Wendy and I had a wander round the Scottish National Gallery last weekend, as we often do when we visit Edinburgh. I know really nothing about art; Wendy knows a bit more. But we both enjoy a few minutes which take our minds of anything that bears any resemblance to stuff we do at work.

As I wandered, I was reminded of two research papers, one of which I’ve intended to feature on here for years, and the other which came out only last month.

The first was written by a neurosurgery registrar I once worked with. I’m sure he’s a high-flying surgeon these days. It’s from JRSM (where else), and is called Brain ‘imaging’ in the Renaissance. He wrote about the resemblance of Renaissance paintings to brain anatomy. I like this paper because of the slightly off-kilter thought process it would take to notice these things, and also because—in reference to Gerard David’s painting of the Transfiguration of Christ—it contains one of my favourite paragraphs from any paper:

Gerard David’s painting of the ‘Transfiguration of Christ’ resembles a coronal section of the brain. We find again the concept of the ventricles as the abode of the soul. God is represented in the third ventricle, with Elijah and Moses in the temporal horns of the lateral ventricles. Jesus, conduit between the Word of God and the human race, resembles the brain stem/spinal cord, conveying the message from the brain to limbs and organs.

Even with the annotated images in the paper, I can’t even begin to buy the argument that there’s any intentional resemblance (or, indeed, much of a resemblance at all). But that doesn’t matter: the fantastical combination of high-level anatomy, religion and art in those sentences tickles my grey cells no end. It’s like worlds are colliding right in front of my eyes.

The second paper is similar, but has a slightly different—though equally bizarre—though process behind it. Consider, if you will, Pinturicchio’s Madonna and Child with St John the Baptist:

Clearly, there’s only one reaction anyone could have when examining this masterful artwork from centuries ago: what the hell is going on with Madonna’s little finger?! And it’s not just Madonna as painted by Pinturicchio that has something funny with the fifth finger—Botticelli’s Portrait of a Young Man depicts something very similar:

Having noticed the weird finger in a load of art from the same period, Lazerri et al undertook a systematic reappraisal of the fifth finger in Renaissance paintings, in which they try to explain the funny finger from a medical or anatomical perspective. They don’t really come to much of a conclusion. They say that lots of subjects of Renaissance paintings seem to have camptodactyly of the little finger, while others might just be holding their little finger in a weird position.

But the conclusion doesn’t really matter. I’m just in awe that someone can notice something so offbeat, and then pursue it right through to researching, writing and publishing a paper in a medical journal. That takes a serious degree of self-confidence in your own random thoughts. Brilliant!

Answer me this: what happened to waiting times in A&Es in England last week? To help you answer, here are some tweets published by reputable news organisations today:

A&E waiting times in England improve to their best level since November, figures show http://t.co/N2ib5ttFyO pic.twitter.com/YVALTkJ9qW

— BBC News (UK) (@BBCNews) January 23, 2015

A&E waiting times in England improve http://t.co/mQtiuk12yc

— The Guardian (@guardian) January 23, 2015

NHS England pays tribute to staff after figures show slight reduction in A&E waiting times http://t.co/PNOq2Yyv9Y pic.twitter.com/mvQfNX3eHS

— ITV News (@itvnews) January 23, 2015

A&E waiting times improve but fail to hit target http://t.co/cC7NO055aB

— PoliticsHome (@politicshome) January 23, 2015

A&E crisis: Waiting times improve for second week running http://t.co/tNTEYstIx6 pic.twitter.com/jWk9FKELmH

— Telegraph News (@TelegraphNews) January 23, 2015

You would be forgiven for thinking that waiting times had reduced. You would be… possibly right, possibly wrong. The correct answer is that we don’t know. Performance against the weekly A&E waiting time targets—which is what all of the above are actually reporting—tells us nothing about the waiting time in A&E.

As an aside, before we get into this properly, I should clarify that “waiting time” doesn’t mean what most people think it means. The “waiting time” referred to in these statistics is the total time a patient spends in A&E, from the moment they walk in the door, to the moment they walk out again (whether that is to go home, to go to a ward, to go to the pub, or wherever). That’s not what we think of as “waiting” in common parlance: while you’re with the doctor, you are—in statistical terms—still “waiting”.

The NHS doesn’t report on waiting times, only on the proportion of patients seen in less than four hours. When the reporters wrongly say that A&E waiting times have improved, what they actually mean is that a greater proportion of people entering A&E are leaving again in less than four hours. This tells nothing about the amount of time people wait on average.

Imagine an A&E department that sees only five patients: A and B have minor injuries, and are seen and treated within 30 minutes. C and D need a more complex set of investigations, so end up being in the A&E department for 3 hours. E needs a very full assessment and ultimately admission; as a result, E ends up being in the department for a total of 5 hours before a bed can be found. The average time these patients spend in A&E is 2 hours and 24 minutes; 80% of them were discharged in 4 hours.

Now let’s say that someone puts a laser-focus on that 80% and says it’s unacceptable: whatever the cost, it must be brought down. So the department tells the nurse that used to do the “see and treat” job (which served patients A and B so well) that she must help with only the most complex patients, because they are breaching the target.

The same five people with the same five injuries now come into the revamped A&E. A and B have minor injuries, but now must wait alongside everyone else. They hang around for 3 hours. C and D need complex investigations, but these are slower to start because of people with minor injuries clogging up the queue. They are discharged after 4 hours. The new complex patient team deals with patient E slightly faster, getting her up to the ward with seconds to spare before the four-hour deadline.

100% of patients were seen within 4 hours. The hospital’s management is overjoyed! The BBC tweets that A&E waiting times have decreased: 100% of patients are seen within four hours instead of 80%. Politicians become a little self-congratulatory.

Yet… what has actually happened? The average waiting time has increased from 2 hours and 24 minutes to 3 hours and 36 minutes. 80% of patients are waiting longer than they did before.

And that is why—whatever the news tells you—we have no idea what happened to A&E waiting times last week. The average time could have doubled; it could have halved; it could have stayed precisely the same. We simply do not know.

A number of politicians have recently made absurd statements about the role of the market and profit in healthcare, and specifically in the NHS. In political terms, the two worst culprits are the Labour Party and the National Health Action Party.

When the Labour Party left office in 2010, data¹ showed that roughly 5% of NHS procedures were carried out in the private sector. Under the current Government, as of the most recent set of statistics, this is roughly 6%. It’s just worth bearing those proportions in mind whenever you hear Labour pontificate on the role of the private sector in the NHS. But I digress.

In his Party Conference speech, Andy Burnham asked:

And for how much longer, in this the century of the ageing society, will we allow a care system in England to be run as a race to the bottom, making profits off the backs of our most vulnerable?

I’ll answer that question in a moment. But to illustrate that Burnham is not alone, let us turn to the National Health Action Party.

You may not have heard of the National Health Action Party: it is a well-meaning but misguided Party whose platform—to defend and improve the NHS—is as vague as it is logically flawed. Dr Richard Taylor, co-leader of the party, was previously an MP; he signed an Early Day Motion in support of homeopathy, and praised the use of acupuncture and reflexology in cancer treatment. To date, the party has contested and lost nine elections² with their best result being a 9.9% share of the vote for a single council seat in Liverpool. Again, I digress.

In The BMJ, in reaction to the news that Circle Health plans to withdraw from its contract to run the Hitchingbrooke Hospital in Cambridgeshire, a National Health Action Party representative said:

This perfectly illustrates the difference between the private sector, which seeks profits, and public NHS Trusts … This shows exactly why the market has no place in healthcare.

So, you ask me, what’s wrong with those quotes? They seem like perfectly sensible sentiments to me!

Both of these quotes are simply nonsense. Neither the Labour Party nor the National Health Action Party are campaigning for the removal of profits and the market from the NHS—and nor is anyone else.

Any modern business, be it a hospital or fishmonger, is reliant on suppliers who will draw a profit. The NHS doesn’t manufacture its own light bulbs and baths, nor generate it’s own electricity,³ so people will draw profit from supplying them.

Alright, you might be saying, but that’s not really medicine, is it?

But of course, profits are made on medicine too. Sure, the NHS could manufacture all the medicines it needs—it already manufactures some.⁴ But many medications are under patent. Are NHS patients to be prevented from accessing patented drugs? Of course not: so companies will draw a profit. And the more sick people there are, the bigger the profit there is to draw.

OK, you say, but medicines are a special case.

Except they’re not. Almost every product used to deliver healthcare—from syringes to catheters to implants to surgical tools—will generate a profit, as it is almost all bought in from commercial manufacturers.

Come now, you say, supplies are a red herring. I’m interested in healthcare—a human caring for another human. There’s no profit to be made there!

Oh, but there is. Management of human resources is a tricky business. Often, Trusts will hire in external experts to help with training, planning or management, many of whom will work for consultancies which make a tidy profit.

Everyone knows human resources officers aren’t human, you intone—though I couldn’t possibly comment, I’m talking about a nurse looking after a patient at the bedside. Where’s the profit in that?

The scenario you describe is just dripping with profit—from the agency that recruited the nurse, to the profit on the manufacture of his uniform, to the cut of his pay which goes to the nursing agency he’s working for, to the cut of his car parking fee which is given to the private company managing the facility.

Ugh. You do go on a bit. What’s your point?

Suggesting that the NHS be removed from the commercial market and freed from the pursuit of profit is nonsense. Of course, the internal market in which NHS providers compete with one another could be reformed or removed, but the NHS is involved in a wider external market which is here to stay. The NHS is one of the country’s biggest purchases of goods and services, and each supplier will be doing the best they can to—effectively—profit from the sick.

Even if, for the sake of a thought experiment, we say that the NHS could be isolated totally from the battle for private profit, the end result in terms of the health service alone might not be that different: there would be continual pressure to reduce costs to the taxpayer, which is effectively the same financial pressure as increasing profits to shareholders.

The true argument is about the extent of involvement of the private sector.

Consider privately-employed doctors. Would we trust doctors to the same extent if we knew their interests balanced our interests with profit potential? This isn’t something we have to treat as a thought experiment: most GPs are small businesses and work on exactly this principal with little discernable effect on levels of trust. But, again, it feels icky.

Consider private sector management of whole NHS hospitals. This might look like a step too far: it takes a layer of previously publicly-funded management, who perhaps tried to balance the drive for profits with the best interests of patients, and moves them to the profit-hungry private sector. Yet, the management would always be accountable to commissioners, who would be looking out for the patients: so does it really matter? Perhaps not from the conceptual standpoint—but I’ll admit that it makes me more than a bit uncomfortable. And while a sample size of 1 makes for a poor trial, the fact that the first hospital so-run has become the first hospital to be rated as “inadequate” on patient care does not feel reassuring.

Consider public health campaigns teaming up with well-known brands. Is it okay if public healthcare money inflates Aardman Animations’s bottom line, if using Aardman characters is a good way to get health messages to children? I’m not sure: evidence about cost-effectiveness could sway me one way or the other.

Wouldn’t it be wonderful if we could have a debate on these issues that’s based in the real world, rather than the five-word soundbite world? Wouldn’t it be great if politicians would describe the extent of private involvement in the NHS that they believe to be appropriate, and we could then vote for the Party whose ideas most closely align with our own? Wouldn’t it be peachy if our politicians would stop patronising us all and treat us like adults?

As I said in my last post, the current model of delivery for the NHS is unsustainable. This is a problem that needs statesmanship, cross-party exploration, and—most importantly—tackling by adults.

We’re 120 days from the UK General Election, and I’m already truly fed up with hearing absurd nonsense about NHS spending from politicians of all colours.

Society is ageing. There are 3 people of working age for every person of pensionable age in the UK.¹ A little over two-thirds of working age people work, so there are, roughly, 2 working people for every person of pensionable age in the UK. By 2050—within my working lifetime—this ratio will approach or exceed 1:1.

Mean health spending per annum for a person of pensionable age is currently circa £5,000. That’s exclusively health spending; it doesn’t include social care costs, pensions,² or anything else the Government spends to support the elderly. That £5,000 estimate is rising fast, and will continue to do so.

As the proportion of the population which is of pensionable age increases, and the costs per person of pensionable age increase, this model quickly becomes unsustainable. You reach a point, within decades, when the total tax burden becomes untenable. And before anyone says “but what about corporate taxes?”: these are, of course, paid by people, be they customers, workers or shareholders (which are mostly ordinary people via pension holdings).

Of course, it’s not all about the elderly—the young are getting sicker for longer too. As one of many examples: it’s been postulated that fully 10% of the current NHS budget is spent on diabetes-related care, and the prevalence of diabetes is rising by the month.

I believe passionately in the provision of healthcare free at the point of use. But I also believe that our current model for delivering this is broken. I don’t know how to fix it. This is where I’d like politicians to put forward bold and coherent visions of alternative ways of making this work.

What do we get instead? Monkeys arguing over peanuts. Even the National Health Action Party, whose raison d’étre should be to put this on the agenda, fail to articulate anything resembling an alternative.

Over the course of her term in office, Margaret Thatcher increased NHS spending by an average of 3% a year above inflation. These years are recalled as some of the darkest in the history of the NHS due to the perception of cuts—cuts which were, in reality, simply a level of investment which did not keep up with the rise in demand. The current budget of the NHS in England is £100m:¹ a 3% per year above-inflation rise is £16bn extra funding per year by 2020.

Over the course of the next five years, the NHS estimates a £30bn per year budgetary shortfall if funding rises only in line with inflation.

Consider those two figures. £16bn per year on a Thatcherite scale of investment, £30bn per year needed according to the NHS itself. How do our political parties compare?

• The Conservative Party claimed to be increasing the budget by £2bn in 2015/16 as a “down-payment” on £8bn per year future investment. However, it emerged that only £1.3bn of this was actually new money, and was for the whole of the UK, with Scotland and Wales taking £300m between them. So it’s a £1bn increase. Whether or not the rest of the £8bn will be made from smoke and mirrors—it’s way below what’s needed.
• Labour want to invest an extra £2.5bn per year, which—depending on the announcement—they want to spend on one of myriad things, with seemingly no understanding that money can only be spent once. Not to mention that it’s far, far below the level of investment required to maintain the NHS in any case.
• The Lib Dems have the most generous offer: £8bn per year. Half of what Thatcher would invest, a quarter of what’s needed. They expect NHS ‘efficiency savings’ to make up the shortfall. Where do they think the NHS is “wasting” £22bn at the moment? Perhaps I’ve too simplistic a mind, but it’s hard to see how a reduction in spending of £22bn isn’t a “cut”.

All three parties appear to have reached the same conclusion as me: it is unfeasible to continue to fund the NHS under the current model. Yet instead of tackling this head on, they are arguing over whose inadequate increase is biggest. Each party is complicit in maintaining a veil over the true scale of the problem, and bereft of anything approaching a plan to address it.

I appreciate that saying the current model of delivery for the NHS is unsustainable is a great way to lose an election. It’s a problem that needs statesmanship. It’s a problem that needs cross-party exploration. It’s a problem that needs tackling by adults.

1. The figures used in this post are intentionally rough and ready. They’re based on national statistics, but aren’t exact for a whole variety of reasons to do with stuff like rounding and comparability. I promise it doesn’t matter – the thrust is the same even if the figures are a bit out. ↩
2. Talking of pensions, the entire £100bn budget of the NHS—for people of all ages—is currently matched almost pound-for-pound in state pensions. This surely cannot be sustainable. ↩

Since this is my blog, I reserve the right to geek out once in a while… and today is one of those times. My recommended read for this weekend is a fascinating bit of historical epidemiology published in The Lancet back in 2012 (it’s free to access). Gunn and Gromelski present their review of the documentation from 16th century coroners’ inquests (Who knew there were coroners, let alone inquests, in the 16th century?!)

Earlier this year, I was lucky enough to have some of my work featured in the British Library’s Beautiful Science exhibition, and – just a few exhibits along from mine – they had some brilliant Parish records of deaths from the 19th century on display. It was intriguing to see diagnoses like “rising of the lights”, which killed an awful lot of people – especially when one considers that knowledge of what this phrase actually described is now lost to history.

The Gunn and Gromelski paper is interesting for its analysis of what the deaths tell us about lives during that period, and how things have changed over the years. My description of the paper may sound geeky, but it really is fascinating, and well worth spending a few minutes reading this weekend.

And can any of my medic friends honestly say they wouldn’t love to write something as artistic as “a rush of water entered his mouth and nose and stupefied his spirit” in the relevant box on a crem form? I know I would.

My recommended read for this week is The Body Electric by Ferris Jabr in Outside.

As it turns out, lightning strikes are commoner than one might think, and the odds of surviving are pretty good. But there are bizarre, under-researched and under-explained after effects associated with survival.

In his article, Jabr interviews some of the 500-a-year US survivors of lightning strikes, and explores several of the after-effects. It’s a really absorbing story, almost all of which was new to me. The only thing I remember from medical school about lightning strikes is the distinctive skin marking but I have learn from microcurrent machine reviews that people use this machine to help with this a reduce a little the impact on the skin. This article made me wonder whether I should have been taught more – but then, probably as a result of the more temperate UK climate, human lightning strikes are rather less common here than in the US.

Anyway, it’s well worth a read.

The BMA is asking members to sign a petition asking Government to repeal the Health and Social Care Act 2012. The leadership’s rationale is that the Act requires providers to compete, while the BMA believes that “collaboration and not competition is more likely to allow a greater integration of community and hospital services”.

I could not agree more: collaboration is more clearly in the interests of individual patients than competition, and collaboration seems at odds with competition. Yet I don’t think the BMA’s position should be to call solely for repeal of the Act: after all, the Act is not solely about competition. The legislation brought about many changes, some of which are working well.

For example, we are beginning to see the value of a new local authority perspective on influencing the wider determinants of health, as shown by the exemplary nominees for NICE’s local government public health award. This sort of progress can be found in many Local Authorities across England. To campaign for repeal of the Act is to surround this progress with a fog of uncertainty: repeal would reject this progress outright and move staff back into PCTs.

The Act limits the Secretary of State’s powers to intervene in the day-to-day running of the NHS. While the success of this has been questionable at best, we are beginning to see push-back against Government diktat. No one, except perhaps Lansley and Hunt, would argue that the NHS benefits from the Health Secretary holding operational control; yet repeal would reintroduce this.

The Act confers new responsibilities on NICE to support evidence-based social care. The Act provides the first (baby) steps towards regulation of healthcare support workers. The Act gives an unprecedented level of legislative support to research in the NHS. These may be small considerations in comparison to the problems of the Act, but outright repeal would (if I may mix metaphors) cast the baby and the bathwater both into uncertain territory.

How quickly the BMA seems to have forgotten the pain inflicted on our profession through restructure, job uncertainty, and redundancy. Excellent professionals left medicine — and especially public health — to pursue other careers, while others lived for years with the stress of the uncertainty of their positions. For the profession’s trade union to argue for yet another overnight reorganisation “so big, it can be seen from space” seems utterly perverse. Perhaps this is why, despite the BMA’s repeated urging, fewer than 4,000 people have signed the petition. Even if every signatory were a BMA member, this would represent less than 3% of the membership.

Repeal represents only a return to the past. It behoves professionals to put forward an alternative vision. For example, politicians refuse to discuss the threat to universal healthcare of having fewer taxpayers per patient as a result of an ageing population; yet the BMA is uniquely placed to devise a considered, collective, professional vision of the future of the NHS. To campaign only for repeal of what exists, and allow the next government propose and introduce yet another short-term model, seems to me to be a sure route to unhappiness.

The BMA should not call for repeal of the Act: this is opposition without a position. The BMA should identify the most insidious parts of the Act, and work tirelessly to scrap or rework them. But, more importantly, the BMA should thoughtfully advocate for the future health of the nation, not for a return to the systems of the past.

If you can, you should – blood.co.uk

I am implacably opposed to capital punishment. There are few issues on which I'm so certain. The state should not kill people. As I've said before, humanity is better than that.

It was only a few weeks ago that I learned that the European Union forbids the export of drugs used for killing prisoners in the USA through lethal injection. For perhaps the first time, I felt a real swell of pride at what seemed a surprisingly strong and principled stand. It is rare to see ethics translated to action on this scale.

But today, Owen Dyer's article in the BMJ (paywalled) has given me pause for thought. This excellently-written article discusses, in some detail, the difficulties drug shortages have caused for the lethal injection programme in several states.

Dyer's article talks through a number of horrendous botched executions, as well as the methods (some illegal) by which states have attempted to procure drugs for lethal injections. I found it a deeply thought-provoking piece. Towards the end, Dyer comes to this point:

Arkansas’ attorney general last year called the state’s capital punishment system “completely broken … it’s either abolish the death penalty or change the method of execution.”

Initiatives are now cropping up in state houses to return to more violent methods. These methods are not so far behind us as some imagine. The last execution by firing squad was in 2010, the last by gas chamber was in 1999, and the last hanging occurred in 1996. The last use of the electric chair was in 2013 in Virginia.

Is it better to bend our principles to supply drugs and assure a more humane death, or to withhold them and ensure a violent death?

The dilemma is complicated by the knowledge that violent methods have less public support, so may – or may not – bring about the end of capital punishment in the USA sooner than non-violent methods.

I tentatively lean in the direction of the greater good, and suggest that drugs are withheld. But it is certainly a complicated issue.

My recommended read for this week is a long but very engaging extract from David Quammen’s book Spillover. It was published in PopSci. It reads like some sort of adventure novel, but discusses the reality of tracking where the next pandemic virus might come from, and the work scientists do to prevent it. It’s well-worth reading!

The electron micrograph of a varicella zoster virus at the top of this post is from NIAID’s Flickr feed, and is used under its Creative Commons Licence.