Tag Archives: NHS

Although now dead, the Cholesterolosaurus will march on

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A meta-analysis including 530,525 people, partly funded by the British Heart Foundation, and published in the Annals of Internal Medicine has just come to this conclusion:

Conclusion: Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats1.

Or to put it another way, there is no evidence that saturated fat consumption has anything, whatsoever, to do with causing heart disease, or strokes. Once again I get to say ‘I told you so.’ Ah, the four most satisfying words in the English language. That is, when arranged in that particular order.

So, eat butter, drink milk, and throw away the horrible sugar-loaded low fat yoghurt. Go to France and enjoy the highest saturated fat diet in Europe and you, too, can enjoy the French rate of heart disease. Yes, of course, the lowest in Europe.

But now what happens? You see, the entire edifice of the cholesterol hypothesis is held together by two links in a chain. Link one is that saturated fat consumption raises cholesterol levels. Link two is that raised cholesterol levels then cause heart disease.

Various ‘experts’ have simplified this to the very simple equation:

A (saturated fat in the diet) > B (high cholesterol levels) > C (heart disease)

This is the cholesterol hypothesis, or the lipid hypothesis, and it has driven medical thinking for the last sixty years.

I have had it painstakingly explained to me, by very clever people, exactly how saturated fat raises cholesterol levels. Indeed, you will find ‘evidence’ for this almost universally accepted fact in literally thousands of clinical studies. Here is what Wikipedia has to say on the matter

‘There are strong, consistent, and graded relationships between saturated fat intake, blood cholesterol levels, and the mass occurrence of cardiovascular disease. The relationships are accepted as causal2.’

Okay, let us accept that eating saturated fat does raise cholesterol levels. However, if consumption of saturated fat does not increase the rate of heart disease then….. Then raised cholesterol levels can have nothing whatsoever to do with causing heart disease. Just keep chasing the implications of that statement around in your head for a while.

So what happens now? We now have a cholesterol/lipid hypothesis that just had its head blown off. Yet, it still continues to wander about, unaware that it is actually dead.

As everyone knows you can chop the head off a chicken and it can wander about for years. I was also informed, when I was an open-mouthed child, that you could shoot a dinosaur through the head and it would continue to blunder about for some time, the rest of its body blissfully unaware that it was actually dead.

Well, the cholesterol hypothesis has just been shot dead, but I suspect it will continue to rampage about, stomping on puny humans for many years, before it finally keels over and admits that it is dead.

But I say, farewell Cholsterolosaurus. You are now a deceased hypothesis. Gone to meet your maker. You just don’t know it yet. Because the people that believe in you do not understand logic.

1: http://annals.org/article.aspx?articleid=1846638
2: http://en.wikipedia.org/wiki/Saturated_fat

The pharmaceutical industry now controls NHS policy – hoorah.

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I noticed the other day that the pharmaceutical industry have managed to achieve something they could surely once only have dreamed of. Creating policy documents. Here is the offending headline from the Guardian newspaper:

NHS hires drugmaker-funded lobbyist

As the secondary headlines say:

‘Conflict of interest concerns as Specialised Healthcare Alliance (SHCA), funded by pharmaceutical companies, advises NHS England.’

A lobbying organisation with links to some of the world’s biggest pharmaceutical companies and medical equipment firms has been asked by NHS bosses to write a report that could influence health policy, it has been reported.’

It seems lobbying is now ‘so five minutes ago.’ Who needs a lobbyist when this organisation, the Specialised Healthcare Alliance (SHCA), which is entirely bought and paid for by the pharmaceutical industry, has been commissioned to write a report on funding specialised services for the NHS.  Services worth £13,000,000,000.00p (£13Bn/$20Bn) per year.

The article does point out, though, that we are misguided to think that this could be in any way an issue. For John Murray, the director of the SHCA, a lobbyist, and author of the report, has made it clear that:

.…..there was no link between his lobbying business and the SHCA other than providing secretariat services and said the SHCA “never takes a position on particular products or treatments in any of its activities”.

John (Pinocchio) Murray’s nose is now in the Guinness Book of Records for being the longest nose ever recorded on a human being, at seven point three miles. He is a lobbyist, paid for by pharmaceutical companies, and his organisation never takes a position on particular products…..hahahahahahahahahaha. Well then, sack him immediately for being useless…. sack him for failing to do what he is handsomely paid to do.

The final part of this newspaper report, which I savoured, is the following:

‘James Palmer, clinical director of specialised services at NHS England, said he was aware of Murray’s role as a lobbyist but “there are no opportunities for lobbying in the process of forming clinical policy”.’

This, of course, is true. There are no opportunities for lobbying in this particular process of forming clinical policy. Once a lobbyist starts to write clinical policy, they have moved well past the annoying requirement to lobby anyone. For the lobbyist has now managed to become the very person that they should be paid to lobby.

Instead of trying to influence someone who may not listen to him, he can just talk to himself…. Imagine that this short section of imagined dialogue is like Smeagol talking to Gollum in Lord of the Rings (Smeagol and Gollum are, or course the same person):

John Murray: ‘We must put the following phrase into the report, my precious. A “clear commitment” to “disinvest in interventions that have lower impact for patients” in favour of “new services or innovations”.’

John Murray: “But why would you like me to put this in the report, wont this harm the hobbits? Hobbits have been kind to me…yes they have.”

John Murray: ‘I needs it in the report you fool. I represent precious pharmaceutical companies that are bringing new products onto the market. We needs to ensure that there will plenty of money to pay for them. So they must stop paying for stupid old fashioned treatments…yes, they must, foolish Hobbits.’

John Murray: ‘But won’t the kind Hobbits be worried this will just look like lobbying.’

John Murray: ‘Don’t be so stupid. How can the nasty Hobbits accuse me of lobbying? I am their friend, and I am trying to help them…yes I am.. Yes John Murray likes the friendly Hobbits. John Murray want to help the Hobbits, yes he does.’

John Murray: ‘You are so clever Smeagol, our master will be pleased.’…….

Duchess: ‘You’re thinking about something, my dear, and that makes you forget to talk. I can’t tell you just now what the moral of that is, but I shall remember it in a bit.’

“Perhaps it hasn’t one,” Alice ventured to remark.

“Tut, tut, child!” said the Duchess. “Everything’s got a moral, if only you can find it.”

How medicine now works – or doesn’t.

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It may surprise some of you that read this blog that, amongst other things, I still work as a doctor in the jolly old NHS. Yes, one can be a critic and still remain inside the system….although for how long, who knows. In fact, in some ways I am quite establishment, as I sit on the main BMA negotiation committee for GPs, the General Practitioners Committee (GPC). I am also on the Local medial committee (LMC) and local negotiation committee (LNC).

From within the NHS you can more clearly see how the world of medicine is gradually going completely bonkers.

In one of my jobs I do Out of Hours (OOH) General Practice work. That is working in the evenings and weekends. In East Cheshire, where I work, we had a system which was highly rated by patients and everyone who came into contact with it. However, in line with the rest of the country we were told we were now to be incorporated into the Government’s latest and currently stupidest idea, called NHS111. The 111 bit being the single telephone number for people to call for urgent – not 999 care.

NHS111 call handlers get about six weeks training, and are supposed to act as front line troops to direct patients to the correct urgent service. Before this we had nurse triage, with experience nurses dealing with local residents and their health issue. We now have non-medically trained staff given superficial advice on how to go through a treatment algorithm. First question:  ‘Are you alive or dead?’ Not quite, but nearly.

At the end of asking ten thousand questions, or so, the call handler reaches the end of the algorithm where it states ‘You must see a GP.’ Actually, not quite true.  If there is anything actually wrong,  then the call handler tells them to phone an ambulance immediately [Yes, ambulance calls under NHS11 have risen stratospherically]. In my opinion, these people are not doing triage, they are just appointment Clerks.

As we repeatedly warned the Government NHS111 rapidly went wrong.  In East Cheshire and many other areas, NHS111 immediately collapsed the moment it went live, and we had to take back all the call handling. Why, primarily because the private providers running the service had so badly underestimated demand that the system went into melt-down, and patients were left waiting for hours to be called back. (Oh the joys of competitive tendering. In order to get the contract you have to bid so low that you cannot actually provide the service).

Anyway, we still get some calls coming through from NHS111 (A system now running in parallel – at double cost – with the old system).  With the old system we used to get the key facts e.g. a rash, non-blanching, child floppy, temp 39oC, mother worried. Now we get the following (this is an actual transcript of a very, very  simple case, with any patient identifiable data taken out – by me).

  • Symptoms: Cough
  • Case Summary
  • Disposition: The individual needs to contact the GP practice or other local service within 6 hours. If the practice is not open within this period they need to contact the out of hours service. Dx06
  • Selected care service: OOH – GP OOH Service (xxxx Base)
  • Pathways Assessment: Birth had not occurred within the last hour. An injury or health problem was the reason for the contact. The individual was breathing and conscious at the time of the assessment. Heavy bleeding had not occurred in the previous 30 minutes.
  • An illness or health problem was the main problem.
  • The individual was not fighting for breath.
  • A probable allergic reaction, a fit within the previous 12 hours or successful resuscitation were not the main reason for the assessment.
  • The child was not limp, floppy and/or unresponsive.
  • The skin on the torso felt normal, warm or hot.
  • Pathway selected – Cough
  • The individual had not coughed or vomited blood.
  • There was normal breathing between bouts of coughing.
  • Severe illness and a rash suggestive of septicaemia were not described.
  • There was no difficulty rousing.
  • There had been no episode of choking within the previous 24 hours.
  • There had been no inhalation of a hot or poisonous substance in the previous 24 hours.
  • There was no fever at the time of assessment or within the previous 12 hours.
  • There had been no previous diagnosis of heart disease, asthma or other lung disease.
  • There was not a problem for which medical advice must always be sought.
  • There were no severe coughing bouts with whooping, a red or blue face or vomiting after coughing.
  • The cough for had persisted for less than 3 weeks.
  • Instructions given were: The individual needs to be seen
  • by the GP practice or other local service within 6 hours.
  • If the practice is not open within this period they need to be seen by the out of hours service.
  • Directory of Services referral: OOH – GP OOH Service (xxxxxxx Base)
  • Advice given: Worsening
  • Advice given: If the condition gets worse, changes or if you have any other concerns, call us back.

As you can see, if you bothered to read it, 99% of this is just meaningless guff, stating irrelevant negative findings. But it does take a considerable amount of time to read. Some of it just made me despair. For example, the report states that: ‘An injury or health problem was the reason for the contact.’ Well really, how completely amazing. Someone calls a health line and they may have an injury or health problem.  Who’d a thunk?

This is followed later by…’ An illness or health problem was the main problem.’ Well at least they had narrowed it down from an injury or health problem to an illness or health problem. [So it now seems that illnesses are not health problem?]

What did I actually need to know? I needed to know that a child had a cough that was getting worse. Whilst it is possible to establish this from reading the report (just)  other key information was conspicuous by its absence. Past history of asthma, for instance (which this child had) or other respiratory problems? Any medications?  That type of thing.

As with most new initiatives in the health service I am now getting swamped with information – but the vast majority of it is completely and utterly useless, and just gets in the way of finding out what I want to know.

This, by the way, was a very small part of the report that the GP (in hours), will receive. They will get about ten more pages of other extraneous guff that they have to wade through. At some point my consultation (the only bit they are interested in) will appear so they will know what I found and what I did – and if they need to do anything. This will not be at the front of the report, no, it will be stuck in the middle, surrounded by information about when the call came in, how long it took to respond, what pathways were used etc. etc. etc. thud.

This, ladies and gentlemen, is the type of nightmare bureaucrat driven nonsense that is turning healthcare in the UK from something local, flexible, and responsive to patient needs, into a flabby form filling, algorithm following, arse-covering exercise. Millions of hours spent producing lengthy reports that have no value; they simply get in the way of providing useful information and de-skill, demotivate and de-professionalise everyone involved.

I imagine the UK is not alone in this. Somehow or another we need to fight back.