Tag Archive: NHS

Jan 07 2012

“French-maid Breast Implants”

I’ve been struggling a bit with the story of PiP and the breast implants, because every time radio presenters say “French-made breast implants”, I hear “French-maid breast implants”.

The BBC has a useful Q&A on the subject here. Essentially the problem is that PiP manufactured breast implants using industrial rather than medical grade silicone, subsequently there have been reports, initially in France, that the rupture rate of these implants is significantly higher than expected. There is no evidence that the implants lead to an increased risk of cancer, given the prevalence of breast cancer it isn’t surprising that some patients with the implants have gone on to develop cancer. The striking thing is that the implants were banned for use in 2010 because they were found to be using industrial grade silicone gel, surely it was at this point that they should have been recalled (i.e. the decision made to remove those already implanted)?

The situation in the food industry is quite different: if a company discovered that one of its suppliers had provided non-food grade ingredients then the product that the company made would be withdrawn from sale pretty much immediately. There would be no waiting around to see if the ingredient was actually hazardous, it would be withdrawn on the grounds that it was out of specification. I’m pretty sure similar applies in the car industry, and the aviation industry. I know this because Mrs S used to work in the food industry; food scares on the morning news always led to an exciting day at work as every retailer sought confirmation that the company she worked for did not use any of the products involved in the scare. Food companies trading legally would have this traceability information.

Healthcare does offer a slightly different scenario, in the sense that carrying out an operation to remove breast implants does carry a risk which means there is a downside to removal, but this is the only relevant consideration: all other things being equal the implants should be removed, by the original installer where possible.

Some people seem to feel that women having breast implants have brought this on themselves, that they shouldn’t be helped on the NHS. Clearly the first port of call for removal is the installer but there are cases in which the installer no longer exists; the NHS is a universal service – if someone has a qualifying medical problem then regardless of how they came by it (excessive eating, drinking, drug taking, climbing, skiing) they are treated free of charge. The same should apply to people who have medical problems arising from surgery outside the NHS – the liability is with the original supplier but sometimes they no longer exist, the patient should not be punished for this.

The Medical and Healthcare Products Regulatory Agency (MHRA) is responsible for regulation in the UK. There is a page on their website about the subject of the PiP breast implants here. Other medical devices, such as replacement joints, appear to be handled differently: alongside the MHRA there is the National Joint Registry, which attempts to register all joint implants, here on the National Joint Registry there is a list of alerts for joints. The MHRA has issued a series of alerts, dating back to March 2010, regarding PiP breast implants (you can see them here), the emphasis has been on establishing the potential toxicity of the filler material. This, presumably, can be done using lab-based testing. The problem seems to be that the rupture rate is relatively unknown, this report in the Telegraph says:

A UK Breast Implant Registry was established in 1993 on the recommendation of the Department of Health to track implant patients’ health, but it closed in 2006 as too few women wished to take part in the scheme.

The final report of the UK Breast Implant Registry is here, and the MHRA confirms that the scheme closed because too few patients would consent to remain in long term follow-up here. This would seem to be the significant factor in this case: there is some follow-up for medical devices but it is voluntary and in the case of breast implants the uptake rate for follow-up was not considered high enough to warrant continuing the process.

It still leaves the question as to why the removal of breast implants made from out of specification materials is not assumed, except for considerations of the safety of the removal operation.

Dec 27 2011

‘Planned 49% limit’ for NHS private patients in England

Mention of the NHS seems to result in a serious outbreak of irrationality amongst the commentariat, this week it’s because the new Health and Social Care Bill with contain a cap of 49% on the fraction of income an NHS hospital can earn from private patients (BBC news here). Clearly this represents end-times, privatisation of the NHS etc etc…

Currently most hospitals are limited to a cap of 2% income from private patients, although a quick search shows that the Royal Marsden already gets 26% (source), Christies 6% (source), Papworth 4.5% (source). These are not hospitals renowned for poor service to NHS patients.

The key point here is that 49% is a cap, not a target. Since only 8% of the UK population has private health insurance, amounting to 14% of health expenditure (source) it’s very difficult to see how NHS hospitals as a whole will reach anything like 49% of income from private patients. The current situation must be that private patients are largely (lets say 90%) serviced by entirely private hospitals – NHS hospitals will only pick up that trade if they offer something better. The area they will offer something better is in specialist care – which isn’t viable for a private system serving less than 10% of the population. The limit case is that NHS hospitals would get 14% of income from private patients and the private hospital sector would disappear, clearly this isn’t going to happen.

Private patients in the NHS wouldn’t be displacing publicly-funded patients from beds, if that were all they were doing then what would be the point for the patient? To get private patients an NHS hospital would need to build (or convert) private “wards”, this is what hospitals like the Royal Marsden do already. To do this they’d need a fair expectation that they could attract the custom otherwise they’d simply end up poorer.

I’ve had private medical care – I liked it a lot, I wish everyone could have it. The benefits I received were in getting rapid treatment for a non-emergency condition, having my own room for the run-up and post-operation and having consultations in a slightly more pleasant environment. As a family (unborn included) we continue to use the NHS for most of our medical care. As someone with private health insurance, I get to pay twice for some of my health care – I pay for NHS treatment which I don’t use, then I pay again for private treatment. I don’t resent this, I do resent the idea that my private care must be entirely separate from any public provision that is available – in that case why can’t I withdraw my contribution to the public system?

The figures on health expenditure in the private sector give some idea of the potential funding gap for the NHS – what we’d need to pay for a gold-plated NHS where, for example, there were no waiting lists and we all had private rooms (if that was medically appropriate). Currently the NHS gets £106billion per year, equivalent to 25p basic rate tax. Private health insurance appears to cost about 1.75 times as much per head therefore a crude estimate is a gold-plated NHS would cost  £185bn or 46p basic rate tax. This would put us at a level of spending that is equivalent to Switzerland and only exceeded by the US (source). It’s possible that you could do it for rather less but not if every attempt to change anything in the NHS is met by a hysterical and apocalyptic knee-jerk response. The important thing is patient care, not the institution that provides it. Providing a healthcare system isn’t simply a choice between the NHS or US-style system, you can see the range of systems here.

And before we get hoity-toity about people paying directly for health care – all the NHS does is launder the process of paying for health care. We pay tax to the government, the government funds the NHS – it isn’t some vast charity run on goodwill. Consultants and doctors in the NHS are really paid quite well, and in my experience individual consultants are working for both public and private sectors at the same time. It is rather offensive to the wide range of people in the private sector service industries to imply that the service they provide is somehow inferior because they are paid by the customer, not by the government.

Update

More on this at NHS Vault (here), definitely worth reading.

Sep 10 2011

Don’t call me scum*

Scum. Goodbye NHS. Goodbye Lib Dems. RT @skynewsbreak: MPs vote in favour of NHS reforms by a majority of 65

This was retweeted on timeline by a number of people on twitter on Wednesday last. As a Liberal Democrat this upsets me, I take it personally. According to Ben Goldacre, Evan Harris is okay, “good scum” presumably – the rest of us have obtained no exemption.

At roughly the same time my twitter feed was full of people decrying Ken Clarke for describing the rioters as a “feral underclass”, not so many were bothered about me being referred to as scum. Clarke had a point but he made it poorly. His point was that what we should be concerned that 75% of the rioters were already known to the police, our justice system had failed to rehabilitate them. It’s a useful example though: if you use language which offends you’ll find people will ignore your argument, assuming you simply don’t have one.

Interestingly Tony Blair was on the radio this morning, a man that lied in order to take us into war in Iraq and stood by as the country disintegrated, unwilling to persuade the US of the critical need for a post-war recovery plan. People on my timeline were upset but no one called him scum.

*It’s a reference to that fine film, Barb Wire.

Jul 29 2011

Still love the NHS?

In todays news: reports that some NHS trusts were setting “minimum waiting times” which were “too long” for elective surgery. The reason being that if you wait long enough people will drop off your waiting list, either by going private or dying. That there even exist minimum waiting times set by the trusts should be a cause for concern, let alone how long they are.

For me this is personal: last year I had minor elective surgery – I started off in the NHS but then decided to use my private medical insurance. I wasn’t going to die of my condition, the worst-case was an emergency circumcision; however I was in discomfort, a bit of worry and occasional pain, and as time progressed things were getting worse.

So the idea that the NHS was waiting for me to drop off their waiting list pisses me off somewhat. If they’d said at the earliest possible instance “please piss off”, I would have done so immediately. Of course they didn’t tell me to piss off because had it become public they would have suffered from some opprobrium.

My private medical insurer had me treated within a month from first presentation, the only reason it wasn’t quicker was that my surgeon was going on holiday for two weeks and I decided not to make the time before he went – it could have been under two weeks. The NHS would have taken 4 months – I know this because through an administrative error I received an appointment for my operation on the NHS as I returned to work.

The behaviour of the trusts in this instance is entirely rational, as is that of my private hospital. The trusts have been paid already, if I don’t have an operation then they’re “quids in”. My private hospital, on the other hand, wants me to have an operation, because they won’t get paid until I have it. This is actually the problem with fully private medical systems: for people that can afford treatment it is in the interests of the provider to provide as much medical treatment as the patient can pay for.

The problem with the NHS is that it is a highly cost effective system directed at providing universal second-rate care. It will remain so because anyone proposing a change radical enough to make it better will be assailed by people who “Love the NHS” and want to “Save the NHS”. Notice here they don’t care about your treatment, they care about the service provider.

Don’t love the NHS, it is a public corporate entity, it can’t love you back. Only people can love you.

Nov 09 2010

A diversion in my life

In the past my blog was my diary, which was entirely private. I kept a diary on my Psion for a number of years before the feeling that I should make a daily, or at least a regular, entry on the minutiae of my life became oppressive and I gave up. More recently I resumed as a blogger, and rather than writing down minutiae I wrote in a more formal, extended style on things that were happening, or on my mind, for a more public audience. It still provided a record of what I thought when.

This post is difficult in the sense that it is somewhat private: I had a minor operation on the 23rd September and only now am I about to go back to work. My minor operation turned out to be a little more complicated then expected. The aftermath has taken up a significant portion of my time and dominated my thoughts for the last 6 weeks. I hasten to add that at no time has my life (or any part of my body) been at serious risk and I have only occasionally been in minor, localised pain and been a little inconvenienced. This is all a storm in a tiny little teacup, but it is my teacup and I have had some sort interesting experience along the way.

I will be circumspect about the exact nature of my affliction. I started with a visit to a GP, who packed me off to the consultant at my local hospital. This is where I had my “unexpected prostate examination”. *That* wasn’t the affected part! A useful experience really, because at some point later in my life a semi-regular prostate exam will probably be a good idea and to be honest, there’s nothing to it. Warning signs: men, if you are semi-clad and a doctor asks you to roll on your side and pull your knees up to your chest – ask him why first!

I have medical insurance as a taxable benefit of my job. My initial intention was to stick with the NHS – my local hospital is over the road from where I live, whilst the private hospital, I believed, was many miles away. It turned out the private hospital was closer, and the wait was shorter and the consultant clearly thought me mad for not exercising my insurance. My initial private consultation was just 4 days after I raised the issue, on a Saturday morning, with potentially my operation the following Thursday. As it was the operation was delayed a few weeks because I had visitors at work on the Friday coming from Sweden – and it seemed wrong to bounce them and then my surgeon was going on holiday, to Sweden, for a couple of weeks. Compare this with initial consultation wait of 1 month, and operation scheduled for almost three months later on the NHS. I don’t see this as a criticism of the NHS: to provide fast service requires that you have more capacity than you strictly need – we choose not to fund the NHS to that level. I’ve been very happy with my local NHS GP service, and the quality of the medical care they provide – I’m sure that the quality of the medical care I would have received from the local hospital would be similarly excellent.

The nice things about private medicine are: it happens pretty quickly (and conveniently), the surroundings are nice and you’re better separated from your fellow man.  The people who join you in private medical care may or may not be more pleasant than those with whom you are treated with in the NHS but they do not generally share a room with you!

I didn’t sleep the night before my operation: I’d never had a general anaesthetic before and to be honest I was a little bit scared – it didn’t help that I’m passingly familiar with historical pre-anaesthesia tales of operations for bladder stones and a mastectomy: I had a minor fear that I would be fully conscious but unable to communicate. I was also scared I wouldn’t have my operation, because to be honest things were getting a bit difficult. My final fear was that I would wake from my anaesthetic with caffeine withdrawal – I’d been fasting for the previous 18 hours or so.

To start the day of my operation properly a wasp stung me on my toe!

General anaesthesia is extinction: there is consciousness, there is nothing, there is consciousness. Chatting to the anaesthetist as I went under I discovered I was getting propofol. I suspect the porters tasked with returning post-operative patients to their rooms have a collection of the most utter gibberish known to man. For my part I supplied them with the prime factors of my room number: 2 and 13, thank you for asking.

The first week or so after my operation passed easily, I’d expected to be off work for a week and I had some books to read. I even made a new website for the Chester Liberal Democrats. The next week or so it sort of dawned on me that the consultants slightly sweaty brow after the operation and the advice that I would take “a long time to heal” did mean something and I was indeed going to take “a long time to heal”. So here I am 6 weeks later during which I’ve largely been confined to the house.

Somewhat surprisingly I’ve done OK: I’ve read a lot, I’ve fiddled around with various computer programs, blogged a bit, shredded many old bills, re-organised things and not watched daytime TV and not even listened to the radio a great deal.

A visit to the consultant at about week 3 was somewhat surprising – I didn’t things were going too well, he thought they were going great! He has always appeared somewhat disdainful of patients, GP’s and a willingness to prescribe antibiotics for imaginary infection. He said mine was one of the more difficult operations of my type that he’d done. I suspect he wanted the medal I claimed for myself on that one.

The doctor (and consultants) views on the solubility of soluble stitches are quaint – their reported view is that they dissolve in 10-14 days. I started off with 20 stitches, six weeks ago. Number of stitches which have disappeared through dissolution: 3; Number that I’ve helped out: 12. Number remaining: 5. The nurse seemed a bit more clued up and said they “took ages”. I suspect the problem is that patients assume that they shouldn’t tell the doctor they’ve been fiddling with their stitches, so the doctor continues in the happy belief that stitches dissolve.

So that’s the story of my last 6 weeks, the funniest thing in all this is something my dad said; unfortunately it makes it pretty much absolutely clear what my operation was, and so I might leave it to an ephemeral tweet.