credentialed than am I but comes to similar conclusions.

Sadly, it is highly likely that such a tax/ban may be invoked by the current Government (the 'toffs') who cannot grasp the concept of reading the evidence prior to rushing to legislate, especially if their efforts yield some more of  'our cash' for them to squander in the pursuit of some pointless policy or other, or to hand to their favourite consultants or offshore equity capitalist. Denmark's death rate from CHD also seems to be one of the lowest in Europe. France of course still manages to be the country with the lowest events per 100,000, despite the fact that it has the highest intake of saturated fat in it's diet! So once more science is traduced by dogma, integrity by greed. Politicians, what can you do with them. Wall and firing squad appeals to me.

Tuesday, 4 October 2011

No Shit Sherlock!

The Royal College of Surgeon's (RCS) recent report on the appalling death toll of patients admitted for out of hours and emergency surgery is to be commended. It has been a long time in coming and highlights the dangers associated with being admitted to Accident and Emergency in the evening, or worse, at the weekend. It sheds light on the dangerous and often fatal, lack of care imposed upon patients who present with, often simply diagnosed conditions, who then become even sicker than on admission due to lack of manpower, facilities and very basic care that all of us hope to avail ourselves of, should we be unfortunate enough to have an accident or become ill outwith the Primary Care pathway.

The NHS is quite good at the provision of elective surgery, especially cardiac surgery. It is however significantly lacking in safety when it comes to major general and emergency surgery, with both higher mortality and complication rates than are acceptable in the setting of modern hospital care. Of 170,000 patients treated for non-cardiac surgery we manage complication rates of more than half at 100,000! And of those, we actually manage to kill 25,000! Mortality rates for emergency surgery in England and Wales is over 25%, with early discharge and subsequent re-admission being a significant factor in these statistics. The other horrifying figure is that our chances of dying is 10% greater if it's a weekend!

Well I'm no stranger to this situation, when she, with whom I have have decided to end my days, became part of these same statistics. Delays, both in pain management, diagnosis and treatment at a very basic level were missing, possibly because it was early on a Friday evening. No Consultant on duty, just a few nurses or rather 'healthcare assistants'. Of Doctors, well none until some five hours into admission. Tests, well there were plenty of those, in fact it seemed to be a goal rather than any sort of pathway to treatment, as hindsight indicated that none of the results were followed up! An X-ray was eventually carried out, but nonetheless a a treatment protocol was then pursued that was contraindicated and injurious and resulted in an outcome she still lives with to this day and which will blight her life until it's end.

Weekend surgery did take place, 'squeezed' into the list between the 'elective' private patients who had the surgical suite given over to them for some Saturday 'bunce' for the Consultants. Postoperative care was poor to non-existent with severe hypotension ignored, as was the diabetic keto-acidosis, and very low oxygen saturation that kept triggering alarms ( to my alarm).

So, this report does not surprise me in the least. The apathy and stupidity demonstrated to me by my personal involvement in this event did at the time. Up to then (2008) I had not had any chance to witness first hand the terrible position in our hospitals especially in emergency care. Any contact I did have had faded, like most bad memories do; part of that 'defence' mechanism our minds have to retain sanity. Despite my many ailments, and a minor wound in my early history with firearms, none was dependant on a hospital stay and I hope that it remains so. So dear reader, I would suggest that you plan for any emergency you may have in health care for you and yours, on a weekday between 0900 and 1700hrs. Or of course join with me and others to press for a whole new paradigm in health care and medicine, that is patient centred and based on scientific treatments. I want to tear it all down, rip it to shreds, along with many of those that perpetuate it by virtue of vested interest or hubris or worst, apathy.

Tuesday, 27 September 2011

The Road to Perdition.

So as the Greek storm threatens the destruction of what is left of it's fragile democracy, and the two Ed's join together in a trip to Knotty Ash, in an attempt to rival Ken Dodd's stage presence, I look to our leaders for guidance and comfort. Cameron's not for turning; I vaguely remember that from my past. No, it's gone. Ball's will not promise any change. And Angus is pissed off with Tesco.

So, as the sun slowly sinks over the UK economy I am left to my own devices to ponder the solution for our ills, and I am reminded of something that one of my few hero's said. "The world cannot get out of the current crisis with the same thinking, that got it there in the first place." Yes it's from the wondrous Albert (Einstein that is). As is usual, that which he said about the crisis of capitalism applies equally now, as it did way back in 1949.

The British political classes, irrespective of whichever party to whom they belong, have one priority; the repayment of the 'deficit' by those who can ill afford it, and didn't cause it, rather than those that did and can. The Financial sector, basking in the sunlight of handouts and bonuses, is completely unperturbed, safe in the knowledge that Governments all, are held in thrall by their pronouncements about whole economies, and remain hostage to the fortune of diktats honed by wankers bankers in boardrooms throughout the Western World, despite their implication in the very crisis to which they profess to have the solution. All whilst we continue to wage wars in lands afar, support the 'Arab Spring' with strong (ish) words to the dictatorships to which we still peddle arms, and rain down Brimstone missiles on the opposing side, and the innocents, in a Libyan 'proxy' war, fueled more by the prospect of oil, than any righteous hope of the rise of Democracy. I have no time for Gadaffi, but frankly none for the self styled rebel leader Mustafa Abdel Jalil either, who is staging little more than 'coup' than any revolution, and has slaughtered thousands both in the past, and now in his pursuit of power. Not of course forgetting the Napoleonic ambitions of one Nicolas Sarkozy.

This moral bankruptcy is redolent of the paradigm in politics of the past thirty years, the Neoliberal agenda. That which espouses the 'market' as the most efficient tool of Administration and accepts, on behalf of those who vote for them, that a large proportion of the people will be condemned to both poverty and/or inequalities that spring from it's policies. It's democracy usurped by the rich for the impoverishment of the remainder. Forged by the 'Iron Lady' in concert with an aging film star who ruled the USA in the early eighty's, it has predominated Western politics ever since. This is why politics is bankrupt of any new ideas that can extricate us from the hole in which we now reside, but which nonetheless pursues the same one's anyway, as it has for the past thirty years. The word 'Socialist' has been eliminated from all the parties of power in the Western World just like 'nuclear' was expunged from the names of the power generators, and who now hold out their hands for subsidy from the people, to build a new generation of reactors, so they can charge even more for the product we can none of us live without.

Neoliberalism is the reason why the NHS is what it is now and more, what it is to become. The Paymaster once more becomes the supplicant, hoping for some crumbs that may be scattered from the 'top table' of Serco, Carillon, Crapita, and all the myriad facilities managers, management accountants, hedge funds, merchants bankers who 'leech' off the funder of their profligacy, the people. This agenda is not openly touted, so the 'paranoid indifference' of the masses is largely a myth, invented at the dinner parties of the chattering classes, and the pages of the 'Indy' or the 'New Statesman'. It is in fact a hidden agenda, an open secret that is almost the 'elephant in the room'.

It's the movers and shakers, who 'flit' through the revolving door of public service, and back again with the ease of those who know power and relish in it who have shaped this model. Heavily subsidised from the taxpayer, they feign resolute independence and ardent if not passionate belief in the 'market' to sort out all of economy's ills whilst enjoying the hypocrisy of their six figure comfort of taxpayer gold. The rest of us look on in startled incredulity that such a belief system can be sustained, but that is the supreme tenet of politicians; perverse and single minded confidence in their own stupidity, as being wisdom. It is the MP's who have never known what it is to work for a living in a 'real' job, who came straight from University, to research assistant, to PPS, or the 'Parliamentary Silk' from a lowly place in 'chambers'; all of these are responsible for the paucity of 'real people' in the corridors of power, and for the rise and rise of the Neoliberal agenda.

So then Ed and err...Ed. Try to remember you are in the Labour Party, an organisation formed from the blood, sweat and tears, all spilt on its foundations, in a world that was different from today's. We can return there if you continue with the cowardice and hypocrisy of Blair and Brown. But I cannot forget the men of my youth who recounted tales of fighting in the Spanish Civil War, of battles with mine owners, and of blood spilt to provide the children with enough food to sustain life. If you want us to return to those days then just go as before. You and your ilk will not feel the sting of poverty, wrought in the name of the 'deficit', your deficit will be in the integrity that you fail to display. Less 'bollocks' and more balls is what we need!

Friday, 23 September 2011

Lying Bastards!

Writing this post on my shiny new computer, after the old one gave up the ghost and left me bereft of data, that I still have to retrieve, and of course the means to post anything. Should have gone to 'laptop savers' ie; Angus Dei's Kitchen but took it to my local poxy computer shop, where it still resides.

Andrew Lansley has been bemoaning the dreadful position  of NHS Trusts who have been burdened by huge debt born of the Private Finance Initiative 'foisted' upon them by the 'previous lot' ( Blair and Brown). In the process conveniently forgetting that, for all their faults, which were legion, it was an inheritance of Conservatism of the Neo-Thatcher era, who actually 'spawned' the beast. Politics has a dreadfully short memory.

PFI was the invention of a certain Norman Lamont (with others) upon the relaxation of the Ryrie Rules in 1992. In fact a number of major projects were well under way or had even been completed prior to the victory of the Blair Administration in 1997.

The M6 Toll Road (1992)
The Second Severn Crossing (1990)
Croyden Tram link (1996)
Northern Line Trains (1995)
And many others, including the Channel Tunnel.

Blair of course embraced PFI with almost evangelistic zeal and built further upon it, to the extent that almost every public project on his 'watch' was financed in this way. Graham Allen's paper from 2003 details the position taken by 'NuLabour' in its flawed construct to sell off our childrens' futures, to finance grandiose plans, that would make them look good, but conceal the real cost. Even to the extent of selling the Army's estate along with that of HMRC, then leasing it back at guaranteed rates. The company involved was of course based off-shore so we don't even get any tax back for that which we pay. Which is that which all parties involved in PFI actually factored into the cost, so as to represent the deals as 'better', than less complex vehicles for funding that were cheaper, and at least left the taxpayer with an asset at the end.

What has happened, is that the Governments Advisers, both now and then, (KPMG) factored in the taxation element into the cost analysis for public consumption, then were retained by the PFI outfits to advise on how then, to avoid the tax. Some might call them treacherous bastards, but I could not possibly comment. What is sure is that Government, both central and local were queueing up to get deals brokered and operated by the 'usual suspects' ( Carrilion, Serco, Interserve, Capita et al) which were then often sold to offshore equity' finance outfits and they then 'pocketed' the difference, or simply refinanced once the rates got lower. After all, the new owners were looking at profit stream of the order of 15% to 17% per annum and the operators were able to charge £200 to change a light bulb, or £500 to hang a picture, (I've just hung 12 in 1.5 hours for £6 in hooks) as well as exorbitant service charges.

As all these participants were and are contributors to the Tory party 'coffers' and a number of the cabinet have either worked for them directly or indirectly, and they objected little about the use of PFI during Nu-Labours years, it seems a little hypocritical to 'cry wolf' about at this stage. And of course Gove has just sold the Governments share of the 'Building Schools for the Future'  LLP, (as reported in Private Eye) which owns the 700 schools already built under the PFI scheme, he recently closed on the grounds of "massive overspends". And to whom were they sold? Yet another 'offshore' investment outfit called International Public Partnerships, based in Guernsey. So no tax there then!

This Government, despite all the rhetoric they spout about about PFI, seem to be just as hell bent on utilising this highly flawed model of financing, as the 'last lot', and they did after all both invent it and facilitated the legislation needed to allow its rise. So I would posit that Lansley's complaints are really for 'public consumption' only, with  a whole different agenda, being planned behind the scenes. So is anything safe in the ConDems hands? Well probably not; they are politicians after all. A treacherous breed at best!

Thursday, 8 September 2011

The Point of Departure.

As the Leviathan that is the Health and Social Care Bill, lumbers inexorably to a vote, shrugging off the attacks on its content, like a Tank does small arms fire, I have pondered as to what I would like to see the NHS become. Certainly not that which it is now, so I do not want to 'save it'. And 'curing it' does not appear in any agenda for Health that I can conceive of, because the cancer within has all but consumed the host. Spectacles of a rosy hue, seem to have been donned by the 'liberals', now that their precious NHS is under threat. All the transgressions of the past seem to have been forgotten and it is now to seen  as a beneficent, almost angelic body that we should strive to save from the evil machinations of the Tory's. In reality, nothing could be further from the truth.

At it's inception, the NHS was a construct based upon universal health care for all. Sadly that did not compute with Doctors of the day, so it was 'hijacked' by the Consultants and whilst the 'proles' got their boils lanced and their teeth pulled for free (well almost), there still existed a 'cabal', a 'mafia' of senior Doctors and Surgeons who dispensed their largess very much on a part-time basis, but nonetheless held sway at the BMA and called most of the shots. Several incarnations later (there were many), once a few of the miners son's had made it to Medical School and infiltrated into Hospitals it became it little less elitist, but the 'firms' still held sway, with the 'rugger playing' registrar being more the norm than a lad from the terraces of an Allan Sillitoe novel, even more unlikely a girl! So we move forward through time and seventeen major reports and reorganisations later we arrive to today, or rather the white paper of the Coalition of July 2010 Liberating the NHS (didn't realise it had been imprisoned) from which sprang the Health and Social Care Bill. But, long before then the NHS had lost it's way.

The Thatcher years saw the invention of 'fundholding' and of course the bureaucracy attached to that hugely expensive and pointless accounting system that it was, causing mountains of paper invoices to be generated and mailed to each component of the system. The invention too of the Hospital Trusts, and of course the 'internal market', providing an entry for Private Health care to the NHS, and a proliferation of 'for profit' organisations and Hospitals. Tony Blair, not wishing to be seen in any way as 'socialist' perpetuated and embellished many of these policies including privatising the 'out of hours' provision of Primary Care, Foundation Trusts, incentivisation of GP's and of course the spectacularly useless and costly IT projects, together with the expansion of the Private Finance Initiative. In fact the only good thing he did was to eliminate the internal market, only sadly to decide to reinvent it just before he left office.

In all of this we have seen the 'legacy' of the Thatcher years become the Neo-Thatcherite agenda of today which sprang from the Neo-Liberals of yesterday, all completely oblivious to the vast sums of money they were spending, to achieve little other than the enrichment of an 'elite' cartel of Accountants, Facilities Management Companies, and Consultants, not forgetting 'Big Pharma' of course and to the detriment of the 'end user', the patient, who had no input to all of this, except of course to become a 'victim'. I say victim without any hesitation, because the joint efforts of the politicians, GP's, Consultants, and all the retinue of Nurses, Bureaucrats and hangers on have done virtually nothing to improve the lot of the patient but simply improved their own. I have no desire to save anything for any of them, they are completely undeserving even of the the little patience that I have left.  The GP's are more concerned about their pensions than patients, the Hospitals more interested in the preservation of their empires, even if it's at the expense of patient safety, than adopting better and less invasive protocols, or the concentration of specialist services in regional centres and thus improving mortality (childrens heart surgery?). The health care charities have been 'hi-jacked' by Pharma as patient advocates, to peddle drugs like Avastin which may prolong very slightly, the lives of terminal cancer patients, at enormous expense (and their profit) and with a whole host of side effects that can be terminal in their own right. All in the NHS and those outside it who will be 'willing providers', have an agenda that has nothing to do with patient care and everything to do with profit, with preserving power, extending control and personal gain.

Why for instance do we continue with Angeograms when we can utilise Electron Beam Computerised Tomography which is non-invasive, less dangerous and considerably less unpleasant. Because it's cheap and a lot of people will lose their jobs, power and influence if we 'can' it. Why do we continue with the 'sham' treatment of healthy people for heart disease they haven't actually got, because they have fulfilled some test criteria for a 'surrogate marker' evidenced by one of (several) computer 'risk scores' that are frankly useless and have been proven so. We also 'treat' perfectly healthy pregnant women, simply because 'we can', to ultra-sound scans, hospital births, inductions and other invasive procedures that for most are not needed, when we should be saving them for those that are 'at risk'. Why do we allow 'Pharma' to 'bribe' physicians and Surgeons with nice little 'jamborees' in exotic locations, 'free lunches', financial support for 'pet' projects and studies, all in the interest of promoting their dubious and often dangerous drugs and devices. Of course no Doctor would be influenced by such largess (and Genghis Khan was a really nice guy).

That is where I depart from the 'curers' and the 'savers'. I have seen my best friend die from stupidity and misdiagnosis. My father from neglect of his chronic illness. Almost lost my sight in one eye and watched the woman I love treated with appalling callousness, have her life endangered and her future blighted forever, for the want of diligence in simple protocols that are the foundation of medicine. Many of my friends have lost everything in their lives at the hands of those who swear to 'do no harm' and I have seen them rage at the impotence they have felt in their pursuit of justice and candour.

Denial of their incompetence seems to be the only thing at which Doctors are actually any good. So I want not to save the NHS, I wish it to be demolished like a fire gutted, dangerous building. Let the ConDems do their worst and destroy what is left whilst the Labour dissemblers snipe at the minutiae of the Bill, sure in the knowledge that they would have done little differently. Perhaps then, when we see yet again the differences and inequalities that will have been forged in England's NHS and we look North to Salmond's fiefdom where a new social democratic model is being invented, we can rebuild it as it should have been. I truly hope so, before I'm saddled with the DNAR.

Thursday, 1 September 2011

Screening for Cancer Fails to Prove its Worth.

I have talked at some length about Breast Cancer Screening  before, and accused those involved to be more interested in perpetuating the myth that 'screening saves lives' than in providing facts for women to make an informed decision. Well, the clamour is getting louder for 'real information' to be available for this and other screening protocols and what are the advocates doing to quell the disquiet? Closing their eyes, ears and more importantly their mouths.

The recent study in the BMJ showed clearly that screening (mammography) is not responsible for the reduction in Breast Cancer mortality seen in six Eurpoean populations. In fact, in a few of these countries, mortality was reducing prior to any screening protocols being in place. The response of the screening lobby   ( a powerful vested interest), has been resounding silence, to these obvious negative inputs to the argument. Displaying the trait it seems of the 'three wise monkeys', as Richard Smith  explained on his BMJ blog.

Screening for Bowel Cancer too has been having some bad press as the relative risks are presented as absolute in the leaflet provided to the prospective cohort (including me). In truth the risks are quite small and the relatively 'crude' methods involved in screening lead to many false positives, waits for confirmation, and much unneccessary treatments, investigations and, the attached risks of harm involved in colonoscopy are actually higher than the likelihood of Colerectal Cancer (much higher at 1 in 150) and the risks of  procedure causing perforation and the consequent risk of pertonitis is 1 in 1500. Risk of death is pretty low at 1 in 10,000, but that is close to the absolute risk anyway, which is less than 1 per 1000 in ten years of screening.

Mitzi Blennerhassett, wrote in Macmillan blogs about the dearth of information, and indeed the bias of that available and she is (thus far) a survivor of colerectal and breast cancer, so she talks from the frontline. The replies to the BMJ about the study also make fascinating reading, with much criticism of the lack of evidence and indeed the arrogance portrayed by most in the 'business' (for that is what is) when questioned as to the efficacy of mammography or indeed most forms of cancer screening.

The NHS spends vast amounts on these protocols, allegedly to save us from 'harm' and an untimely end, but fails consumately in simple areas of diagnosis of illness in so many patients, treats the elderly with appalling disdain, even cruelty. Is lacking in 'adequate out of hours' trauma provision. Trains Doctors to be patently less good at the job than in the past, then 'throws' them into the maelstrom of A&E with little or no mentoring or backup. When scientific evidence is presented that indicates that a drug or procedure is harmful, especially Primary interventions for prevention using 'surrogate markers' or end points, rather than a patient actually being ill, they ignore it!

Prof. Michael Baum with others, ( 3 pages of them) wrote to the Sunday Times about this lack of information and the virtual conspiracy of silence that exists around the harms, way back in 2009. He was ignored. He wrote again recently but that's behind a paywall now so I can't post that link. The signatories are seeking  a judicial review of the screening programme because they are so incensed by the lack of information and potential harms it causes. The conspiracy of silence continues with evidence stacking up in the aisles that we do little to end the tyranny of Cancer but much to find it, where it doesn't exist and even more to treat it with questionable drugs and procedures that may in fact add to it's virulence. A scientifically informed choice is what is needed and an NHS dedicated to curing the sick and the lame, and giving comfort to the dying, not that which we have now.

Tuesday, 23 August 2011

Obesity (Again).

Being overweight remains in the news, with bulk of opinion being slanted toward the view that people who are in this state (obesity and the UK) are largely responsible for their own predicament. I not only find that somewhat cruel, but also founded in poor or even bad science.

I've already said in my previous post that is unlikely to be the fault of the 'fatties' but more of those who are advising them to eat a 'healthy diet' which in the DH 'speak' will largely be carbohydrate based and 'low fat'. In the latter's case that will be monounsaturated fats and polyunsaturated fats instead of saturated fats. Plant based oils (generally) then, in lieu of animal fats. This last bit of advice seems to fly in the face of the fact that homo-sapiens have some problems in metabolising some fats with CIS bonds (and even more problems with fats containing trans bonds). Animal fats such as lard, tallow and dripping, also contain quite large amounts of mono and polyunsaturated fats despite their undeserved reputation for being  entirely 'saturated'. Yet, it is patently obvious that this advice to avoid saturated fats and animal fats in particular, has done nothing to reduce the incidence of obesity and the associated risks of Diabetes, CHD, CVD and Cancer, because it continues to increase.

Looking in more depth at Nutrition and it's relationship with obesity we have to consider the mechanisms involved in becoming overweight. 'Hyperphagia' is synonymous with obesity, that is over-eating in simple terms. It can be a result of some genetic disorders or Diabetes, especially in Type 1's who inject insulin. It also manifests itself in Type 11's who are in advanced stages of the disease. High Carbohydrate diets typically can bring about this problem due to increased gene expression of the neuropeptide Y(NPY) in the hypothalamus, and causing a reduction in the expression of the hormone (CRH). What that means is that the brain is increasing its output of orexigenic (hunger generating) agents and decreasing output of anorectic (hunger suppressing) agents. This is how the brain stimulates our nutritional needs of hunger and satiety. So, it is evident that early stage diabetics (metabolic syndrome), Type 11 diabetics and the obese subjects will be permanently hungry. If, however we feed them a diet of fats and proteins and eliminate most carbohydrates, this phenomena is suppressed in a more 'normal' manner and appetite is curtailed at a much earlier stage in eating.

Forcing people then, to eat a 'healthy diet', two thirds of which is carbohydrate based, if we include the vegetables and fruit, is contributing to the obesity that it is meant to be reducing! Once we become 'insulin resistant' as well, we can arrive at a position where almost all intake is rapidly stored as fat, despite the fact that we are hungry, even starving, and our ability to 'feel full' is almost non-existent. Low carb diets, especially in the context of this section of society, are proven to have a considerable success in enabling obese and diabetics to attain an optimal weight and, more importantly, to maintain it. The mechanism is not fully understood, and there is considerable conjecture amongst biochemists that it may be down to ' metabolic advantage' with fats and proteins, or the satiety afforded by this food group actually reducing the calorie intake, or even the fact that increasing saturated fat intake, replaces vegetable/seed oil intake (generally Omega-6's) and that in itself helps to reduce obesity. Many hypotheses are propounded, reputations impugned, the science examined, re-examined and much that is known is based upon animal studies, not humans, but whatever the mechanism, it is certain that for most, a low or minimal diet of carbohydrates does bring about considerable weight loss and a 'normalisation' of blood sugars in most diabetics (Type 11's). Dogmatic views about diet and nutrition, without examining the science involved and ignoring outcomes, is what has brought about the ever rising tide of obesity and diabetes.

Those of us who are 'insulin resistant' respond to this more readily than any other cohort, and it is not a panacea for all, by any means, because all of us reach a plateau with our bodies, some quicker or slower than others. In fact being slightly over weight has some advantage for humanoids and was likely a defence mechanism against famine or periods when food was not abundant. The body in fact conserves energy in fat reserves and is quite loath to give them up, which is why so many dieters fail in their endeavours to lose weight because basal metabolism 'slows' as we begin to diet, especially with low fat/low calorie diets. Your body is attempting to 'save' you from yourself.
Completely Unnecessary Picture of Low Carber J- Lo

So why does mainstream advice for lowering the risk of obesity and the morbidity's that stem from it, continue to advocate measures, that are most likely to fail either in the short or long term? Well having your beliefs undermined, no matter how much evidence exists to prove you are wrong , is hard to bear, even for Doctors and Scientists.Being told what you want to hear, is comforting and reinforces preconceptions at the expense of the truth. Selection bias is something we are all guilty of at some time and I admit to it myself. We should not defend the indefensible but all too often the truth becomes clouded by hyperbole. Scientists delight in the rigour of 'peer review' often tearing quite good studies to pieces because 'they can' rather than due to any poverty of evidence. Equally as well they often lose the ability to reflect that 'correlation (and observation) does not prove causation' in the data they present. Which is why we get 'scare' stories extrapolated from views and opinions of Scientists, rather than hard evidence of harm.

It should not be countenanced and I have always believed that all of us  need to be as objective as possible in our search for truth, even when that truth challenges our basic and long held belief system. 'On the word of no-one' (Nullias in Verba), only the proof, is what we need.

This post has been devoid of links thus far. I've saved them  to the end. I've used some before, so don't be surprised to see them again. They all possess the 'gold standard' of trials, they are RC T's.
      1. Brehm BJ, et al. A Randomized Trial Comparing a Very Low Carbohydrate Diet and a Calorie-Restricted Low Fat Diet on Body Weight and Cardiovascular Risk Factors in Healthy Women. J Clin Endocrinol Metab 2003;88:1617–1623.
      2. Samaha FF, et al. A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obesity. N Engl J Med 2003;348:2074–81.
      3. Sondike SB, et al. Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents. J Pediatr. 2003 Mar;142(3):253–8.
      4. Aude YW, et al. The National Cholesterol Education Program Diet vs a Diet Lower in Carbohydrates and Higher in Protein and Monounsaturated Fat. A Randomized Trial. Arch Intern Med. 2004;164:2141–2146.
      5. Volek JS, et al. Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women. Nutrition & Metabolism 2004, 1:13.
      6. Yancy WS Jr, et al. A Low-Carbohydrate, Ketogenic Diet versus a Low-Fat Diet To Treat Obesity and Hyperlipidemia. A Randomized, Controlled Trial. Ann Intern Med. 2004;140:769–777.
      7. Nichols-Richardsson SM, et al. Perceived Hunger Is Lower and Weight Loss Is Greater in Overweight Premenopausal Women Consuming a Low-Carbohydrate/High- Protein vs High-Carbohydrate/Low-Fat Diet. J Am Diet Assoc. 2005;105:1433–1437.
      8. Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and learn Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women. The a to z Weight Loss Study: A Randomized Trial. JAMA. 2007;297:969–977.
      9. Dyson PA, et al. A low-carbohydrate diet is more effective in reducing body weight than healthy eating in both diabetic and non-diabetic subjects. Diabet Med. 2007 Dec;24(12):1430-5.
      10. Shai I, et al. Weight loss with a low-carbohydrate, mediterranean, or low-fat diet. N Engl J Med 2008;359(3);229–41.
      11. Krebs NF, et al. Efficacy and Safety of a High Protein, Low Carbohydrate Diet for Weight Loss in Severely Obese Adolescents. J Pediatr 2010;157:252-8.
      12. Summer SS, et al. Adiponectin Changes in Relation to the Macronutrient Composition of a Weight-Loss DietObesity (Silver Spring). 2011 Mar 31. [Epub ahead of print]
      13. Daly ME, et al. Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes–a randomized controlled trial. Diabet Med. 2006 Jan;23(1):15–20.

      Thursday, 4 August 2011

      Obesity - The Bing Crosby Approach.

      "Accentuate the positive, eliminate the negative!" That is the 'spin' of politicians and doctors,  who wish those endowed with excessive subcutaneous fat to be nudged into a healthier paradigm for life. Yet most of their 'crooning' is patently wrong. It is said that more and more of us are getting fatter, and as a consequence, putting ourselves at higher risks for heart disease, diabetes, liver and kidney failure, together with a myriad of co-morbidity's associated with the 'obesity explosion'.

      Fellow blogger the masked crusader has a rather darkly humorous solution, but his description of the obese as 'pie eating lardbuckets' is somewhat harsh to say the least, because it is the advice that many of his colleagues provide to 'fatties' that is fueling the crisis. It is also obvious that his cunning plan to recycle the result of liposuction is fatally flawed. The energy needs to enable such a 'rendering' would far outstrip that provided by the resultant product. So, put down that pie and pay attention!

      Obesity is defined by having a Body Mass Index of 30kg/m2, which can be ascertained by dividing your weight in kilo's by your height squared. For someone 6ft tall (1.8mt) and 11 stone (70 kgs) that would be a BMI of 21.60kg/m2. There are, as one can imagine, quite a few people with lots of muscle who would then be called 'overwieght' (BMI of 25 - 29.90) and even obese, so the formula does not fit all. In fact, whilst subcutaneous fat is an indicator of obesity, it is visceral fat (the fat around internal organs) that is a better predictor of disease.

      The recent survey on health and obesity from the NHS shows some quite interesting data, especially on diet (although it will take some time to read all 112 pages), which does show that advice to eat '5-a-day' is working with the 5 to 15 year old's as consumption has doubled. All people are also eating less trans-fats, saturated fats and sugar than 10 years ago, and calorific intake has tended to decrease since 2006. Yet we are still getting fatter, have more diabetes and heart disease (despite the fatalities from it decreasing). We are as a whole also taking more exercise, with a 7% increase (absolute) between 1997 and 2008, with men exercising much more than women. Surely, it is sensible to assume then that this advice, issued to the public and taken up, should have made some inroads into the obesity epidemic, even if only small, but it hasn't, if anything things are getting worse! Could it be that the advice is wrong? Err... well yes!

      Looking at the advice we have; eat less fat, eat '5-a-day', take exercise, don't smoke, drink only a little of alcohol, don't eat sweets or sugary drinks, and of course consume carbohydrates in vast quantities, up to two thirds of your food intake (when you take fruit and vegetables into account). Now that we have been doing that for about thirty years, at ever increasing frequency, we are then told that; we are all lying about what we eat and we are eating far too much, remembering of course that average calorific intake has diminished since 2006, which together with lack of exercise (or not enough of it) is the reason for the spread of obesity and disease. So by 'accentuating the positives' of low fat, exercise, and non-smoking, and 'eliminating the negatives' of saturated fat, meat, alcohol, lack of exercise etc. etc. we have achieved, well nothing!

      Now we are told, that if we are above a certain BMI, we smoke, or drink above a certain limit, that we will be proscribed from various treatments on the NHS, because it's all our own fault and we are a bunch of lying, drunken, "pie eating lardbuckets", who do not deserve the largess of the NHS to help us fix the problems that ensue from our aberrant behaviour. What a crock of s**t! What about the other cohorts in society, who run in marathon's or just run in the the vain hope of 'super fitness' and end up in dedicated 'sport injury clinics' in the NHS? Or those who diet to the point of death, because society's model of beauty is a size 6, or indeed children diagnosed with ADHD, because their parents take the advice of the DH and feed them sugar laden grain products for breakfast, because it's 'healthy grains', pasta (wholewheat of course) and bread with almost every meal (brown of course). Surely all of these are equally responsible for their plight as is anyone who is said to be a chronic 'over eater'. This is Eugenics for 'fat people' and in my view is bordering on racism for adiposity.

      You get fat not because you eat too much, or don't exercise but because you eat the wrong things, usually based on the advice of the Dept. of Health, or Heart UK, or Diabetes UK or one of the other self serving organisations we allow to govern our lifestyle choices, simply because they are heeded as being 'expert', when in truth they preach misguided and unscientific dogma. Despite the fact that they have been doing so since the late 1970's with no tangible proof of success, or indeed any evidence to support their ludicrous claims that they 'know best'. Often their advice is based upon Food Industry claims completely unsupported by any evidence because they want to sell you something. Or indeed some pseudo science from the USA that has long been disproved as fantasy.

      There is no evidence that fat, makes you fat. None at all. Never. There is no evidence that eating saturated fat causes heart disease. In fact there is considerable evidence that the converse is true, with low carbohydrate, high fat and protein diets being the best solution for weight loss and health. There are many proofs of this but the most meaningful is the biochemistry involved in food intake. Carbohydrates are the food group that requires an insulin reaction to enable them to be metabolised, and conversion to glucose, no matter what their glycemic index is, will be extremely rapid, and more importantly virtually completely, to provide energy needs. The problem is that glucose, if not used up immediately is stored as fat and it is very difficult to utilise all of the glucose from a high carbohydrate meal immediately no matter how much exercise is taken. Fats and proteins are somewhat different in that they are not metabolised rapidly but quite slowly and not with the same ruthless efficiency as carbohydrates. Protein intake is needed for cellular generation from the amino-acids formed from their product in the body, so little is stored as fat. Fat is metabolised very slowly and with very low efficiency with nearly half of intake being 'wasted' and passed as ketones in urine. And of course, the 'calories in calories out' paradigm peddled as the 'gold standard' for diet is fatally flawed because of this.

      The use of a 'low carb' diet has proved to be the most effective for weight loss for over a hundred years and it's modern equivalent 'The Atkins Diet', the 'Paleo Diet' or indeed any of the more up to date versions of diets reliant on fats and proteins in varying mixes to achieve a reductions in body fat are in the ascendant, yet the DH and Doctors generally seem hell bent on ignoring evidence of its efficacy. I find it difficult to see why.

      It seems perverse to refuse treatment to any sector of society however guilty they may be of their predicament at the same time as providing it to others who are intrinsically as guilty, but worse have deliberately pursued a reckless course of exercise, or driven too fast, when drunk, or taken drugs. Fat people have usually tried hard on low calorie diets, or worse taken some of the awful, and generally useless drugs for obesity and consistently failed. If healthcare continues down the road of diets that set up the obese to fail, they are just as complicit as those they refuse to treat, indeed more so. Taken to extreme, why not have an undertaker posted permanently at A&E to wait whilst undeserving patients expire?

      I seem to remember that a certain Steve Field, once head 'honcho' at the RGCP (now replaced by the excellent Claire Gerada) was a bit of a 'lard bucket' at the same time as he was selling us the idea of a 'healthy diet', didn't seem to work for him either! (Sorry, couldn't resist).

      Sunday, 10 July 2011

      Counting the Harms (and the cost),

      I hold the view that the NHS is responsible for considerable harms. The cost of those harms, both financial and in lives, are often overlooked by the populace, because they hold to their bosom's a number of myths about disease, and how it can be avoided by 'screening'. That protocol is more of a political imperative than one borne out by the science. Cancer is one of these. We all want to believe that the NHS can save us from a terrible termination of our lives by 'catching' this scourge of contempory existence, in it's early stages and thus saving, or at least prolonging our lives. We are deluded. And it is 'bosoms', probably most of all, where screening concentrates it's efforts.

      Breasts, define the difference between the sexes, perhaps more than any other element of  appearance and they are an emotive indicator of feminism, much admired by men and cherished by women, whose fear of breast cancer and the loss of that essential feminism, seems to be a real and present danger. But, that is largely a myth. Incidence is in fact between 1 and 2 per 1000 per year, dependent upon whether you are pre, or post menopausal. In fact 80% of detected breast cancer occurs in women over the age of 50, so this cohort is the most at risk. However, if we compute that into a ten year risk analysis, then 994 women out of 1000 will not get breast cancer.

      Fiona Godlee in the BMJ of March 2006 questioned the ethics of screening and came to the conclusion that it was overstated for efficacy and 'over diagnosis' was a considerable failing of the system. This is reflected in the views of Professor Michael Baum in this critique he wrote in 2008, shortly after he resigned from the programme which he had helped to set up. Principal amongst his thoughts, are that screening does not cure anything it just detects asymptomatic disease; breast cancer, well maybe. But 'catching it early' does not devolve any cure, merely a postponement of the inevitable fate of us all, for a somewhat flawed paradigm of periodic testing, that in itself has unpleasant and somewhat dangerous implications for the recipient, with no gaurantee of longer or better life than would have been the case without it.

      Mammography is the current test protocol for the early detection of abnormalities, which involves quite high levels of ionising radation, being delivered in several doses, to ensure an 'allegedly' complete picture of the breast. In fact the dose is equal to 1000x that from a standard chest X-ray, so there is some considerable dangers attached to screening in this manner. This holds true when pre-menopausal women are screened, as is the current plan (coming soon to screening centre near you), because the cumulative dose will increase significantly due to the longer screening periods. A dose level of 1 rad in total is often the case, so over time this can add up to a significant risk for cancer in it's own right. In fact the estimated risk of cancer from mammography was calculated, based upon a life total of 24 screenings, of the digital type (which uses a much lower dose than film screening, usually employed in the UK) that 8.6 women per 10,000 would develope cancer as a result of screening, in itself. That, I would add is not far short of the overall risk of 1/1000 of getting cancer anyway.

      The Nordic Cochrane Centre has conducted extensive research on the subject and came to the following conclusions;-

       Absolute risk reduction for screening is 0.05%
      Screening led to an absolute risk increase of 0.05% due to a 30% overdiagnosis and overtreatment.

      So, for 2000 women screened for 10 years, 1 (that's one) will have her life prolonged and 10 (that's ten) healthy women, will undergo unnecessary treatment including breast removal, chemotherapy and radiotherapy, for no useful purpose. The Centre has produced a leaflet which gives an unbiased and scientific evaluation of screening to enable women to make an informed choice, as opposed to the over emotional and biased view portrayed by the NHS and indeed most Physicians.

      There have been many studies undertaken to prove or disprove the efficacy of mammography, and the results have been ambiguous a lot of the time, but the the Canadian Trials are viewed as being amongst the best and it is clearly stated that screening had no impact on mortality (post menopausal women 50-59). Here is the view from the Cancer Prevention Coalition in the US who have considerable reservations about it's outcomes and the forces at work that advocate it's use. And this riposte published in the The Lancet from February of 2002 looked at the attempts to 'rubbish' the Canadian and Malmo trials which, when evaluated showed no difference in mortality between screened and unscreened women (see here for more comment). Even the quite militant screening advocates, the US National Breast Cancer Coalition, indicate that screening only reduces the absolute risk by 0.07% ( in women between 50 and 65).

      So at best we can hope for a very small, numerically insignificant reduction or no reduction, in breast cancer in post menopausal women, by mammography screening, for some extremely unpleasant side effects and a 10x higher risk of over diagnosis and treatment. Many cancers detected are in fact benign or self limiting and will regress if left or simply stay the same. We do much harm and very little good by screening and for women with breast cancer, a majority will have found it themselves and screening will have played no part, or worst the lump will have appeared between screenings. In other words screening finds very little vigorous tumours but is good at finding and treating cancers that are not usually life threatening. This skews the picture even more.

      And what of cost to the NHS? Well around 2 million tests are undertaken each year and rising. The cost of the tests was £166 million (in 2008) but obviously more now. If we add in the re-tests, biopsy and operation and therapy costs so that we save one women in 2000 (in 10 years) but at the same time treat 10x that number who do not even have cancer, we are talking about £500 million or more. How can the NHS justify this enormous cost without having better outcomes? And why do women tolerate this appalling invasion of their bodies with all the attendant risks, amongst which is the fact that if they have already got cancer at testing, the 'squeezing' effect of the plates is likely to cause it spread much more quickly because of the force employed which is about 200 newtons (45 lbs).

      Screening is not prevention, merely the detection of a marker for a given disease, or an actual tumour in the case of cancer. We 'sell' to women the view that we are preventing their untimely demise from cancer by screening, which is of course a complete lie.  It is in the interests of all involved in this 'industry' of testing that it continues and proliferates as it has done since 2008, when the 'saintly' Gordon (Brown) decided, without any scientific input, that he would fund a whole new paradigm of test protocols to enable the 'plebs' extend their life spans. As is usual Physicians and the NHS leapt at this opportunity for even more incentive payments to increase their wealth (and power).It reinforced the  utilitarian principles that have driven the Neo-Liberal doctrine since Tony Blair's ascendency and for all his heirs and sucessors including the tossers 'toff's' who now rule.

      There are other alternatives for those who are particularly 'at risk' like the genetically disposed cohort, such as MRI and/or thermographic imaging, both of which are significantly more benign, or even entirely so. There is also considerable hope for a simple saliva test that will provide a non invasive test. There is also considerable evidence that maintaining sufficient levels of Vitamin D3 by exposure to sunlight (without sunscreen) can confer protection against breast cancer.

      Well ladies, I have strayed into territory that many men would fear to tread, but I feel that you are all being manipulated by the emotional baggage surrounding this issue. Mammography is oversold and is wanting of evidence to justify both it's expense and it's outcomes. It appeals to the emotional attachment you have to a part of your body that feeds your offsprings, tantalises and fascinates most of mankind, and in many ways defines your femininity. It plays to the fears we all have of the 'big C' as John Wayne called it, and gives false hope for a dubious protocol that feeds an industry without morals, and an NHS that kills 25,000 people a year due to preventable adverse events ( Ian Kennedy's report of the  Bristol Heart Inquiry). Let us 'clean the stables'of that mess instead of  venturing into prevention strategies of little worth.