The problem faced by public health campaigns in the UK is the tendency for people to react to being told what to do.

Benjamin Daniels, Confessions of a GP

Five reasons why this video (whilst it makes an important and valid wider point) irritates me:
1. It doesn’t acknowledge that both A (on the left) and B (on the right) are both, ultimately, working for profit rather than purely for the benefit of patients.
2. It doesn’t acknowledge that A likely employs salaried doctors like B, with similar issues.
3. It doesn’t acknowledge that since A opted out of providing out-of-hours care, B has stepped in to provide it. In fact, it’s B who’s illustrated at walking out at the end, just when B’s colleagues are kicking into action.
4. It suggests that non-partner doctors hold less professionalism, and are less concerned with patient welfare. Such doctors include many GPs, as well as virtually all secondary and tertiary care physicians and surgeons.
5. It doesn’t acknowledge a single advantage of the corporate model. A’s approach may well be preferable as a whole, but B’s approach is not without merit, and it’s idiotic to suggest that it is.

Re: this article.

A mother chooses to disclose the contents of a private letter telling her that her son that he’s on the 98th centile for BMI. She does this by calling him “fat”. This upsets him. So she has a picture of him printed in a national newspaper with a report explaining that he’s reportedly “fat”. And then blames the NHS. Exasperating!

Perhaps the letter she received needs refining. Perhaps a letter isn’t the appropriate way to communicate this info.

But the bare choice is between:
a) Not monitoring children’s health
b) Monitoring but not disclosing the results
c) Monitoring and giving advice to parents of children with a high BMI

I can only ever see “c” being the ethical option.

Would this mother really have preferred not to know that her child is at statistically increased risk of a variety of diseases? Would she really rather not have been given advice on how to help? Was it really ethical of the Daily Mail to cash in on her unhappiness rather than pointing her in the direction of her GP?

I suspect the answer to all three is “no”.

Rant over.

A story is doing the rounds today, much like recent similar stories, about a child called Tom Halton and receipt of a letter telling his parents that his BMI was higher than expected for his age.

Before I go any further with this post, I need to point out that the BBC are talking rubbish about the story. Their second paragraph:

Tom Halton, 11, of Barnsley was told he was overweight after taking part in a national scheme which measured children’s body mass index.

Not true. The letter was sent to Tom’s parents, not Tom. They chose to share it with him. This upset Tom, and he didn’t eat his dinner that night.

The facts are these: Tom’s BMI is heavier than 93% of children his age. The World Health Organisation classifies him as overweight. An increased childhood BMI is associated with lifelong adult illness, in particular Type II Diabetes.

Yes, there are problems with using BMI for purposes like these, particularly in children, and the letter should have acknowledged those more clearly. But it is wrong to simply ignore the best indicators we have in children of their future adult health.

Tom’s dad said:

These letters are doing more harm than good. You might as well send a T shirt with FATTY on it. The impression it gives is that your child is fat, it’s your fault and they will die from a horrible disease.

The letter is not the best written in the world, but it makes the point fairly clearly that the high BMI increased Tom’s risk of future illness. Which, to be blunt, it does.

As for the T-shirt comment, it strikes me firstly that it was the parents who shared this letter with their child, and have now plastered him over the papers with headlines calling him “fat”. Why?

I note that the “grovelling apology” from the DoH actually apologises for causing the parents offence if they felt their parenting skills were being derided – which is not suggested at any point in the letter.

So where do Dan and Tracy Halton suggest we go from here? I’m genuinely interested to hear their views – and yours. Do we inform parents of modifiable statistical risks to their children’s health and wellbeing, or not? If so, how do we go about it? Is writing to parents not the best way to tackle this? Would individual consultation where the full facts could be clearly explained be a better option? Or does that come across as being “summoned to the headmaster’s office”, and yet more punitive (and expensive)?

What do we do? How do we tackle this? I’d love to know your thoughts.

The inefficient status quo - surely there's a better way?

There’s been a lot of heat about the NHS National Programme for IT recently, with both Labour and the Conservatives suggesting that it will be, at best, scaled back. Often referred to as “the £12bn NHS Computer”, the idea of having a national IT system for the NHS is often ridiculed as one of Whitehall’s biggest white elephants.

But, contrary to what almost everyone else thinks, I firmly believe that a national NHS computer system is a good idea. I think it has the potential to revolutionise healthcare, and vastly improve the health of the British population in a much more meaningful way than anything else the NHS has ever done.

As a doctor, I’ve worked with a variety of NHS IT systems, some of which are brilliant, and some of which are terrible. On the one hand, I’ve worked with an electronic patient record system in a hospital Trust that is an absolute disaster of a system. It does not fit in to the way anybody works, it is obstructive, and it actually provides less data in a less useful manner than the paper system it replaced. It is terrible, and should never have been introduced. Projects like this give NHS IT a bad name.

On the other hand, I’ve worked with SystmOne in Primary Care, which is a Department of Health endorsed Über success of a computer system. The data is stored in a secure cloud, the program auto-updates, and it is constantly being improved. It’s a massively powerful system. When recent research showed that a high proportion of patients with diabetes and a history of heart attacks would have undiagnosed heart failure, it was the work of moments for a practice near me to generate a list of such patients and invite them for screening. The upshot was that the detection rate for heart failure soared by a factor of ten, and those patients are on the right treatment for their condition.

Without the IT system, this could not have been efficiently acheieved. It would have involved looking through thousands of sets of paper notes, which is just not practically possible. The implications for the availability of this sort of intervention are manifest. And that’s on top of the often sold benefits of all doctors, wherever you go, having access to the same set of complete medical records.

The disease-coding in SystmOne is done in an intelligent and unobtrusive way. If I type someone’s blood pressure in as part of a consultation, this is coded instantly and automatically by the computer, which merely highlights the data to show that it has been entered into an encoded database. Similarly for when I enter a diagnosis – coding is quick, automatic, and accurate. If, for example, I note that someone has diabetes, this is automatically captured and the patient is automatically sent letters for diabetic annual reviews. That is astoundingly clever, and stops individuals falling through nets.

Incidentally, the crap IT system does none of this. It is badly designed by people not familiar with the day-to-day workings of individuals in the hospital, and is actually obstructive when it comes to getting things done.

In most hospitals which remain paper-based, data intelligence just does not exist. The data on millions of pages of paper notes cannot be effectively mined. In order to receive payment for the services an NHS hospital provides, all the paper notes are shipped to a department named ‘coding’, where they are combed through by a team of non-medically trained secretaries, who decide from the often illegible medical notes how many patients with a given condition have been treated, and what interventions have taken place. It is slow, innaccurate, labour intensive, and doesn’t result in a patient identifiable database for mining. It is an extraordinary waste of time and money.

If a system like SystmOne could be extended to cover all NHS care, all over the country, the database it would produce would be immense, and the opportunities for mining of that data would be far more advanced than anything else undertaken by any country on earth. We would know at a glance if an outbreak of a disease was happening in a paticular area of the country. Research could be acted upon in a flash with intelligent, national, targeted screening programmes. And that is just the start.

A well implemented national NHS IT computer system would revolutionise care in the NHS – and frankly, for that, £12bn is an absolute steal.

This post is based on my contribution to Episode 17 of The Pod Delusion, originally broadcast on 15th January 2010. Other topics that week included “The Big Freeze”, Google, and ITV’s regional decline. How could you not want to listen to the whole thing at poddelusion.co.uk?

I’ve recorded a bit on IT in the NHS for this week’s Pod Delusion. Other topics covered include “The Big Freeze”, Google, and ITV’s regions – how can you resist?

I intend to try and remember to add a note here each time I contribute, given that this site was intended to bring all of my writing from all over the internet into one repository – even if that ideal has never really come to fruition.

Plus, I wanted an excuse to use this ‘Diary’ template which hasn’t seen service in some considerable time, but which I think is rather pretty. So there.

Back in September, the Family Planning Association was publicly worrying about the fact we were in a recession. With something rivalling the foresight of Derren Brown, they came to the conclusion that a recession would mean NHS budget cuts, and they were frightened for the future of their service. They thought that a lack of willingness to talk about sexual health issues would lead to their services being the first to be cut. Or, as they more memorably put it, their services will be the first to be cut because

no-one will complain to the local paper about a longer wait to get their genital warts seen to.

Frankly, I don’t think they need to worry so much. Whilst, perversely, sexual health services aren’t sexy, there are much less celebrated parts of the NHS. Like those that deal with children with serious mental health problems.

Back in 2006, I wrote a polemic on here about the underfunding of Child and Adolescent Mental Health Services (CAMHS), and I guess it’s become something of a recurring theme on here. Back in 2006, services were underfunded to such an extent that 25% of the country didn’t have CAMHS crisis teams.  If, like Newt in Hollyoaks, a schizophrenic teenager wants to kill themselves, there was no-one to call to get immediate specialist help. For adults, there are dedicated teams.

We’re now in 2010, at the dawn of a brave new decade, and over the intervening years not much has really changed. Just last year, The Guardian reported how many young people were waiting almost three and a half months for specialist assessment of their mental health problems – with 75% of them having no support whatsoever in the meantime.

Compare that level of service to the sexual health drop-in clinics or the guaranteed two-week cancer wait, and you begin to see the level of neglect of CAMHS in the UK.

Child and adolescent mental health problems are the very definition of unsexy. All of us regularly see tin-rattlers and chuggers asking us to support a whole range of childhood cancer charities, or raising money for hospitals like Great Ormond Street or the soon-to-be-opened Great North Children’s Hospital – All worthy causes in their own right.

But collecting-tins for children with mental health problems are very seldom seen, not because the diseases are less common, but just because of the level of public misunderstanding of the field, and a general perception that mental health problems are unpalatable.

1 in 3 of us will have cancer at some point in our lives. Similarly, 1 in 3 of us will have a mental health problem at some point in our lives. And, thanks to the chronicity of mental health problems, 1 in every 6 people are suffering with a mental health problem right now. And 1 in 10 children have a diagnosed mental health problem.

Which of those statistics have you seen on a TV ad or bus-stop poster recently? I’m guessing only the first.

Thanks to tabloid newspaper obsession and the underactive imaginations of TV and film scriptwriters, popular conception links mental illness and criminality. Criminals and the mentally ill are one and the same to many people. Of course links exist – I’d be a fool to deny that mental health problems are rife in our prisons for example (there’s a post for another day) – but when such vast numbers of people are affected, it is hardly the case than one equals the other.

Problems of perception likely affect CAMHS even more than adult services, as I’m sure many Daily Mail readers fail to believe that mental health problems can affect children: They’re probably seen as a Guardianista cover-up for naughty kids who should be caned rather than mollycoddled. Against that background, I’d wager that many people would rather write to their local newspaper about their genital warts than about their personality disordered child.

Luckily, there are some people out there who care enough to try to change the status quo. There’s a great charity called Young Minds who recently launched a manifesto on child and adolescent mental health issues, in an attempt to influence the political classes in a General Election year with a view to tackling these issues for the long-term. To his credit, Nick Clegg of the Lib Dems seems to be broadly in support of what they’re trying to do.

But the fact remains that CAMHS are chronically underfunded, and definitely underappreciated. As things stand, CAMHS win no political votes, and so when looking for things to cut, they will likely be first in the firing line.

In this context, I hardly think the Family Planning Association needs to worry. As long as preventing teenage pregnancy remains a vote-winner, their services will be well-funded.

Perhaps one day, CAMHS will be able to enjoy that level of confidence and certainty too. For the sake of our children, I hope so.

This post is based on my contribution to Episode Two of The Pod Delusion, originally broadcast on 25th September 2009. Other topics that week included the BNP on Question Time, an undercover homeopathy sting, and the future of intellectual property rights. How could you not want to listen to the whole thing at poddelusion.co.uk?

Andy Burnham has written a piece for today’s Guardian announcing that

For Labour, it all comes down to defending the N in NHS … By contrast, the Tories are ambivalent about the role of the centre, preferring localism in health as in other areas.

It’s probably churlish of me to point out that Mr Burnham has previously espoused about the paramount important of locally, rather than natioanlly, influenced healthcare (“The hospital and Primary Care Trust must listen to patients and local people and involve them in shaping the future of the hospital” – hardly a nationalistic approach).

To point him in the direction of the Conservatives’ 45-page Green Paper on the NHS in response to his claim that “on health, Cameron doesn’t do detail” would probably be missing the point.

And let’s just ignore Mr Burnham’s complete lack of insight into the effect of his target-driven culture – Patients being moved like pawns around a hospital-sized game-board to avoid staying in one place for too long – regardless of their clinical need.

Let’s just park all of those thoughts in the vastly overpriced hospital multi-storey, and concentrate on his main point. The ‘N’.

I’m an ardant supporter of the broad principles of the NHS. I think healthcare free at the point of need is a wonderful thing. But I don’t subscribe to Andy Burnham’s ideology of a national health service with national targets to tackle national problems.

The residents of Byker have different healthcare needs to the residents of Mayfair, and the needs of the residents of Tunbridge Wells or Toxteth differ equally again. Whilst it’s true that residents in none of the above places would relish waiting more than four hours in A&E, such meaningless targets do little to disprove the inverse care law which appears to be Burnham’s prime argument for focusing on the ‘N’.

In fact, quite obviously, the most imporant bit is the ‘HS’. The country needs a Health Service that is adaptable to the needs of all. Different locales will, necessarily, have different priorities. Giving Respiratory Medicine the same priority in the North East (where lung disease is relatively common) and in Southern England (where it is rarer) would appear to me to be a failing of a nationalised system, not a benefit.

Targetting outcomes seems eminently more sensible – The respiratory services in the North-East and the South don’t need to be equitable, provided the outcome – measured in cure rate, death rate, or howsoever seems most sensible to the respiratory physicians who are far more intelligent than me – is equitable.

That’s the kind of Health Service I would like. One with an ability to respond to the local health needs of local people – not by “national standards, national pay and national accountability” – all three of which have everything to do with bureauocracy, and nothing to do with healthcare.

Some years ago, when I used to be involved in public speaking and debating competitions, I relied heavily on one strategy: Choose the most ridiculous point of view, and argue forcefully for it.

Thus, over a time, I ended up arguing in favour of littering, staunchly defending the poaching of endangered species in Africa, and strongly advocating the bypass an upcoming election and the simple investiture of me as the next Prime Minister.

This strategy always served me well. It allowed for wit, a re-examination of issues from a completely new perspective, and – ultimately – the chance to guide people down a seemingly sensible path to a position where the most absurd solution suddnely becomes the most logical.

This is actually something that’s really quite simple to do, and it always attracts attention – and, in my context, often attracted prizes.

Having seen today’s Daily Mail, I’m beginning to wonder whether Amanda Platell is employing the same strategy to boost her fledgling career. Unfortunately for her, she’s terrible at it.

In an admittedly arresting column, Platell tries to argue against preventative medicine. There are many well rehearsed arguments against preventative medicine, not least that the logical conclusion is that everybody is in need of some form of ‘treatment’, the cost of which will ultimately be unsustainable within the NHS.

But Platell tries to be provocative, by picking on ‘fat people’. She suggests that fat people should not be supported by the NHS to lose weight, as the money would be better spent on Herceptin and Aricept.

She’s comparing the furore surrounding the delayed provision of drugs whilst evidence about them is weighed against their cost effectiveness with the provision of weight loss treatments which are not only proven to work, but allow a person to improve their physical wellbeing to a point that they are likely to use fewer NHS resources in future.

This would possibly be passably illogical – after all, one has to skirt around the logic of an issue to convince people that something ridiculous is right – had she not then gone and pointed out the flaw in her theory in the fourth sentence, where she points out the long term costs of providing knee replacements, hip replacements, back pain treatments, and mobility aids to fat people. But Amanda! If we stop the people being fat, those costs disappear!

She points out that the patients of her friend who works in an NHS weight-loss clinic – a ‘friend’ she evidently wants to see sacked – don’t know what foods are healthy and unhealthy, and then suggests that withdrawal of services advising them on healthy eating would ‘shock a huge number of the overweight’ into losing weight.

She talks about her childhood in “post-war, food-scarce, ration-booked Britain”, despite growing up in Perth, Australia, and being born three years after rationing ended.

Right at the end of her column, she slips in that alcohol and tobacco are equally ‘the result of individuals choosing an unhealthy lifestyle”, and we should only treat the malignant results of these aberrations rather than stop the original cause.

There was a time when I liked Amanda Platell’s writing. Back in her New Statesman days, her column would be a must-read. I rarely agreed within anything she said, but in a strange way, that made it all the more compelling.

So why is she wasting her time writing sub-standard articles for the Daily Mail – not quite spiteful enough to be Melanie Phillips, not quite outraged enough to be Richard Littlejohn, and not quite far enough up her own backside to be Quentin Letts?