Polarising Opinion

The current 'listening' phase of the reform of the NHS is no doubt well under way and I cannot help reflecting how opinion has been polarised into two separate camps. One seems to want to 'save' it (the NHS), presumably as it is, and the other wants to embrace the changes with the sort of fervour usually preserved for a new lover. There is an animosity to these changes within much of the GP cohort, although they seem somewhat more agitated about having to pay more and retire later it would seem, than the reforms effects on patients, but 'nothing new there then'. There is, as Dr. No says, confusion amongst the proletariat as to what these changes may mean together with a touching belief that 'doctor knows best' so he/she would be the best one to trust to deliver that change.

He is of course correct; the patient at least until they come up against poor care, delays in treatment and being given into the care of the local ISTC, is unlikely to notice or care much about the changes. I can honestly say that until a few years ago I was much the same. Confident that all the cash I had handed over to NuLabour, had vastly improved the NHS because I had not had the need to call upon it. When I did however, horror of horrors I found it be peopled by, well ... idiots, who seemed to have been promoted well beyond their IQ and certainly their pay scale. Care or even interest, was missing. Drugs were handed out like sweeties for virtually no reason with no explanation of effect or prescribing reason. It seemed to be based on a 'just in case' protocol. Of tests there were many, but no results conveyed to the patient, (and probably to the Doctors), in fact the general status of the patient seemed to have a similarity to that of a mushroom; kept in the dark and doused (dosed?) with s**t, every day.That was the beginning of my antipathy toward the NHS and Doctors, which escalated with subsequent years of further mistreatment and lack of candour, culminating in an event of near death, that almost left me alone, and a legacy for one that I love, that continually intrudes into my life and thoughts.

For me then, the NHS was already 'not fit for purpose', long before Lansley's cynical escalation of the 'privatisation' model he learned form Kaiser, dressed up in the clothing of a 'Health and Social Care Bill' that escalates the NuLabour agenda of the NHS as a bounteous 'Facilities Manager', ordering Health care from a menu provided by Spire, Circle, Serco and all the plethora of Private Provision that expanded on Blairs 'watch'. I do not want it like this, any more than I want it to be as it is. But, a number of my friends as well as a good number of those I might call enemies, seem to feel that the reforms are so completely wrong, that they have to side with the NHS as it is, not as it should be.  This model so out of step with need, with competence and any pretence of the provision of scientific treatments to promote health, now seems to be something we hold so dear that it has to be talked about with fiery rhetoric and a tearful eye. Even some of the architects of ISTC's, QOF and many other steps to Privatisation, such as the appalling Andy Burnham, the last Secretary for Health,  have ranged themselves against Lansley's reforms purely for cynical political reasons. I am uncomfortable with him as a fellow traveller. Is the NHS so good that we should defend it with such passion, when before we did not, just because we don't like the new model? Well I think not.

So then, what has it achieved since the current model Circa 2004, has been in place, as regards one of it's foremost protocols, the Quality Outcomes Framework? A study from Finland shows that the actual cost and outcomes for osteoporosis are some way from the model upon which the protocol was based. And it is clear that the Randomised Control Trial bore no actual relationship to real clinical settings or the cohort for which they are prescribed. The outcome then for those who are taking a significantly awful medication was  negligible. Equally as well, the study by Brian Serumaga of Nottingham University of the outcomes for hypertension in 470,000 individuals showed clearly that no discernable difference was found after the application of 'payment by results' for GP's, to reduce BP in the cohort than before. This was despite the payment of some £1.8 billion of taxpayers money to GP's!

We need to change the paradigm. Incentives for prevention have been expensive and counter productive and have actually been dangerous for a large number of people; the 'worried well' in particular. Most Doctors do not, and should not need incentives to enable them to perform. Those that do require payment, on top of an already generous salary and pension, to simply do their job, I would proffer, are not suited to the vocation. Any assumptions that Doctors are influenced by pay for motivation are flawed and should not be countenanced. The NHS is not a 'milch cow' for the unprincipled few who look to it for enrichment. These are those who continue to take the Clinical Excellence Awards, long after their achievement of any excellence was concluded, because once established there is no mechanism to end them.

The NHS is then perverse, corrupt and lacking in care, so change it we must. But the polemic employed by each camp is far too simplistic, should not the argument be better than this? And do not Doctors have have any responsibility for the appalling debacles that have occurred in the last few years, and indeed throughout history? I do not wish to share any platform of opposition with opportunists like Dr. David Owen who seems to think his No to AV stance will not close the door to electoral reform, when it patently will. We need progressive change, not another 'top down' Whitehall dictated revolution to empower cash hungry GP's and Private providers to even worse excesses than they have already perpetrated. We need no more PFI's and ISTC's because they deliver little other than profits for the shareholders. And we need to make Doctors answerable for their actions as a first priority. If we do that one thing maybe all the rest will fall into place.

For Julie and maybe Dr. No.

The Pet as Predator

Felis Catus

Whilst the NHS burns, under the blinded eyes of the populous, I thought I would deviate from my rants about politicians and doctors and look closely at what we do to one of our closest companions in the this life; our cats.

As a long time lover and keeper of cats, having had ten of them, it seems we do a lot of damage to their health and well being, by foisting our own nutritional stupidity upon these denizens of the back garden. Long domesticated,  they have enjoyed a relationship with humanoids that is unique, in that they often still forage for food within the environs of our (and their) homes. For an animal that is usually fed quite regularly by its owner, if we could ever 'own' a cat, this is somewhat strange behaviour and has fascinated me as to its reasons. Dogs, unless they are trained to hunt, rarely display this trait, except when perhaps abandoned in the wild and of a breed adapted to hunting.

Teeth Adapted for Hunting

Well, it seems that this trait is part of an instinct of self preservation. When fed an over abundance of the sort of diets, that we in our wisdom endeavour to feed them. they naturally, it seems, self select that which suits their metabolism and almost perfectly balance the intake of protein, fats and carbohydrate, to ensure they survive. When they hunt it seems they do so (in my view) to supplement any deficiencies in the food we provide. I well remember, that many of my cats, despite a diet that I was feeding them, alleged to be replete with all the requirements of the feline metabolism, still hunted and ate their prey. Well except of course the one's that they brought home for me! They always had a tendency to 'raid' the butter dish too, if it was left undefended by a cover!
  
When given the power of self selection however, it seems from  a study funded by the pet food manufacturer Waltham, which seems to have been well conducted, interventional and lasting some two years, that our cats decide to balance their intake to a similar one they would utilise in the wild. As 'obligat carnivores', we do them a dis-service if we do not give them the diet that is as close to prey food as is possible. This may not sit too well with the vegans and vegetarians, I know, but we are not talking about you, but your pets. So it seems the ideal is, 52% protein, 36% fat, and 12% carbohydrate. The latter would normally be provided from the stomach contents of prey and already be part digested, because cats are unsuited to the digestion of carbohydrates because of their physical make-up.

They have no salivary amylase to metabolise starches, and they have intestines that can only take up low ratios of glucose. They also do not have any 'sweet taste' receptors, so they should not be given anything with sucrose in it. Nor they should they ever be given chocolate although they may take it offered, especially if young and inexperienced. It is poisonous to cats and dogs and can be fatal!

What then to feed them? Well as close a diet to one they would eat as a predator. That means meat, fish and organ meats with a small amount of vegetable carbohydrates. Raw is best, but to ensure parasites are destroyed, if you do go 'raw' then freeze it first for at least three days, which kills off any parasites. If your cat has been eating dried food, then introduce gradually, using lightly cooked meats initially. But cook any vegetables you add, to ensure partial breakdown of the starch and fibre and keep the content low.

A Near Eastern Wild Cat (just like yours)

Cats do not often drink, except when it's hot, or if you feed them dried foods. And dried food is well, 'dry',and as cats obtain most of their water from their prey food,  the food that we feed should also be 'wet', otherwise we are storing up a lot of problems for our cats. These include, kidney and liver disorders, together with gastric problems. In addition, diets high in carbohydrates, will cause obesity, especially in older cats, together with thyroid problems, pancreatitis, diabetes, and vascular problems. And whilst this 'self selection' process will always occur to some extent, as cats get older they will hunt less and accept the diet you give them more readily, so get it right. Enjoy your cat, it's the wildest thing you are likely ever to have a relationship with, so keep it fit and healthy, not like us.

Hope you found a cat Julie!

Drugs Nemesis?

And so, we say farewell to many of the most profitable drugs of 'Big Pharma' this year, with big names consigned to the bin and the 'generic' versions now being born to treat symptoms or more realistically, the surrogate marker of those. I say 'treat your symptoms' because Pharma rarely invents anything to actually make you well, or even better than you were, except perhaps for Antibiotics. However, that strand of drugs design is getting ever more difficult, ever more unprofitable, because the life span of such drugs is getting ever shorter and drug cartels are becoming ever more reluctant to pursue the goal of a new and better antibiotic because the returns are diminishing with each year.

Here is list of the more important items coming off patent during the coming year. Clicking on the name will take you to an explanation of it's use, but many of you will know them already. They are;-
1. Cozaar/Hyzaar - Merck
2. Lipitor - Pfizer
3. Flomax - Boehringer Ingelheim
4. Arimidex - AstraZeneca
5. Climara - Bayer HealthCare
6. Aricept - Aricept
7. Invirase - Roche
8. Hycamtin - GlaxoSmithKline
9. Protonix - Pfizer
10. Levaquin - Levaquin

Things are in fact getting so bad that the Investors are fleeing the market.  $50 billion is the estimate of lost sales that will occur accumulating to $250 billion by 2015. And money is leaking from the coffers to settle bribery cases that have been brought to light in many areas of operation.

Pharma also faces the loss of income from the harder line now being taken by the FDA about approvals of both new and existing drugs for use outside original approvals. There is in fact a new era of stricter regulation that seems to be dawning in the USA, with bribery scandals abounding at the same time as many drugs are being 'canned' due to failure in trials.

It may mean that NICE may actually look at some of the drugs it has approved on the back of FDA approval (that's the way it works, or maybe doesn't) and review it's strategy because huge amounts of our taxes are being wasted prescribing drugs that do little or nothing to improve the patients lot and in many cases are proven to be dangerous or even life threatening, such as Avandia or Risperdal. Often newer drugs are brought to market because the old one's are running out of patent, not because the newer one's are any better and Pharma goes to tremendous lengths to 'sell' the new one which includes bribery, false reporting and trials that are 'fudged' in an attempt to reap more profit.

They undertake this in many and disparate ways, but one of the most common is to 'fund' trials. Now those who undertake these are often viewed as 'indepenent' but considerable evidence has now accrued that often these researchers are far from such. And reporting is always subject editing by the sponsor with some extremely onerous conditions applied that then prevent the academics involved from having access to the full data.

Failures are not only confined to drugs, because Pharma also does a nice line in joints and prosthetics, quite a lot of which are used by our NHS and they fail. Fail quite badly, causing the recipient much pain and distress and the horror of undergoing re-operation, often when their overall health means that such procedures can be life threatening.

I could go on almost ad infinitum, about the drugs and medical devices and I must acknowledge that modern medicine does need drugs. From time to time most of us will require some intervention that a drug can provide. My feeling  about this is  the same as that for penetrating radiation, 'as little as reasonably practicable' or ALARP. I do not feel that any person should be on a drug protocol, simply to fulfill some 'surrogate marker or end point' such as statin therapy, except in rare cases, because we do not need to medicate 'well' people. We also do not need to over prescribe antibiotics because by doing so we will reap a harvest of problems in the future, which is already manifesting itself in the spread of MSRA and other 'hospital born' infections. There are plenty of treatments for minor ailments that do not warrant their use and we certainly should ban the use of them in animal feeds, because by doing so we are less exposed. We should also review their use in routine surgery; are our Hospitals so filthy that we need to dose people with them on a 'just in case' basis?

Preservation of life is the most important goal of Medicine, but this is not the goal of the Drugs Industry, it's primary aim is to make money for shareholders, that is enshrined in company law. All too frequently this has overridden patient safety and the QOF protocols of 'payment by results' has seen a huge rise in the drugs bill for the NHS; see;-You Spent How Much! So far as most of the outcomes are concerned, certainly for many of these drugs, little has been achieved. Is it not time to refrain from gifting 'Big Pharma' with undeserved benevolence, when it is really little more than a corrupt pariah, that occasionally comes up with something worthwhile, but most of the time contributes little to the nation's health and often endangers it?

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.