Saturday, 28 September 2013

The Quantified Self: A Clinician's Perspective

Digital health was a hot topic at Social Media Week London (#SMWLDN) this week and I was lucky to be involved with a session called The Next Stage of Digital Engagement: The Quantified Self (hosted by CIPR). The session was voted runner-up by MarketMeSuite in (take a breath) The Most Slightly Terrifying and Yet Apprehensively Exciting Talk Award category.

Our chairman was Drew Benvie, founder/MD of Battenhall and author of Body Data: Applied Thinking in Quantified Self and Wearable Technology . My co-panellists were David Clare, Digital Consultant at Hotwire and author of OneMoreLifeHack, and Steve Davies, Director of Ruder Finn UK and author of

We all gave our very own and different perspectives on The Quantified Self (QS). This is the concept of self tracking body data and sharing this via social media. It also concerns the application of the web, apps and wearable tech to personal health and productivity.

Steve spoke about how he and others in the QS community are monitoring their bodily functions, blood biochemistry and genetic makeup to learn about their health. By 2023, the computing power of an iPhone will fit into a red blood cell raising all sorts of exciting possibilities for invasive body monitoring.

David spoke of how the rise of the QS movement is being driven by an explosion in DIY digital health technologies, how businesses (including the pharma industry) might tap into this body data to tailor products more appropriately, and how the QS community is growing from a small hacker community to a mainstream phenomenon.

I spoke about how patient body data is monitored and transmitted between ambulances and hospitals during the treatment of heart attacks, how cardiologists are using implantable devices in patients which can be monitored remotely, and how the QS movement may provide us with healthy body data that allows us to predict and therefore prevent illness.

During the interactive session, we touched on the concerns regarding data privacy, the dangers of over-testing and medicalization of healthy people, and much more.

The session was streamed live and is available to watch here (there are some issues with sound overlay at the start, so you may want to fast forward to the start of Steve's talk at 04:00. My talk starts at 14:00) :

Photo of panel courtesy of @ManeeshJuneja


Wednesday, 28 August 2013

London's First Health Tech Forum Meet

The London chapter of the Health Technology Forum (HTF) met for the first time earlier this month and I was fortunate to speak at the event. The HTF is the brainchild of Silicon Valley health tech enthusiast and deal maker, Pronoy Saha, who has created an international network of HTF chapters based in the US, Singapore, India and now the UK. Pronoy hopes that this network of HTF chapters will answer the following question: How can technology be used to narrow the healthcare gap between rich and poor?
He believes that by bringing entrepreneurs, technologists, futurists, and clinicians together, answers to this and similar questions will be found in the health tech space. A feature of these meetings is the involvement of clinicians who play a vital role in the adoption of healthcare technologies.

My impressive co-speakers were Battenhall founder Drew Benvie, MedCrunch's Ben Heubl, and telehealth expert Charles Lowe. For me the talk of the evening was Drew Benvie's vision of the Quantified Self and how this will apply to digital health in the future. Continuous harvesting of personal data for maintaining personal fitness, disease prediction/avoidance and management of chronic illness is an exciting prospect. Applying these technologies to healthcare will no doubt lead to more personalised treatments during illness.
I spoke about how several technologies are being applied to the emergency treatment of heart attacks. These include technologies used during treatment (drug coated coronary stents, a variety of other invasive technologies, genetically engineered monoclonal antibody based drugs and so on) as well as for communication between ambulances (or helicopters) and coronary care units. A recent radio interview where I describe such a case can be heard here. Implantable devices which can be monitored remotely are routinely used in cardiology departments.
I also emphasised the role of the UK's National Health Service (NHS) in future digital health. The NHS is uniquely placed to apply new technologies to cost effective, patient centred healthcare. A nationwide healthcare system with comprehensive data capture has the ability to apply new treatments effectively, safely and rapidly to a huge number of patients, as it has done in the treatment of heart attacks.
Details regarding the London chapter of HTF are available here. Another review of this meet is available here.

Sunday, 11 August 2013

The Stenting of George W Bush: Why the Controversy?

A coronary artery stenting procedure performed last week on former US President George W Bush has generated controversy. After an abnormal treadmill test (done as part of a routine screening programme), he had a CT coronary angiogram which demonstrated a coronary artery stenosis. He was then transferred to an interventional cardiology centre where a stent was inserted into the coronary artery via the femoral artery. Two physicians (neither a cardiologist) claimed that the stent was unnecessary in the Washington Post. Larry Husten writing in Forbes asked a similar question. Burt Cohen writing for Angioplasty.Org gives a more balanced view. Meanwhile, on Fox News, Professor Marc Siegel struggled to get a stent out of its packaging with his teeth on live TV ('Pull the flap at the back,' I could hear many of us screaming). If nothing else, watch the video for a really good laugh.

The simple truth is that it is not possible to make any comment about this case without knowing all the details. And those details are private between the patient and his cardiologist. 
The debate about routine screening tests is not the focus of this post. Briefly, routine screening treadmill tests in the ABSENCE of symptoms are not recommended in the UK, but they do happen (for example, in athletes). I learnt last week that in France all men aged 65 years are offered an appointment with their cardiologist (which I suspect might lead to a treadmill test; can anyone confirm?). It is entirely possible that Bush said something to trigger concern, despite his excellent level of fitness.

In symptomatic patients, treadmill tests are not a 'rule out' test. In other words, a normal result does NOT rule out coronary artery disease. But treadmill tests are cheap, often immediate, and an abnormal result can guide further investigation. In some patients who have no obvious symptoms, a treadmill test can be used to unmask these. The value of treadmill testing (compared to more expensive tests for which patients may wait several weeks) is still being debated.
Once the treadmill has been performed, changes on the ECG (or EKG) can indicate ischaemia, in other words reduced blood flow to the heart muscle. Minor ECG changes may have quite reasonably led to a CT angiogram ('I think that this is normal but I want to be sure'). Major ECG changes would have led directly to an invasive angiogram.
An anatomically severe narrowing of the coronary artery is likely to have been stented. While 'ad hoc' stenting is frowned upon by some in the elective/stable setting, the interventional cardiologist may already have had evidence of ischaemia. The treadmill test was abnormal. Alternatively the interventional cardiologist may have performed a pressure wire study, measuring what is known as an FFR (fractional flow reserve) across the stenosis. This would have indicated whether the narrowing was functionally important.

Much attention is being paid to the COURAGE trial in this debate. This study (published in 2007) recruited 2300 patients between 1999 and 2004. Patients who had a 70% coronary stenosis AND objective ischaemia (<10% in most patients) or angina were randomised to PCI (Percutaneous Coronary Intervention; stenting) or optimal medical therapy (For more on randomised trials, click here). PCI did not provide a mortality benefit over 4.6 years.

In this study, less than one third of the patients had significant (>10%) ischaemia and so to me it is not surprising that the study did not demonstrate a benefit. It is probably reasonable to ask why patients with no angina and no significant (>10%) ischaemia were having angiograms in the first place. 38% of patients had had a previous heart attack and 85% of the PCI procedures were elective (planned). This does not reflect current clinical practice in the UK where only 30% of PCI procedures are elective (the remainder are emergency or urgent) and all patients with heart attacks are treated urgently.

We know that FFR guided PCI improves clinical outcomes in patients (11% were asymptomatic) from the FAME II trial. We now await the results of the ISCHEMIA trial where patients are being randomised BEFORE angiography. The results of this trial are therefore more likely to reflect current clinical practice.

In conclusion, I think that it is impossible (and perhaps even rash) to say that Bush's stenting procedure was unnecessary. Perhaps a more pertinent question should be this. Why was the PCI performed via the femoral artery? In the UK, 60% of PCI is performed via the radial artery.

Vinod Achan is an interventional cardiologist and clinical lead for primary angioplasty at the Surrey Heart Attack Centre. Listen to his recent interview on BBC radio regarding the treatment of heart attacks and cardiac arrests.


Monday, 24 June 2013

Is Relentless Media Attack on NHS Justified?

The UK's National Health Service has been under a blistering media attack. First, Charles Moore in the Telegraph describes the NHS as the “worst in the Western world” (1). According to him, “the NHS cannot look at the whole patient and meet his/her medical needs”. On Twitter, his editor Tony Gallagher describes the article as “really good”, and he is praised by Douglas Carswell MP. Next, in The Independent on Sunday, Ian Birrill describes the NHS as “a toxic institution”, one where “myopic worship has fostered a culture of complacency that kills patients” (2). Again he has been praised on Twitter by Jane Merrick (political editor of the IoS), Charlotte Leslie MP (MP for BristolNW) and Lord Ashcroft.

What is going on? It would appear that at least two of the above have had bad personal experiences of the NHS with care of relatives or themselves. Could that justify such vitriol in the national press?

Now might be a good time to clear up a few things. Firstly, the NHS is not the CQC (Care Quality Commission). We need a powerful regulator of hospitals in both public and private sectors, and the CQC has failed us in that. But do not tar the NHS with the same brush. Secondly, there are pockets of excellence within the NHS just as there are pockets of abject failure. To use examples of failure as a rod with which to strike all NHS staff demoralises them and fails to recognise their vital role in society.

The NHS is the backbone of healthcare in the UK. It is who we turn to when we are really sick. It doesn’t matter how sick you are, the NHS takes you in and does its best to fix you.  It also trains all our doctors and nurses. Yes, even those who now work in the private sector. Of course, the NHS is not perfect. But it does its utmost to deliver healthcare as a basic human right. It certainly is not complacent.

Funding cuts, staff shortages and increasing patient expectations are putting a strain on the NHS. See how our funding compares to other systems:

Is it the worst healthcare system in the world as Charles Moore and Ian Birrill would have us believe? Three years ago patient satisfaction with the NHS was the highest it had ever been. Research clearly demonstrates that the NHS provides the most cost efficient, high quality healthcare when compared to all other healthcare systems in the developed world (3). A report by The Commonwealth Fund (4) puts the UK in the top two for safe care, effective care, efficiency and equity (see chart).
We scored poorly on patient centred care (communication, continuity, feedback and patient preferences), and that may have been the price we paid for delivering the most cost-effective universal healthcare system in the world. For most of us in the NHS, this shines a light on where we must focus our efforts next. No complacency there.

How do we persuade the media to stop this unjustified attack on the NHS as a whole? What are their motives?

Please participate in the Twitter debate using #stopNHSattack.


3. Comparing the USA, UK and 17 Western countries’ efficiency and effectiveness in reducing mortality (C Pritchard, M Wallace), J R Soc Med Sh Rep 2011

4. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally (K Davis, C Schoen, K Stremikis), 2010 Update


Sunday, 16 June 2013

Effective Data Transparency: Cloudier Than You Might Think
Data transparency, the development of a safe and open culture of data sharing between clinicians and patients, is a noble aspiration. I have no doubt that it will improve the quality of data collection and lead to improvements in clinical care. Tim Kelsey, NHS National Director for Patients and Information, says that data transparency is the future of the people's NHS (1). It is one of the core strategic principles of NHS England. As part of this drive to improve data transparency, outcome data for nine surgical specialities AND interventional cardiology are being published this summer. An important issue that has not been discussed is how this data will be presented and interpreted by the public.

Jeremy Hunt says that patients will see which surgeons apparently have the best outcomes (2). Patients will be able to choose the best surgeons. Really? Cardiac surgery is cited as an example of how this model can drive improvement. Cardiac surgeons have published their outcome data since 2004 and mortality rates have apparently dropped to half those in Germany and a fifth of those in Portugal. What is often not discussed is how this may have led to risk avoidance amongst some surgeons.

MACCE (major adverse cardiovascular and cerebrovascular events) data for all interventional cardiologists in England will be published shortly. This is not a bad thing. However, we should exercise caution when looking at the data and bear in mind the effect this may have on many cardiologists. BCIS (British Cardiovascular Interventional Society) explicity states that you CANNOT compare the performance of cardiologists on the basis of the data. This is unlikely to be the view of government and the public.

For one thing, the data does not discriminate between cardiologists working in high volume heart attack centres and those only doing planned (elective) cases. Cardiologist A in a high volume heart attack centre will have a high volume of complex emergency work (usually 1/3rd of his/her cases) of which a proportion will be of extremely high risk. Patients following cardiac arrest who have been intubated and ventilated (and possibly on a Lucas chest compression device) have a high risk of death even if their angioplasty is successful, but are not considered separately in the data. Cardiologist B may only perform low risk elective cases or avoid taking high risk patients to the operating theatre (known as a catheterisation laboratory or 'cath lab'). While Cardiologist A has an elective mortality of 0%, his/her overall mortality may be 5%. Cardiologist B may have an elective mortality of 1%, and yet appear better overall.

Imagine the following clinical scenario (imagined but based on cases we frequently treat). A 50 year old man has a cardiac arrest at home and receives CPR from his wife. An ambulance crew arrives within 5 minutes and shocks him out of ventricular fibrillation. He is intubated on the scene, airlifted to a Heart Attack Centre by an air ambulance where a specialist interventional cardiology team reopens his blocked coronary artery within 15 minutes of him landing on top of the hospital.

The interventional cardiologist who takes full responsibility for treating this man considers many factors. One, that he may already be brain dead and that saving his heart may not save his life. Two, although the situation appears futile, there is a real chance that this man’s life may be saved. To adopt a non-interventional treatment strategy is to guarantee death (3). Three, the best chance of saving this man’s life depends on an immediate angioplasty and cooling. This is evidence based. Four, the man’s wife, an ambulance crew and an air ambulance crew have fought hard to this point to save his life. Is it fair that the cardiologist may deny potentially life-saving interventional treatment when the patient arrives at the door of his/her 'cath lab'?
Now there is a further consideration, namely the effect that taking on this extremely high risk case may have on the cardiologist's published outcome data. Many of us will swiftly put this consideration to one side and get on with the urgent job in hand.

Data transparency and publication of outcomes are here to stay in a patient centred NHS. But as patients use complex data to make comparisons between cardiologists, will some cardiologists begin to avoid high risk emergency work? How do we help patients to navigate the jungle of data they will be faced with?

Vinod Achan is a Consultant Cardiologist and Lead Consultant for Primary Angioplasty at the Surrey Heart Attack Centre, Frimley Park Hospital





Saturday, 1 June 2013

From Skullduggery to Scurvy: Patient Centred Evidence Based Medicine

James Lind (1716-1794)

Good clinical practice depends on the following: the individual expertise of the clinician, an understanding of the best available external evidence and informed patient choice. Education of patients is increasingly important so that they can make informed choices about their own treatments. The importance of clinical evidence must be emphasised to patients as well as all clinical staff.
Clinical evidence typically comes from clinical trials. A comparison of a new treatment with a control, ie. an existing treatment or placebo (a fake treatment with no plausible biological effect), is known as a controlled trial. The first documented clinical trial was performed by James Lind (pictured above), a naval surgeon who proved in 1747 that citrus fruits (now known to contain vitamin C) cured scurvy (which at the time killed a huge proportion of sailors). He took 12 sailors with scurvy and divided them into six pairs. Each pair was given a different diet which varied from seawater, a mixture of garlic, mustard and horseradish, and citrus fruits. The sailors given citrus fruits made a striking recovery.
Until this point, treatments were largely unproven and often quackery (skullduggery even). An example of this was the popular practise of blood-letting which most famously killed the first US president, George Washington in 1799. Over 5 litres of blood were drained over a day to treat his throat infection, resulting in his death.
Now clinical trials often involve hundreds if not thousands of patients. These patients must be randomised, in other words selection of patients for both (or more) treatment arms of the trial must be completely random. This ensures that there is no difference between the treatment group and the control group at the beginning of the trial. For example, randomisation ensures that healthier patients are not selected by chance to receive the new treatment. After receiving informed consent, patients must not know whether they have received the new or control treatment (single blinded trial). Where possible, physicians must also not know which treatment they have given (double blinded trial). The best possible trial therefore is a randomised, controlled, double blinded trial.
The best available evidence for a treatment does not end there. One positive trial should stimulate other trials to confirm the evidence. A single positive result can be the result of sheer luck (despite statistical significance). It is important that ALL available evidence is considered by the treating clinician. These are best obtained from rigorous systematic reviews of treatments, such as those provided by the international non-profit Cochrane Collaboration.
Negative results MUST also be included in any analysis of the best available evidence. Evidence that a treatment does not work is just as important as evidence that it might. However, it has been estimated that only half of all registered and completed clinical trials are published. Positive trials are twice as likely to be published than negative ones. The reasons for these are complex and being addressed by the AllTrials campaign. One example of this is the failure of the pharmaceutical company Roche to disclose all trial data concerning Tamiflu to the Cochrane Collaboration. The UK government has spent £500 million stockpiling Tamiflu on the basis of data that is not complete.

All clinical staff should be trained in interpreting clinical trial data and placing this in the context of best available clinical evidence. As patients play a more central role in their treatment, we should also make a bigger effort to educate them on how to interpret the evidence about their own treatment.
May 20th marked International Clinical Trials Day, commemorating the anniversary of the very first clinical trial by James Lind


Tuesday, 23 April 2013

An Elevator Pitch (or Lift Pitch) on NHS Reforms


The Health and Social Care (HSC) Act was passed in March 2012 and came into effect on April 1st 2013. GP led CCGs (Clinical Commissioning Groups) became responsible for the NHS budget and are now compelled to use competition as a means of improving NHS services. To most of us this seems like a good thing at first glance. Many of us are unaware of what this really means. To help public awareness, here is my ‘Elevator Pitch’ on NHS reforms. An Elevator Pitch is a summary of a concept or argument, short enough to be delivered between floors in an elevator. In the UK, we might call this a Lift Pitch.

The NHS is one of the most efficient healthcare systems in the world. It provides universal, comprehensive healthcare to EVERYONE. Healthcare is free at the point of delivery. We do not run the risk of personal bankruptcy when we fall ill. NHS hospitals are run on a non-profit basis where savings are reinvested in healthcare. Clinical outcomes are excellent. The US spends 2.4 times more on health per person than the UK, yet Britons live longer than Americans. Despite these achievements, the NHS has come under significant attack in the media. Budget cuts at a time when the NHS is at its most efficient have led to staffing shortages and ultimately problems outlined in the Francis Report.

The HSC Act 2012 removes the Secretary of State’s legal obligation to provide or secure healthcare for everyone. The NHS is also now subject to EU Competition law. Section 75 (being debated in the House of Lords today) compels CCGs to invite bids for all health services from ALL willing providers. This leads to a free market based system where expensive tendering processes will consume much of the CCG budgets and time. In the US, administration costs account for 20% of healthcare expenses, three times higher than in the UK.

Healthcare providers will compete against each other for the contracts. This may improve some services. However, barriers between primary care and hospitals will move us away from integration and data sharing. There is a risk that profit making organisations will cherry pick lucrative contracts, leaving difficult and expensive services to non-profit organisations. The irony is that a last minute amendment to the HSC Act makes this even more likely. The amendment declares that the only services NOT subject to competition law are those which can ONLY be provided by a current provider (most likely to be complex, expensive services).

As NHS budgets become tighter and healthcare becomes more expensive (largely as a result of spiraling administrative costs), the NHS is likely to change from a mostly single payer (government funded) system to a US style multiple payer healthcare system, what Don Berwick refers to as a ‘zoo of payment streams’. We only have to look to the US to see how our healthcare system might look in a few years.

Vinod Achan

For my blog on Don Berwick, see here.

Thursday, 4 April 2013

Nostalgia and the NHS

On BBC Radio 3 last night, Samira Ahmed hosted a debate on whether nostalgia was obscuring clear debate about changes in the NHS? GP and blogger Dr Jonathan Tomlinson argued on  behalf of the NHS. Journalist Ian Birrell argued against.

Ian Birrell painted a view of the NHS that many of us within it would not recognise. One of elderly patients dying in squalid conditions, doctors stifling change, doctors encouraging long waiting lists and disapproving of patient choice. Of course there are isolated examples of these, many of which are put under the microscope by the media. But these descriptions are not typical of the NHS.

Many of us within the NHS would love to and do engage in discussions about how service delivery can be improved. The NHS is constantly evolving and improving. Waiting lists have been driven down considerably. Care is becoming increasingly patient centred. We put the patient at the centre of everything that we do. Or we try to. And we deliver results. Cardiovascular mortality is falling faster than in any other OECD country, for example.

Compassionate care for patients with complex needs, especially the elderly and disabled, is precisely what the NHS strives for as it delivers universal comprehensive healthcare. Hospitals talk to each other and to GPs as a national network of organisations, mostly working together. We believe that healthcare is a basic human right. There are occasions when we fail, but those are the exceptions. As Don Berwick said, we leave no one out.

Healthy debate is essential to progress. What is hampering good debate and progress is the continuous cycle of redisorganisation costing billions of pounds. Teams of excellent administrators within PCTs, responsible for many of the recent service improvements, have been disbanded with a huge drain of talent. Instability leads to poor morale which, in combination with staff shortages, leads to poor care. The current reforms will lead to increasing competition and fragmentation amongst healthcare providers and spiralling administration costs. How we reverse some of these changes, and avoid a US style healthcare system driven by market forces and profit, will be the next big challenge that faces the NHS.

I invite both Samira and Ian to spend a day with me at the NHS frontline to see how things are being done well in the NHS.

Jonathan Tomlinson's response to this debate can be read here.

Tuesday, 2 April 2013

We Leave No One Out: Professor Donald Berwick

Professor Donald Berwick is a Professor of Paediatrics at the Harvard Medical School, Professor of Health Policy and Management at the Harvard School of Public Health, and CEO of the Institute for Healthcare Improvement. In July 2010, Professor Berwick was appointed by President Obama as head of Medicare and Medicaid but resigned at the height of the Obama healthcare reforms debate when it became clear that Republicans would block his appointment. Last week David Cameron appointed him to turn the NHS into the safest healthcare system in the world (in the wake of the Francis report). In his first interview as Cameron’s ‘Health Tsar’ with a newspaper, the Telegraph ran the title: “My Cure for the Sick NHS” (1).
Many of us will therefore be relieved to know that Professor Berwick is in fact a great supporter of the NHS. In the US, he has been denigrated by the Republican press for praising the NHS and wanting to move the US away from its traditional fee-for-service medicine. In a keynote lecture at the NHS Live Conference (July 2008) celebrating the 60th birthday of the NHS, the following were just a few examples of his praise (2):
1.     “The NHS is one of the most astounding human endeavours of modern times” 
2.     “The UK promises to make healthcare a human right. The US does not promise healthcare as a human right and people ask, “How can healthcare be a human right? We can’t afford it.” As a result, almost 50 million Americans, one in seven, do not have health insurance. Here (in the UK), we make it harder for ourselves, because we don’t make that excuse. We cap our healthcare budget, and we make the political and eco­nomic choices we need to make to keep affordability within reach. And, we leave no one out.” 
3.     “In the US, we can hold no one accountable for our problems. Here, in England, account­ability for the NHS is clear.” 
4.     “In the US, we fund healthcare through hundreds of insur­ance companies, a zoo of pay­ment streams. Administrative costs approach 20% of US total healthcare bill, at least three times as much as in England.” 
For a video excerpt, see here.

Professor Donald Berwick is a friend of the NHS. By appointing him, David Cameron may in fact help steer the NHS out of the choppy waters we find ourselves in. Professor Berwick, we welcome you to the UK and look forward to your support and guidance in making the NHS even safer.

Friday, 29 March 2013

How Marketisation leads to Privatisation

The 2012 Health and Social Care Act changes the NHS in ways which we are only just beginning to understand. These will have an impact on how healthcare is delivered and paid for in the future. Some have described it as a privatisation of the NHS by stealth. The changes to the NHS over the years are summarised here in three key stages.

1) Once upon a time: The Department of Health (DoH) funded all general practitioner (GP) and hospital services via Strategic Health Authorities (SHAs). Hospitals did not compete and healthcare was not motivated by profit. But the NHS was not efficient.

2) Creation of an Internal Market: The concept of relatively independent NHS Foundation Trusts (FT) was introduced in 2002. FTs were hospitals relatively free of DoH control and able to reinvest their own profits to improve local healthcare delivery. Local people could become FT members and have a say in how their local health services should be provided. Competition between FTs improved healthcare efficiency but would lead to the closure of less successful hospitals (and sadly some successful ones). Primary Care Trusts (PCTs) would commission (purchase) a variety of services from local hospitals.

3) 2012 Health and Social Care Act: Things are about to change. At the cost of £1.5 billion, PCTs have been disbanded and 211 Clinical Commissioning Groups (CCGs) created. These were supposed to be GP-led but in practice will be managed by support services outside the NHS. From April 1st 2013, CCGs will be responsible for a £65 billion NHS budget in England, commission (purchase) services from a wider variety of providers, and 'have flexibility to use competition as a means of improving NHS services'. Under Section 75 of the Act, CCGs/GPs will be forced to open up every part of the local health service to private companies via time-consuming tendering processes. These processes are almost alien to the NHS but familiar to private providers waiting in the wings. Private providers will compete with FTs. Some may collaborate with FTs but their ultimate objective will be to siphon off profits for shareholders.

PS. Since this blog was posted, the NHS Commissioning Board has been renamed NHS England.

Saturday, 16 March 2013

The NHS: Connecting the Dots

Aneurin Bevan (1897-1960)

Since its creation in 1948, the National Health Service (NHS) has provided universal free healthcare in the UK via a comprehensive primary care programme (general practitioners), a network of secondary and tertiary care hospitals, a superb ambulance service and public healthcare programmes. The three core principles of the NHS at its inception were:

1. The NHS would be universal. Everyone would receive medical treatment when needed.

2. The NHS would be comprehensive. It would cover all aspects of healthcare from mental health to cancer, dentistry to cardiac surgery

3. The NHS would be ‘free at the point of delivery’. No patient would be ever be billed for their treatment, no matter how complex or frequent that treatment or care might be.

Aneurin Bevan, the post-war architect of the NHS, wanted healthcare to be free from profit-making motives and for patients to not worry about how they might afford medical bills.

65 years later, the NHS is under some attack from sections of the media and government, not least because of the Francis Inquiry report which has highlighted failings in care at one NHS hospital. The culture of the NHS has been blamed. For most of us within the NHS, this brings into sharp focus the fact that staffing shortages, financial pressures imposed by government, increasing workloads and chasing of targets can lead to loss of morale and ultimately failure of healthcare. These are issues that can afflict all NHS trusts.

The Health Secretary Jeremy Hunt has described the NHS as 'mediocre' and 'coasting'. He has described the NHS as 'hitting targets but missing the point'. Roger Taylor has written much in support of the NHS but argued recently that ‘the Francis Inquiry report shows that those within the NHS cannot tell the difference between good healthcare and bad, and that we love the NHS too much to make it better (1)’. Enemies of the NHS will make the most of this opportunity to denigrate the NHS. 

I argue here that despite its failings, the NHS is admired by many both in the UK and across the world (2). Those within and loyal to the NHS are in the strongest position to drive improvements in national healthcare delivery, continue to build on an NHS of which we have every right to be very proud, and take it into the future without compromising its core principles. At a time when the NHS is coming under much criticism, it is worth noting that in the US where a very different healthcare system operates, 62% of all personal bankruptcies are related to medical costs. Of these personal bankruptcies, 75% had previous medical insurance (3). Life expectancy in the UK has improved by 4.2 years between 1990 and 2010 (4). The UK had the largest fall in heart attack related death rates compared to any other European country between 1980 and 2006 (5). The US spends 2.4 times more on health per person than the UK, yet Britons live slightly longer than Americans. By laying the emphasis on universal and uniform healthcare delivery across the country, the NHS can and will connect all the dots in a way that many other healthcare systems cannot.