The Constant Patient

Loss of Innocence-It Goes On.

I left the saga last with J' having gained control of her Diabetes and progressing to a more 'normal' lifestyle, but of course once the NHS has it's claws into you it never wants to let go. Between us we decided that we did not want to participate in any of their 'educashun' (sic) programmes for Diabetes, nor did we want to return to that hospital for any tests for osteoporosis, or X-rays or indeed for anything. Whilst both of us had a jaundiced view about DXA scans for bone density, on balance we thought it was justifiable to have at least one done to determine whether any such condition really existed. As a consequence we decided to pay for one at another location. So we did.

The results were pretty much as predicted; her hip and spine were slightly less dense than optimal and she was defined as 'osteopenic', which is pretty much what any post-menopausal woman is likely to be, especially in our Vitamin D deprived country with it's aversion to sunlight, love of sunscreens and paranoia about cholesterol. All these, for those who do not know, contribute to the density of the human skeletal structure or rather don't, if you employ any of the above.

A year down the line from the accident we also saw a 'new' Consultant who X-rayed the hip in which the prosthetic 'lurked' to ascertain the extent of any acetebular erosion or protrusion. There wasn't any; well not that could be seen, but frankly a normal X-ray is unlikely to show any until progression was reasonably advanced. It did provide some assurance however and the Consultant was at least honest and didn't treat either of us like children, probably because I talked the 'language' of his profession, in that I utilised medical terminology. In the meantime, we had both changed to a new (for us) GP practise. Because J' was now a registered Diabetic she then began to receive constant entreaties both in the mail and on the 'phone to attend for this test, that vaccination, sundry assessments most of which were largely pointless, or were largely encompassed by our own protocols.


Out of interest, we eventually gave in to a 'diabetic assessment' more out of curiosity than anything else. Of course it was undertaken by a Diabetic Nurse, which presumably did not describe her condition (it was a woman) but her vocation. Looking as she did I was prepared to revise that view because she embodied the 'don't do as I do, but as I say', philosophy in the NHS of appointing those who look sicker than their patients to advise them of the error of their ways. She looked as if she had been a Diabetic herself for many years, bordering on obese, with a florid face and that constant frown, common in those that have little understanding of  what they are doing because they have no idea of why they were doing it,  (I think she probably drowned puppies for a hobby).

She took J's blood pressure (132/65), weighed her, which was the same as it always was (now) took some  bloods for analysis including for a 25(OHD) that I had requested and laid her on the couch and prodded her feet with a short bristle device. As she weighs herself weekly, I take her blood pressure, and often 'tickle' her feet (it makes her jump) it all seemed pretty pointless to be frank, but she did suggest we come along to the 'club' they have for Diabetics, and also a training session where we would have likely had the virtues of low calorie/low fat dieting, extolled in glowing terms and of course be told that there was no need to 'test' constantly (because test strips cost money and the NHS doesn't have any). We declined I'm afraid. She looked crestfallen at this news, but we had seen the pictures on the leaflet and certainly did not want to emulate any of the antics therein portrayed (watching paint dry seemed more attractive).We left then to await the blood test results which were to be available in about 5 days.

Four days later, whilst we were whiling away the time at the 'hovel' counting the cobwebs on the ceiling, the 'phone rang and lo' it was the lead partner in the GP practise wanting to speak with J' about the test results. As we did not have them as yet I found this curious, but not wanting to prejudge the situation, I put her on the 'phone and listened in on the speaker. After praising J's HbA1c result, of 6.3% (the achievement of which he had no hand in, but would be rewarded anyway on the Quality Outcomes Framework) he raised the question of her Cholesterol level of  7mmo/L and suggested she take a statin. J' then asked me to respond to this so I took over the conversation after she gave permission to the Doc' on the 'phone. I pointed out to him that there was no evidence to support such a protocol for any woman, and that it would likely be injurious to her health, along with a few choice references that supported my view, and perhaps he might do a bit more research? At that point he fell back on the "I am only carrying out orders" defence and then told me how the QOF meant he had to do things that he did not always agree with, just to earn a 'crust'. Forcing back a tear, I expressed my heartfelt regret at such appalling treatment meted out by the PCT Commissars and we left it at that, after he promised to let me have a copy of all the test results.

What then are we to make of this? Well, GP's are paid to monitor Diabetics under the QOF protocols and ours had earned 44 points by undertaking the Diabetes examination and recording the findings. This includes achievement of some points from blood pressure, HbA1c and certain levels in the blood of various components, all of which he had no hand in at all! But of course that is never enough. We already had refused the tests for Retinopathy, because our Optician included it in J's annual eye test, the annual flu' vaccination, because it's counterproductive and now of course we had refused statins'. One gets the idea that curing sick people is merely an adjunct to the more important task of fulfilling certain criteria within QOF that invoke payments. Is this what Primary Care has become? Well err... yes.

Diabetics are treated very poorly by the NHS, and outcomes continue to worsen, mainly I believe because the diets, drugs and lifestyle advice is founded upon poor science, dogma and the touching (but wrong) view that 'Pharma' is a benevolent edifice, searching endlessly for cures and life enhancing drugs to make the lot of Diabetics as 'normal' as possible.The truth is that they only want to 'treat' the condition and symptoms with a cocktail of their products, in ever increasing number and volume to make a profit! Virtually all of the evidence that backs their products as efficacious is funded by them. Diabetes UK is heavily dependent on their largess as is the US equivalent the ADA.

It is not inevitable that Diabetes is progressive and life shortening unless the 'mainstream' treatments are pursued. Many know this and either overtly or covertly follow their own agenda and are considerably healthier as a result. When J' gets a day when her three times a day tests, all come out as normoglycemic purely by gist of diet, a little exercise and a few supplements, it is a cause for celebration. It can be difficult some days, there are pitfalls in many foodstuffs that are not evident at first analysis but by testing rigorously they are soon found. But if you are not taking a hypoglycemic drug they are not funded by the NHS. So you have to buy them yourself. So you save the NHS lots of money by being responsible for your Diabetic destiny and the mealy mouthed idiots then penalise you for so doing. Crock of s**t or what?

I will continue to post the continuing saga as and when it happens. J' is somewhat handicapped as a Diabetic because her piss poor prosthesis is not conducive to vigorous exercise and that is a useful protocol for any diabetic to lower insulin resistance and 'burn off' excess glucose. So she has been doubly damned by the arrogance and stupidity of a system that is incapable of factoring in individual needs in treatment. Thank you NHS for making sure the law of unintended consequences rules!

A Pause For Thought?

Cameron, Lansley et al, have announced their intention to have a 'natural pause' in the Bill to reform the NHS. A 'future forum' including that 'porcine' (honorary) Professor, Steve Field is being launched upon the country, to listen to the views of the NHS constituent about the changes that have been proposed (excuse me whilst I choke). Once this period, which coincides of course with the Easter Recess anyway (yes more holidays for the politicos), is over, the Bill will be sent to the Lords for perusal and possible modification.

The problem I have with the current and past reforms, is that they continue to concentrate on structure instead of quality, organisational change rather than the ethos and tenor of what universal health care should be. For far too long the NHS has stood for invasive and pernicious campaigns to to persuade us  (and now nudge us) into a new horizon of well being with moralistic and ill conceived measures about smoking, drinking, sex, and diet, indeed anything enjoyable. With social engineering at its heart, the anxieties of society are constantly addressed by campaigns to reduce cancer, heart disease and diabetes with little result other than a significant  elevation in the Nations blood pressure.

This has in turn led to poor quality health care, dispensed '9 to 5' (weekends and holidays excluded), in Hospitals and Surgeries, to a somewhat hostile patient cohort, who are now being appealed to by the NHS constituent, to 'save the NHS'. Those who have delivered this inferior and authoritarian 'we know best' standard of that which passes for Medicine, cannot really now expect the public to 'go to the barricades' and fight for them to keep their bureaucratic temples intact.

The NHS has presided over ever increasing levels of interventions into our lifestyles and behaviour, very few of which are founded upon any evidence or indeed have had any success. Doctors have become the 'health police' rather than the healer, and as they have distanced themselves from their patients they have prospered enormously in monetary terms, but lost credibility. They are now pawns in the Neo-Thatcherite construct started by Blair and continued by Cameron and his academy of 'toffs'. An NHS that has treated society with such contempt, despite its huge cost to that society deserves to founder.

I do not like the changes proposed very much. They amount to little more than a bureaucratic reshuffle; a movement of the deckchairs, because the fundamentals remain. But the opposition that has formed against it almost worries me more. If Allan Milburn, the BMA and the King's Fund  ( and David Owen for f***s sake) are against something then I'm afraid I will possibly have to review my position. In fact as the number of unprincipled and opportunistic politicians grows, who oppose this Bill, the more I become alarmed that I may have missed something! Hardly surprising in view of the number of pages it runs to (299 clauses!). Perhaps there may be some nugget of redemption in this pointless, needless and irrational Bill after all? Oh yes, the Quango's are going! But no, they are being systematically saved, if not by name then by transfer, such as the Food Standards Agency to the Dept of Health.

Doctors and the BMA never wanted an NHS, of that be certain. They wanted an elitist cohort of Physicians that dispensed wisdom and medicine to the 'proles' at a price that they set, not one set by some 'oik' in a Government Department who went to a ...Grammar School?  They persisted in this view until the Thatcher years, when Maggie offered them more power and control at the expense of a bureaucratic nightmare of invoicing procedures and budget management, when they decided that it was all too much, a bit like the 'poll tax'. Then along came Blair, all fired up to change the mindset and the BMA embraced him. All at once the BMA discovered it's desire to participate in Government sponsored (and guided) health care resulting in massive financial benefits to the membership and less hours! Well that was a surprise then?

Incentivised, at a level they could not have dreamed possible, most Doctors and Hospital Consultants doubled their pay, and reduced their involvement in patient care. 'Out of hours' was handed to private companies and A & E to trainees and locums (60% of all Hospital Doctors are locums).  The patient became the supplicant expecting little and rarely being disappointed. Many died, were maimed or at best received poor care and continue to do so. Yet the gravy train for Doctors, now irretrievably committed to peddling 'Big Pharma's' often substandard or even useless products, rolled on, with further and more intrusive protocols, even for the 'worried well', moving medicine further and further away from diagnosing and treating disease, to fruitless and dogmatic (usually wrong) prevention interventions that were founded in poor or even bad science.

At no point in this train of events was it thought necessary to involve the patient, save for 'patient, public involvement' rhetoric that only sought the views of an unrepresentative minority, of charities and professional middle class campaigners, with the time and money to be involved in the 'tea and biscuit' culture of meta-quango's, discussion forums and pointless conferences. Constantly harangued, largely ignored, the public in general wants little to do with the NHS or even their Doctor, now ensconced in expensive and shiny Health Centres, except when they are sick or fearful. Then they are treated to an endless list of questions, unrelated to the condition they have presented with, to ensure the practise fulfills the QOF protocol and a test regime more interested in their 'lipid profile' than their pain. Is it any wonder that as 'modern medicine' lurches toward wholly preventative measures, instead of treating "the poor and the lame, the sick and the dying" (1), that we are becoming more and more disenchanted with that which we are financing.

There now seems to be a further erosion of NHS principles, driven by privatisation of Primary Care that has more to do with dogma than need, the desire to furnish capitalism with further subsidy, and the utilisation of the latest 'mousetrap' from Pharma, whose greed continues to know no bounds. Older drugs, and medicines that were 'fit for purpose' before, keep falling off the end of the list, for no reason other than a desire to use the new and shiny one approved last week, irrespective of efficacy. Once in fact, all of those in the NHS have had their piece of the cake, there is little left for the actual patient, except indignity, poor care and nonsensical intrusion into their lives. And yet, are not all of these people there for one purpose and that purpose only, to pursue the practise of Medicine?

Change is in fact needed and drastic change at that. Justice for the harmed, together with Candour. Genuine scientific protocols to improve lives, not the treatment of symptoms for the enrichment of a pernicious industry that no longer is fit for purpose; 'Big Pharma'. A cessation of intrusive, patronising and ultimately fruitless endeavours to engineer social change, with fear. Medicine without the boundary of 'out of hours', peopled by real physicians, who actually know what they are doing. Yes let's have a real and vibrant 'Big Society' in the NHS that recognises its goals are set by its patients, not by its political masters and I include in these the BMA, the GMC and the bloody 'think tanks'. In fact I'd rather like to put a tank on their lawn, and see if I could get Niall Dickson, John Appleby and Penny Dash with just the one round. That would be fiscally responsible would it not?

So whilst you politicians are are all pondering, as to what cosmetic changes you can make to a Bill that is widely reviled, and the GP's squeal about how they will be able to cope with all the extra work, without some extra payment (again!), spare a thought for the poor sodding patient, because they're the reason we have an NHS. They aren't the one's that fucked it up, you are!

"Perfection of means and confusion of ends seem to characterize our age." 
(Albert Einstein) 


(1) Quotation courtesy of Morton Thompson - 'Not as a Stranger' C1954.

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).

The View ?

The title of this blog was conjured from the place I live, looking down from the hill to the Teaching hospital that has been the source of most of my of my fears, misery and trauma. It also lends an air of an overview of life
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That place is one that I avoid, like the plague. In fact I go to quite considerable lengths in this endeavour, often driving a circuitous route to do so, such is the effect it has on my state of mind. Yet it continues to intrude. Letters keep arriving for appointments for this Clinic or that Test for my lovely J to attend, in the very place that treated her so badly as to her never wanting to go there ever again
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This made me think as to why the NHS wants to intrude in the lives of us all so much, as to book appointments out of the blue and then entreat us to attend with an attitude bordering on that of the bully. Often this is for mammography, blood tests or Retinopathy tests, all in the interest of disease prevention. But is it?

The NHS spends a huge portion of its budget finding things to test its patients for. Some of these are without doubt both important and non invasive but many are not. Cancer figures highly on the list and yet real outcomes have altered little in the years that most of these tests have been around and some, such as the exercise to perform mammography on women between 50 and 70 years has had little impact on the incidence of breast cancer. In fact the scheme itself has been shown to be positively dangerous for women who have cancerous growths because it can exacerbate the spread of these and speed progression. It also has an alarming number of false positives that cause fear and suffering to no good purpose. Other detection measures such as self examination and thermography are likely to be less intrusive and give back to women the right to make their own informed judgement as well as exposing them to less radiation, which in itself can be a cause of cancer. This is especially true of J who will have one or two X-rays a year to monitor her prosthesis together with a DXA scan for osteoporosis every two. Mammography itself exposes women to at least 1000X the dose of a normal X-ray, more if you have to return for a repeat in the event of an abnormality.

So why do we do it and more importantly why are bullying tactics employed for this, for blood tests we didn't know we needed, to check our cholesterol, eye tests we've already had at the optician but the NHS feels now only they can perform adequately ( the opticians used to do them but it was taken away). Letters now that not just request you ring for an appointment but tell you one has already been made! This is just the same as the clauses in contracts that you have to positively opt out of instead of opting in. Not only are they spending our money on dubious test procedures they are telling us often that we will fall prey to some awful disease or condition without them!

This is disease mongering and as Big Pharma seeks more markets for its often dubious products, some of which are a rehash of one that didn't quite work in its previous role but will be successful in a new persona for another ailment. So it invents diseases or conditions and the NHS which relies heavily on the Pharmaceutical giants for funding of projects, research and dubious jamborees for consultants and managers, swallows the bait. Just, it has to be said as do a body of GP's and without doubt the Government.

Statins are probably the worst example of this; a drug to treat the 'worried well' for a condition that largely has no symptoms and a hypothetical outcome founded in dubious research (by Big Pharma) to utilise an obscure poison found in a remote Chinese valley that they needed to offload on a gullible ( and well 'palm greased ) FDA to pay for the research they had undertaken. The result is now 450 million pounds of revenue from the NHS every year to pay for the prescriptions most (if not all) that are not needed and can cause the very problem they allege to ameliorate, heart failure. That figure does not include the support costs of maintaining a 'patient' on these drug protocols which usually means six monthly tests for checking results and possible effects that manifest. The obvious one of course is the depletion of CoQ10, an essential for a healthy heart (sic). These tests are likely to double the cost of treatment, all for a highly dubious and contested ailment that is founded in 'bad science'.

'Statinisation' is symptomatic of an NHS that now consumes vast sums of money mainly to no effect to tick the boxes of disease prevention and fulfill pointless targets. At the same time it bullies and entreats for people to lead a healthy life with a healthy diet with hordes of highly paid support staff labelled with dubious titles to support this goal. It is self defeating and many know it but none want to 'rock the boat' of profligacy.

We are in the midst of an epidemic of Diabetes, Obesity and Heart disease that all of these efforts have failed to even dent. I would venture most of the advice and interventions are in fact counter productive. Medics need to get back to basics and Nurses need to get back to Nursing. 'Do no harm' is the clue you idiots. Get back to curing the sick and the lame. Stop trying to prevent the demise of the hypothetical sick until at least you have conquered the goal of treating those that present to you with real and tangible problems. So far, and more and more of late, Medics in particular and the NHS in general has singularly failed in this endeavour. Concentrate your efforts in this area and maybe then we could look at other goals. You are all in a hole so my advice is to stop digging!