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!

Monday, 28 February 2011

Nullias in Verba

Much has been made of the view that red meat, including processed and preserved meats, causes Colon Cancer, in the press and television this week. The advice from the DH, is that we should reduce our intake to take account of this. This is based on the recommendation of the Scientific Advisory Committee on Nutrition (SACN). But this report is on Iron and Health, so what's that got to do with it? Moreover this report has been in gestation since 1998, yet was only published in February of this year. So it was pretty urgent then?

When you get to the report itself you will see it's pretty long and full of data, all 374 pages of it! But hang on, this report refers back to the Committee On Medical Aspects of  Food and Nutrition Policy called COMA, and is likely what you will get trying to follow this trail! However let's persevere. We then find that data used by the SACN, was that provided by COMA for the survey of the Food Standards Agency (yes, that lot again!). And the data used, was from the 2000/2001 survey. Pretty up to date then!

Now we're getting somewhere! So the report on Iron and Health from the SACN, based on data from COMA via the FSA, from the  2000 National Diet and Nutrition Survey, recommends we reduce intakes of red and processed meat.  OK, but where's the evidence? All the SACN say is, there is a "possible link" between high intakes of this food group and Colerectal Cancer (CRC). This report from the BBC, links the 'scare' to the World Cancer Research Fund data from 2007 and at the same time casts doubt, both on that report and on the evidence both utilised in the compilation of the advice and more importantly that ignored! Nothing like 'cherry picking' the data that supports your preconceptions then?

Most of the information about CRC and meat actually stems from the EPIC report of 2005. This is a longitudinal study and it's fourth from the top of the list with regards to evidence, the Randomised Control Trial being the 'gold standard'. EPIC is also observational and 'observation does not prove causation' as I have said many times before. If you actually look at the data, it can be seen that there are some anomalies, not supporting the view of the authors, of CRC being positively associated with red meat intake (they talk like that in 'science'). In the hazard ratios reported, and 1.00 equals no effect, we see that Italian meat eaters are in fact protected (0.96) and we in the UK have an increase in risk of about 3% (1.03). 

Remembering of  course all of the data is self reported, it is spread across ten EC countries with many different cultures, types of meat with both traditional and modern methods of preservation and cooking, all intermingled with other nutrients. Thus I do find it difficult for any real credence to be given to the view, that meats causes CRC. The authors seem at a loss as well to explain the mechanism, but there is allusion to excessive iron or nitrosamines (from the preservatives) which are carcinogens. I would hazard that they have far too many confounding factors, within the diet of the cohort to draw any real conclusions. There are no details of which meat (beef primarily) was fed on grass, silage or corn and wheat. What you feed to animals is critical to the meat you produce, with considerable difference in the fatty acid constituent as well as micro nutrients. So grass fed Angus Beef, has much higher n-3 than n-6. Omega 3's are said to protective against cancer, and it is certainly better to ensure that the 3's are higher than 6's, both for human intake generally, or in the meat we eat.

Is it likely as well that the meat we have consumed for thousands of years, lamb, beef, pork and game, has suddenly become toxic in the last forty years? Except perhaps by man's intervention in the form of feeding animals unnatural diets, preserving it with various chemicals that were never used  traditionally, or mincing it up with other products. There are I would suggest far too many variables, to have any certainty as to whether meat consumption is the sole positive indicator for CRC.

I am not the only one with a sceptics view of this. From the Netherlands we have a study that has a contrary view. A number of scientists were unhappy about conclusions as can be seen here. This Japanese study found no connection, but also came out strongly in favour of  n-3 as protective. And they were very honest in their interpretations and about the cohort size. I found many studies that did not support the view that red meat caused CRC, but found much that supported the view that processed meat and sausage did have a slight association. So what to believe then for self protection?

Well going back to EPIC, the overall risk was only increased by 1%, which is a small risk, and is not borne out by other studies, or even commonsense. Quality meat with a good content of saturated and other fats enables humans to keep their carbohydrate intake low and their level of satiety high for a given calorific load, without getting fat. To suggest that this is going to give them cancer, when we almost never had any cancers at all when society consumed a diet almost completely of meat is perverse. It is backed by the recorded good health and lack of disease in every study of 'hunter gatherers' undertaken. I posit that any association that has any foundation would be the intake of processed meats from animals that are 'lot fed', steeped in preservatives and cooked in hydrogenated oils. These can usually be found in eatery's with Scottish or Royal elements to their name and that are on every high street in the land.

So what then is the average citizen to make of all this? Constantly harangued to eat this but not that, most of which is changed somewhere down the line and then often reinstated. The bulk of this is not 'scientific' in it's true sense, because most of the research is too poor, inconclusive, or perverse. And for many years directives from Governments and it's Agencies seems to be founded in the view, that the 'proles' are too thick to have any idea of what's best for them. The scientists have held a similar view about the politicians (can't say I blame them).

Scientists in fact, are often dogmatic in their views, even in the face of contrary evidence that bursts the bubble of their hypothesis. They will biasly select that which does not confound a theory and conceal data that does. This is not peculiar just to 'Big Pharma', but to many individuals within science especially medicine, who are prepared to dance to the tune of the master or of their own ill founded dogma, for what ever motivates them. They are intolerant and even abusive to colleagues who are sceptics, about views often held for no other reason than laziness or stupidity. So at the end, we arrive at the beginning; the motto of the Royal Society; it means "on the word of no one". And so it should be.

Wednesday, 23 February 2011

Curing the NHS (A Rebels View).

Of What? By whom? Well one thing is certain, it won't be by Andrew Lansley and the cabal of warlock millionaires, headed by ("call me Dave") Cameron. Their proposed acts of vandalism are likely to make the chances of a 'cure' even more remote.

One, who has a pretty good idea as to what is needed, is one Dr. Vernon Coleman. Vegan, (well you can't be right about everything), author, 'cross dresser', columnist, publisher, libertarian. Author, amongst many of "Medicine Men" and "How to Stop Your Doctor From Killing You", both of which intimated how much of a rebel, he really was. He has kindly consented to allow republication of his view of  how to cure the NHS on the website of the NHS Justice Group.

His views, almost exactly coincide with mine. We need to rid ourselves of that which is not needed; that which is not affordable, or even desirable, on the NHS. Give power to GP's, but not all Commissioning, they are neither equipped, nor are they as yet competent to fulfill such a role. Rid ourselves of the pariah's that suck the blood of patients and clinicians; the 'Management' and their lackeys. Stop 'private' medical care being provided in NHS Facilities, and oust the Consultants who control it. Provide 'proper' Nursing, with real Nurses, not the poor quality Nursing Assistants, who have no more idea about 'nursing' than they do about quantum mechanics. Not surprising really, as the qualifications to become one are, err, none! 'Peanuts, Monkeys' are the words that spring to mind.

And Doctors, well they need to realise both their importance, but also their lack of it. It is not possible to legislate for empathy or compassion, but it is possible to enshrine in statute, the 'duty of candour', in the event of harm, being done to patients. It is perverse, that Doctors are the only section of society, that can lie under oath, without any consequences being visited upon them, but they can, as my friend and tireless campaigner Will Powell will attest. Twenty one years is far too long to wait for justice, both for him, and for any society, 'Big' or otherwise. But 'Dave' would have us believe that it would be step too far.

So far as 'by whom', well there's the rub. The ConDems seem unable or unwilling to effectively change the NHS, beyond pathetic attempts to 'privatise' most aspects of it, in the blind hope of saving money. My experience of privatising public bodies and duties has been one of more bureaucracy, less transparency, considerably higher costs due to the additional layer of management required, together with the need to extract a 'profit' from every transaction. And of course, the continuous desire by all parties involved, 'to pull up the flowers to check if the roots are growing'! So then it is left to us, the people, to clamour for effective change, not the 'window dressing' of this and successive Government of the NeoThatcherite persuasion, which they have all been, of "no decision about you, without you" and other such PR platitudes, forged on the playing fields of Eton and in the slick offices, of the campaign managers.

Tuesday, 15 February 2011

Lies, damned lies, and statistics.

Attributed to Mark Twain, about Disraeli, this phrase has received considerable use, in decrying statistics as a means of bolstering an argument, and indeed, sometimes in the support of one. However, when statistics are used, in the support of a drug or treatment in Medicine, or a lifestyle change or recommendation, we are into a different 'ballgame' altogether. It is best policy then to treat them with healthy scepticism.

The The Jobbing Doctor recently referred to the increase in oesophageal cancer, from an anecdote about his own practise. This is in fact borne out by the statistics. In the period between 1995 and 2008 there has been an increase of nearly 50%! But that only means, an absolute risk of 14.4 persons per 100,000 as opposed to the previous 8.8 persons per 100,000. That's no consolation to those with adenocarcinoma of that organ, but the risk is still quite low. And that brings me to the crux, of my railing against, studies that prove very little, but grab headlines and frighten and confuse the populace by mixing up relative and absolute risk, often to sell us a drug, a lifestyle change or a treatment protocol that has little to no effect on survival, or the progress of an illness.

There has been much publicity, about the trials of various drugs recently, highlighting the pro's and the con's (literally) of their worth. The use of statin's, for example, was initially believed to be a panacea for low risk (should that be no risk?) patients in the prevention, of future heart disease. But this has been clearly shown to be of little benefit, whilst at the same time as increasing risks for other diseases such as diabetes. The use of statin's in primary prevention is now pretty much a 'dead parrot', but will GP's stop prescribing them for the achievement of a highly dubious surrogate end point? Well, err, no, because they are paid to achieve them by the QOF (Quality Outcomes Framework). And let not the science, get in the way of a nice little earner!

Trials, generally have been the basis of evidenced based Medicine since 1946, when Austin Hill designed the 'randomised control trial', for tuberculosis treatment with antibiotics, which were in their infancy. I suppose it was easier then, because there was not much in the way of groundbreaking science or drugs around, but as 'Pharma' became bigger and richer, the stakes got much higher, and the opportunities for 'massaging' the results became ever easier, especially once the baffling science of statistics, became a science in itself. So we are today, beset by statistics, that are 'mangled', to produce the right outcome, for a drug, a lifestyle or dietary change, or the cessation of something, that may be vaguely enjoyable.

Until only relatively recently, there was no compulsion to reveal all the results of a particular trial, but now 'Pharma' is compelled to do so, bringing to light a number, that showed particular drugs, to be less effective than previously thought. 'Pharma' had been guilty then, of 'hiding' from public (and other scientists) view, those trials that showed some drugs, had little to no effect, or did harm. This is termed 'selection bias' and has long been used to influence outcomes, in favour of that which was needed to justify, a particular protocol or drug's use. But, random chance, has a part to play, and as most RCT's are designed to ensure at least a 5% success ratio, then 1 in 20 completely useless one's will register as positive. These and others, are those they did not wish us to see, but no longer, they are now compelled to show all.

Another trick, often used, especially when, you can hide the data behind a 'paywall' such as the BMJ, or 'The Lancet' or many of the other journals, is to mix up relative and absolute risk within the 'abstract'. For example; I can double your chance of winning the Lottery. How; buy another ticket! Your relative chance has doubled, but only to 2 in 14 million, your absolute chance. If one extrapolates that into scientific study, as is often done, a somewhat distorted view, is given to the unsuspecting reader (journalist usually). As I have also said, many times, in my posts, correlation does not prove causation. And, as many trials are observational they simply correlate facts about the cohort under observation. The whole of the vegetarian revered book, 'The China Study', was no more than a complex and detailed correlation of observed data. Denise Minger wrote an extremely well researched and devastating critique of that testament to a vegan diet, that blew it out of the water, in my view.

This co-relationship (correlation) between several factors can be co-incidental. For example; many fat people are diabetic, but not all are, and in fact quite a few thin people are also diabetic. But it is not an absolute fact that all diabetics are fat; unless of course you ply them with drugs from 'Pharma', when they almost certainly, will get fat. That was a hypothesis, by the way, borne out by a considerable amount of evidence, and more importantly, the proof implicit, in the biological mechanism of insulin, which is generally enhanced by hypoglycemic drugs, of being an agent of fat storage.

An example of how society has been hoodwinked by both 'Big Pharma' and the GP's is the ever lowering of blood pressure targets, both for those at any risk, and those at 'allegedly' known risk, ( people with a history of CHD/CVD), who are prescribed anti-hypertensives of one kind or another. This is yet another 'surrogate end point', viewed as a possible marker for heart disease, but not actual heart disease. Well, the QOF for prevention, is for GP's to prescribe these appalling drugs, to lower blood pressure, in the targeted cohort, for which they get paid, on a 'payment by results' system. However, it turns out that the QOF for this had no discernible effect at all, on outcomes for the lowering of BP in patients being treated in primary care. There is even an implication, if you click on the whole study (amazingly free), that other 'payment by results' treatment protocols, for other diseases of society are also not effective, except for the pay of GP's. Some Doctors say, that they were already achieving high levels of compliance prior to QOF's institution, so these rewards are simply retrospective. I think that's a cynical manipulation of the facts to suit events. Either way, it's hardly value for money, or indeed of any real use to the patient, who is taking medication to fulfill a 'tick' list, often at cost to their well being.

Have then Doctors, taken the money, despite their efforts having produced no tangible result, or is the whole exercise pointless anyway? Because, further study will show that although the various drugs do lower BP to an extent, in some, but not all patients, the outcomes for the cohort taking them remains unchanged. Exactly the same number die, whether they take drugs or not. This review from Cochran highlights the inadequacies of both the studies and interventions in use, and is pretty damning, in its conclusions.

So, long suffering reader, I would urge scepticism in all data, that is presented to you as 'proof' of anything, especially a drug or treatment, that has been provided as a preventative measure by your 'hard pressed' GP. Was the study an RCT? Was it reproduced in a number of trials ( at least three), with a significant time scale (at least a year), for each? Was it interventional (the drug or device/protocol being designed to change an outcome)? Was it 'blinded' (the cohort and the trial personnel have no knowledge of who is getting what)? Was it longitudinal (over a long time) and if so the time must be long and the cohort large, such as the Framingham Study (60 years). This latter study, interestingly, has been criticised by many as both observational, self reported for many of its facts (by the cohort) and that much of the adverse data was suppressed. However, Michael Eades found that it was reported, just not very prominently.

Finally, be a sceptic, and believe only that, which is proven by real science, not Daily Mail headline drivel, or advocacy research, or perhaps worse, what your Doctor tells you (if it's QOF'ed).

Tuesday, 8 February 2011

NHS plc?

As Andrew Lansley's 'brave new world' of GP Commissioning takes shape, I would like to examine the substance of that which will prevail in the future, and the effect it will have on all of our lives, yes, even the rich!

I have made no secret, of my view that, this is a covert plan, to 'privatise' the majority of services that are provided by the NHS, although a surprising number already are, such as Care UK and others, who almost exclusively contract for Prison Healthcare in the UK. There in fact, seems to be a 'model' forged to an extent by the last Government and continued by this one but at a more accelerated pace. It is the US Healthcare model.

Numerous consultations took place between the 'last lot', 'this lot' and US Healthcare giant Kaiser, to provide advice on the structure of the NHS. The concept of making Hospitals into Trusts especially Foundation Trusts, is a construct largely inspired by them, together with the enforced change upon all Hospitals to become the latter by 2014. As such these bodies will have to be in surplus, or fold. So the prospect of a Hospital closing because it is bankrupt moves ever closer, with Lansley clearly stating that there will be no 'bailouts' (don't remember him saying that about the Banks). This makes them a 'ripe fruit' to pluck, at rock bottom price for an aspiring Private provider.

 Primary in this role will be the FESC (Framework for procuring External Support for Commissioning), who will be ideally placed to design the procurement 'tools' for the GP cohort, flung into the maelstrom of designing a system about which they have little knowledge, or even desire to engineer.In this body we have a list of Private providers, including BUPA, Dr. Foster, KPMG, McKinsey, Tribal, United Health and others, all poised to take a slice of the cake. Close on their heels is the Cambridge Health Network, fronted by Dr. Penny Dash, which provides " Health Leadership and Enterprise", which is a euphemism for promoting the sponsors, which include; Halliburton (of Gulf Oil fame), General Electric, Virgin, BUPA, GlaxoSmithKline and of course, Carillion, to the DofH. Dr. Dash is of course, a McKinsey partner, and ex Head of Strategy and Planning at DofH, and now enjoys the ear of many in Government. Copperfield has this view about her in Pulse in 2009.

Many ex-Government politicians and advisers will be found within this organisations companies, including Patricia Hewitt (BUPA), former Blair adviser Simon Stevens (United Health), Mark Britnell, former DofH, head of commissioning (KPMG), Penny Dash (McKinsey), the list is almost endless, of those employed in Healthcare who have exited by the revolving door between, Public and Private Healthcare Providers. Is it likely that these and others, will be able to exercise influence in directing commissioning toward the 'private' model. Well do bears s**t in the woods?

Would this exercise to bring Private Medicine into the NHS be a bad thing? Well if we are to judge it by simple maths then let's work on Healthcare costs as a percentage of GDP, because the US has a larger population than do we, but is used by many as the model for Western Medicines excellence. It cost slightly more than 15% of US GDP in 2008, but only 9.2% in the UK to provide healthcare universally, but of course healthcare is not available to all in the US, only those who pay, so that comparison is even more favourable than it seems. In world terms we are 20th for life expectancy, yet the US, for all this expenditure, only ranks 36th and whilst we ought to be higher, if the belief that privatising the NHS is to bring benefits, then surely these figures must explode that myth.

The likely result is that cost savings will be heralded, certainly at Commissioning stage,  as it was with ISTC's, but the results a little further down the line will be one of reduced services, 'cheap' operations, based on dumbing down the staff cohort, and doing production line procedures, such as Arthroplasty, and leaving the NHS to take care of Trauma, until it goes broke, because it cannot compete. The end result will be, without doubt, less for the same, or eventually, as in the US, less for more.

Wednesday, 2 February 2011

You Spent How Much!

£8.5 billion to be precise; that is, on Drugs for the NHS in 2009. Or as some of us know it; the 'Pharmaceutical Industry Benevolent Fund'. This is for prescriptions, not Hospital Drugs, which are accounted for elsewhere, and it is an enormous sum.

£33.9 million was spent on aspirin (generic) and £18.8 million on paracetamol (acetaminophen), no doubt which would have been bought at the usual high prices, charged to the NHS. Why not tell people to buy their own, and just recommend the dose?

Close to £360 million was spent on the branded (expensive) and generic (cheaper) versions of HMG-CoA Reductase Inhibitors (or statins), with some £322 millions going to Pfizer's Lipitor. Generally, to treat patients for no scientific reason, other than a target for cholesterol lowering (a surrogate end point), which is considered now, to be of dubious benefit in primary care, especially for the worried well. Hopefully the 25 year long 'gravy train', enjoyed by Pfizer, will end, when the patent expires in June this year, on Atorvastatin (Lipitor), but they have enjoyed years of it being, the top selling drug in the world, at $12.4 billion sales in 2008. Duane Graveline (the space Doc) has a few points about this drug worth reading.

The other 'so called', cholesterol lowering agents figuring quite highly in the league table of costs is the Merck drug, Ezetimide at £73.5 million. This is despite the ENHANCE trial giving it a conclusive 'thumbs down', for its  primary role, way back in 2008. NICE hasn't yet caught on to it's rather limited efficacy, and it's dangers, but GP's still seem ready to prescribe it.

Doctors, spent £106 million on anti-hypertensives, with some £68 million of that going on Merck's Losartan an Angiotestin 11 Receptor Antagonist, and the balance on generics. Well, this is down to the continual, ever lowering of the thresholds, for hypertension, both for the 'at risk' element of the patient cohort, and the belief amongst many, that we should all be treated, if we exceed certain levels irrespective of risk, simply because, being above that level confers risk in itself? Well, NICE, who set these guidelines, also calculated the 'absolute benefits' for this, at an increased life expectancy, of 8-11 months if you're 50, and 3-5 months, if you're 70. Wow!

Now to the drugs for Diabetics. Leaving aside the £71.5 million on the Type 1's, we spent £650 million on drugs for the Type 11's, amongst these, of course we have have the drug (now withdrawn) Avandia, from GlaxoSmithKline. I highlighted it's dangers, on the back of the Panorama investigation, back in September, but, despite the fact, that there had been doubts about it, as far back as 2007, £30 million was still spent on it! Drugs for Diabetes have risen in cost, during the last 5 years by 40%. But Diabetes, despite it's inexorable rise, has only risen from 3.3% to 4.1%, in the same time frame. So, one has to assume that more drugs, and more expensive drugs at that, are being prescribed. So, long as we continue with 'barmy' diet protocols for Diabetics, and for the population as a whole, this bill will never get smaller, and it is now the largest cost, for all drugs, across the NHS!

Of course, we do have some really expensive drugs. Eculizumab, costs £3150, a pop! And that works out for the patient with PNH, to about £400,000 a year! At about an incidence of 1 to 2 per million people, it's unlikely to bother many people. Why drug companies, can't be a little more benevolent, with highly specialised drugs, in view of their exorbitant profits, I cannot understand. Well, unless of course they are greedy, manipulative git's, but of course, I would never take that view.

So then Mr. Lansley. If you really want to save some money in the NHS, perhaps you should review the science behind these profligate and counter productive, prescribing protocols. And should you really be pinning all your hopes, on the 36,000 or so GP's responsible for this huge bill, to run the NHS of the future? You really ought to have better insight, with a Cardiologist brother-in-law, and an ex-wife as a GP.