If there's a question you want answered, I'm likely to know someone who can answer it for you. Try me.
The west needs to learn lessons from modern Indian healthcare:
Despite the "hard" probing by the BBC's Stephen Sackur, Devi Shetty puts forward a strong case for the "industrialisation" of healthcare in an effort to reduce costs, increase access and improve quality.
So much of what he says cuts against the emotional grain of how people feel about how healthcare should be provided - especially for those of us in the warm embrace of our publicly-funded systems.
The numbers are staggering: India needs to do 2.5 million heart surgery procedures a year - currently capacity is at 90,000.
Shetty is building a huge hospital in the Cayman Islands to offer healthcare to Americans at half the price they can currently access. Extraordinary, but even more extraordinary is what he is doing in India and planning for Africa - training is the key thing - he is calling for a global health university. Really, he's a visionary...
My favourite Shetty quote: "You invest in healthcare, and you are going to make a country healthy and wealthy".
It’s worrying that we still see pharmaceutical products as the mainstay of improving health in the future when the evidence tells us, should we listen to it, that the biggest gains to be made to health are social, political and environmental.
This is from a post prompted by announcement that the UK government is proposing allowing commercial organisations access to anonymised patient record data.
There are privacy concerns, yes, but Margaret has hit on another thing that has been missed by most commentators: We need to stop thinking that the answer to our healthcare woes lies in the consumption of more better medicines and drugs. Yes, it's good to develop better, more targetted therapies that are more likely to help the right patient at the right time, but we know that the best interventions in healthcare are preventative lifestyle changes, and then, where possible, an early diagnosis...
I am really struggling with this - it's a very big thinky scratchy-beard conundrum.
I talk to pharma all the time, and I think access to anonymised data could really help companies and health systems make smart decisions that improve patient care - but I think this needs to be reciprocated - if governments are going to allow commercial organisations free access to the data collected on publicly-funded EMR systems, commercial organisations should commit to releasing ALL the data from ALL the clinical trials regarding their medicines.
It's about transparency, openness and fairness. Last time I checked, I thought these were good things. Biased under-reporting of clinical trials harms patients, wastes money and is against the tenets of good science.
There is currently lots in the mainstream media and the medical press about the on-going debate on mammography screening for breast cancer. The BMJ’s letter pages this week devote a double spread to responses to Mike Richards’, the UK DoH’s national clinical director for cancer and end of life care, commissioning of an independent review of the evidence on the effect of screening mammography on cancer mortality and over-diagnosis. Add to this the new Canadian guidelines recommending that women between the ages of 40 and 49, and not stratified as predisposed to cancer due to family history or genetics, not be routinely screened for breast cancer.
I cannot add to the debate as I am not a breast cancer expert, have not conducted research, nor indeed even a thorough reading of the hundreds of publications in the field. However, I think the debate highlights some things that are relevant to how we think about scientific evidence and its role in driving policy and personal health decisions:
Show me the data
First, guidelines and decisions that influence the healthcare of millions of people must be made based on a neutral, independent, transparent, evidence-based, scientifically robust assessment of all the latest available data interpreted in the most transparently unbiased way possible. Integrity demands it, as should the people on whose behalf these guidelines are being drawn up. The Canadian guidelines, for example, make “no recommendation … for women aged 75 and older, given the lack of data.”
The UK’s National Institute for Health and Clinical Excellence is a body that was set up in 1999 to conduct appraisals of medicines, technologies and clinical practice based primarily on robust evaluations of the science behind claims of efficacy and cost-effectiveness. Its independence has made it a credible and authoritative voice on what the UKs health system should and should not do in a wide range of disease pathways. So respected is it, that NICE guidelines are often adapted for use in other countries. This is a good thing, I think.
Neutrality & transparency command respect
Second, bias and vested interests destroy public confidence in science and healthcare decision-makers. Without the credibility of neutrality and scientific rigor at the outset, the risk, indeed the inevitability, is that those with pre-entrenched points of view on such guidelines will seize upon outcomes detrimental to their points of view and kick up a huge media fuss that clouds the public’s understanding (remember them, they’re the ones whose interests are supposedly being looked out for). This makes the slanging match the story, as opposed to helping the public improve their knowledge and health literacy.
Change is constant, progress is made, embrace it
Third, when guidelines are implemented, it is natural for commercial organisations and clinical vested interests to align themselves around those guidelines in order to ensure that their products and services, careers, disciplines and specialities are successful and sustainable in the long term. I don’t think there is anything wrong with healthcare professionals aligning their career interests, or indeed companies their business interests, with the needs of the patient and the healthcare system, especially if those needs have been established through thorough consideration of the latest evidence: the more these interests can be aligned with those of improved patient outcomes for more patients at a lower cost, the better.
I digress. We need to recognise that when these interests align, they will of course then have a further interest in the guidelines remaining as they are for as long as possible, and this is a less good thing. All groups, whether commercial, clinical or advocacy-focused should have the best interests of the patient and healthcare system at their core.
This means accepting, demanding, even, periodical review and improving the way things are done, and accepting that you may need to change and do things differently, and in extreme cases, recognise that your speciality, or service, or product, becomes redundant because of advances in other areas.
It’s tough to hold yourself to account like this, and there are a plethora of examples in the medical field where potential advances in access to improved care at lower costs with better outcomes are being, or have been, held up because the ‘new’ threatens the ‘old’.
We ought to accept that guidelines ought to be reviewed, when advances in medicine and technology move significantly beyond what was common practice when the existing guidelines were established. No one, after all, treats schizophrenia with frontal lobotomy any more, the science has moved on.
Good science well explained helps patients
Fourth, and most important, politically or commercially driven slanging matches between opposing camps on a debate do not help the patient. They urgently need scientifically sound consensus to help inform their healthcare decision-making. And the patient should be our primary concern. One day that patient will be you, it will be me, it will be our children and loved ones. Who would want them treated other than in a way based on the soundest possible assessment of the evidence? So, ask for the evidence.
I've been following the discussion in the UK on the NHS breast screening programme. It's a long-running cost-benefit debate, and decisions about it should be made on good science and good access to information. If anything, this will clarify things and help better inform women.
Here are the links that I have been reading or listening to:
BBC 5Live discussion on Victora Derbyshire's talk show between some brave patients (inc. one with dense breasts, one undergoing chemo while on the phone whose diagnosis took 8 months), GP Margaret McCartney and Professor Peter Gotzsche: http://www.bbc.co.uk/iplayer/console/b016bkqv
Margaret McCartney on informed consent, DCIS and patient information in The Independent: http://ind.pn/vjbupG
and on her blog: http://www.margaretmccartney.com/blog/?p=1192
Mike Richards, national clinical director for cancer and end of life care at the DoH writes in the BMJ: http://bit.ly/tkHHeC
And Mike Richards on video (with an annoying ad to begin): http://bcove.me/6lmz9bec
Susan Bewley, professor of complex obstetrics, Division of Women’s Health, King’s College London calling for a review of the NHS's screening programme in the BMJ: http://bit.ly/w0ZjLP
I'm no doctor, and no expert, but I am learning that women diagnosed with breast cancer today can expect a very different treatment paradigm than what their mothers may have experienced. Their cancers' genetic profiles can be assessed to determine how aggressive they are, what their chances of recurrence are, and which drug regimes they will or, very importantly, will not respond to. Diagnostics and treatment are advancing, and changing the face of the what medicine will look like - making it personalized.
Here's an example of what Personalized Medicine : A Dying Cancer Patient's Plea For Personalized Medicine - Forbes http://onforb.es/vTnJL2
When people in the Dept of Health in the UK, such as Mike Richards, lead reviews of evidence, the result, we must hope, is that the recommendations are followed and that they are truly in the best interests of patients. This is a nice little sofa discussion by the folks at the BBC.
Here's a thought that crashed into the media spolight in the UK this morning by a Commons Public Accounts Committee report into the use of high-value capital equipment in the NHS [stifle those yawns, folks, this is interesting] :
If you buy expensive kit, the more you use it, the better value you get from it - so use it 24/7!
Not exactly groundbreaking, is it? The NHS is the 7th (?) largest employer in the world. Take a report to the CEOs of the biggest 6 and tell them that they are not maximising return on investemnt in their capital equipment, and I think you'll see them act decisively. The PAC report essentially says: club together to maximise buying power, and beast the kit you buy.
I would like to see this in the NHS too - if you have a nice shiny CT or MRI, please, run it all day and all night - how else can you get the most out of it, reduce waiting lists and increase efficiency? Of course I understand there are staffing capacity issues and shift patterns - but these don't stop other industries getting the most out of their capex:
This has been brewing in my mind ever since my father was hospitalised earlier this year following a series of heart attacks [he's fine now, read about it here http://kmckeck.posterous.com/], and he berated the fact that he could not get an angiogram over the weekend when admitted to hospital on a Friday morning. They don't run the interventional diagnostic suite after 5 pm Friday and before 8 a.m. Monday.
"I'd have been livid if I'd found out my capex was lying idle 70% of the time it could be running," he fumed.
He has had a long career as an exploration geologist and in his time ran some pretty extreme gold mining operations in far-flung places. I was lucky enough to get to visit these, deep mines in darkest Sumatra, open pits on south Pacific islands, wild camps in the depths of the Amazon rainforest, and the bush in Botswana and Katanga, Zaire (see below).
I grew up around projects where big multinationals were making colossal invesments in equipment with a long view to the return on the investment. And even in these extraordinary places, under pressing conditions, heat, dust, humidity, lack of infrastructure, political chaos, the operations ran around the clock.
As a kid I never thought to question the fact that the mines ran all day, every day, all year. It just made sense - investors want a return, so they beast the kit. I remember watching the night shifts of workers go down damp humid shafts in jungled mountains, thinking, "Of course, it's dark down there anyway."
In the UK, we, the public, are the investors in the healthcare system. My taxes buy expensive diagnostic kit and operating theatres. For my money, I want a decent return - a fully-functioning, efficient, world-beating health service focused on keeping people healthy and diagnosing disease early please. Much of the time we get that, but I'm livid to find that much of my capex is lying around idle between 6 p.m. and 8 a.m. weekdays and all weekends.
Here's a conundrum that I am sure smarter people than me are pondering. It was brought to my attention by a cancer patient. A young one: 40 years old, and receiveing palliative chemotherapy, tweets:
"I am 40, when I have chemo I notice the ones who have stage 1 cancer with chemo to kill any stray cells are...
the elderly people, many of my age r having palliative chemo as cancer has spread. This is [a] direct result ..
of those older having been regularly screened while younger ones have not, hence cancer caught later :( "
We champion, rightly, the idea of early diagnosis across so many disease areas, and for some, there are national screening programmes designed to catch these conditions, most often cancers, early.
Early detection, diagnosis and treatment, the rationale goes, makes for better clinical outcomes and reduced healthcare costs. This is a good thing.
The UK cancer screening programmes target the people most at risk, again, rightly so, and stratified by aged group: women between 50 and 70 for breast cancer, and between 25 and 65 for cervical cancer; men and women between 60 and 69 for bowel cancer. http://www.cancerscreening.nhs.uk/index.html
All well and good, and much progress is being made. But what about the outliers?
Those that develop, for no clearly understood reason, cancer when they are younger and are not captured in the screening programmes. Their diagnoses are pre-disposed to being made late, and the sad irony is that they are the ones that stand to gain most in terms of life quality and years of life from an early diagnosis.How do we get to them and their cancers early enough to save them, and the impact of their illness on those around them and the finances of the healthcare system. (apologies for that, but in a system of limited resources, cost-effectiveness is what NICE is counting).
Yes, risk profiles can be augmented by family histories, lifestyle factors and genomic testing, perhpaps helping to expand screening groups to those who need it most (e.g. those carrying BRCA1 and BRCA2 mutations); but mostly this is about awareness.
Patients' awareness, public awareness, physicians' awareness; of symptoms, of lifestyles. And there you have the difficulty - the gap between knowledge and action, and the inconsistencies in people's understanding of disease risk. The "wait-and-see" approach in primary care.
Many recognise these issues, many campaign on them; and perhaps slowly, along with breakthroughs in genomics, things are changing for the better. I hope so.
None of which is much comfort to someone aged 40 undergoing palliative chemo for cancer.
Health is more than being disease free - yes.
The things with most impact on my health are things that I can control - yes.
There is a knowledge -action gap in health...which means "we may well know what is good, but we sure as hell don't always choose it".
The suggestion from the health barometer by Edelman is that:
1 - peer pressure on better healthier living could help - yes - but peer pressure works both ways - go on then, just one more beer before I go.
2 - tools & tech can help - yes, but tools and tech work against health too - see the Pizza Hut app, get fat featured on your phone
3 - companies need to help their employees live healthier - yes - but at the same time they want to get their pound of flesh...I know, believe me
All well and good, but the more I learn about this, the more I think there's a combination of carrot and stick in getting people to live healthier.
1 - smoking bans work.
2 - higher taxes on booze work
3 - a change in the law with added social stigma works (drink driving, seatbelts)
4 - targets for salt and fat reduction works
5 - banning trans fats works
So? Now what? How much do we want to legislate for health? It's largely our own making, this explosion of unhealthy-lifestyle-led disease. It took 50 years, and we did a great job of getting fat and sedentary. How do we reverse it?
More soon....
I searched high and low and came across all sorts of crazy designs, but have settled on the simplest. Time to get the jig-saw out.
