Category Archives: In Between

More doctors should engage with arts and health

An article I co-wrote “More doctors should engage with arts in health” was recently published in BMJ careers. A longer version is below. Many healthcare professionals are interested in the arts, as part of their own wellbeing as well as their patients. It may not be clear how to align this interest with day to day work, and arts in health practice can therefore seem inaccessible to clinicians. We hope to bridge this gap with an introductory training event, the first of which will be on 30th June at the UCL Macmillan Cancer Centre, and has been approved for 3 RCP CPD points. Read more about it on the LAHF website, and book tickets via EventBrite.

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What is good health?

Doctors spend their professional lives trying to help their patients achieve good health. Although many start medical school with an idealised image of medicine as cure, most rapidly realise that despite phenomenal advances in science, cure is seldom possible. This is partly due to the nature of disease and the inevitable frailty of the human body, and partly due to the fact that none of us exist in a vacuum, and our potions and pills do nothing to change individual patients’ contexts or experience of illness. In fact ‘illness’ is almost impossible to define, as we medicalise more and more natural life processes and events. How can medicine address modern day phenomena of socioeconomic inequalities, lack of housing, poverty, loneliness, ageing, grief, disengagement from society, struggles with sexuality, or finding meaning in life? Should it? The role of the doctor has historically been to promote, maintain and restore health where possible, and to relieve suffering, and offer comfort to all. In this context, wellbeing as a concept that extends beyond a narrow definition of health becomes increasingly important. The WHO definition of health acknowledges this, and states that health is “a complete state of physical, mental and social wellbeing, and not merely the absence of disease or infirmity.”[1]

The Gallup Global Wellbeing index attempts to quantify aspects of wellbeing and compare across borders, languages and cultures. It defines five elements of well-being;

  • purpose (liking what you do each day and being motivated to achieve your goals)
  • social (having supportive relationships and love in your life)
  • financial (managing your economic life to reduce stress and increase security)
  • community (liking where you live, feeling safe and having pride in your community)
  • physical (having good health and enough energy to get things done daily)

Medicine, as traditionally imagined, only addresses the last of these. Perhaps the social and creative potential of the arts could be harnessed to support the other elements and help physicians to generate a more holistic approach to health in our patients and communities.

What is arts in health practice?

Over recent years, there has been a growing understanding of the impact that taking part in the arts can have on health and wellbeing. By supplementing medicine and care, the arts can improve the health of people who experience mental or physical health problems. Engaging in the arts can promote prevention of disease and build wellbeing. The arts can improve healthcare environments and benefit staff retention and professional development. Arts in Health practice includes a wide range of approaches, projects, disciplines and professionals. It is much broader than what would traditionally be understood as medical humanities.

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What is the evidence for the impact of arts and health initiatives?

The arts have been recognised as central to wellbeing, but there is a lack of engagement from health professionals. Multiple contributing factors include: a lack of curricular time in undergraduate and postgraduate training for arts and health; a lack of interest, expertise, and leadership from clinically trained professionals and educators; poor funding; and institutional priorities. Although many successful arts in health projects exist, with years of experience and anecdotal evidence, those trained in positivist empirical scientific disciplines demand randomised controlled trials and objective evidence of impact before they invest time, energy, and crucially money, in initiatives that may be seen as ‘soft’. This stance, and the tendency to see arts engagement as ‘an intervention’ rather than a part of a long-term personal and therapeutic activity, leads to the prevailing narrative that a link between engagement in the arts and measurable physical and psychological outcomes is lacking. In fact such evidence already exists; there are numerous examples of the measurable impact of arts on health and wellbeing [6-9], in addition to specific effects of individual programmes which include RCTs [10-12]. (Table 1). A DoH working group in 2007 recognised this and stated “the arts are and should be firmly recognised as being integral to health, healthcare provision and healthcare environments.” [13]

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Dr Gorden-Nesbitt of Manchester Metropolitan University reviewed the evidence for longitudinal effects of the arts on health and concluded “Taken together, the research demonstrates a positive association between engagement in high-quality arts activities and life expectancy, disease resistance, (and) mental acuity .” Possible mechanistic explanations include enhanced social capital, psycho-neuroimmunological responses, and epigenetic phenomena [6].

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Why now?

Despite concerns about funding cuts to both healthcare and the arts, now is an exciting time for arts in health practice. There is increasing political interest in the area, with a recent All Party Parliamentary Group convened to explore Arts, Health and Wellbeing. The recent changes to the commissioning landscape are highly relevant. The Health and Social Care Act (2012) established Health and Wellbeing Boards with a remit of improving the health and wellbeing of their local populations. They have strategic influence over commissioning decisions across health, public health and social care, and offer potential for more cohesive, less silo-ed working. Importantly they have a remit to consider the social inequalities within their area, which remain huge determinants of health. Virchow famously stated “Medicine is a social science, and politics nothing but medicine at a larger scale.” [14] And as Dr Gordon-Nesbitt reflected “Whilst the arts and health inhabit two distinct policy areas, and the particularities of each field needs to be borne in mind, both health and the arts are inherently political. It follows that arts/health is a political movement…” [6]

How can you get involved in arts in health?

Having been won over to the inherent value of the arts, and the specific value of arts in health, how can you learn more and get involved? A number of options are open to you, dependant on your personal interests:

  • Seek out information on local arts in health projects and take the opportunity to see them in action (the LAHF directory is a great place to start)
  • Read more about Arts in Health, and the evidence base for enhanced health and wellbeing (see references below)
  • Attend an event such as Medicine Unboxed, or Creativity and Wellbeing Week, to meet those involved in the field and find out more about the huge diversity of organisations and activities
  • Contact your Trust’s arts manager/co-ordinator and find out what is happening locally
  • Consider how you could incorporate the arts and enhance teaching you already have responsibility for, at an undergraduate or postgraduate level
  • Advocate for including the arts in service reviews, whether this be participatory projects, physical environments, or arts therapies. Use examples of other projects, including The Kings Fund’s “Enhancing Healing Environments” to help your case.

For those with a particular interest in the field new ways to engage need to be developed. The London Arts in Health Forum are developing an introductory course for health practitioners who wish to learn more about the theory and practice of arts in health. The first of these will be on 30th June at the UCL Macmillan Cancer Centre and has been approved for 3 RCP CPD points. Read more about the event on the website and book tickets via EventBrite.

As Sir Peter Bazalgette, Chair of Arts Council England said, ‘When we talk about the value of arts and culture, we should always start with the intrinsic – how arts and culture illuminate our inner lives and enrich our emotional world. This is what we cherish. But while we do not cherish arts and culture because of the impact on our social wellbeing and cohesion, our physical and mental health […] they do confer these benefits and we need to show how important this is’. [6]

By facilitating front line health workers to become better equipped and engaged with arts in health, we can start to open opportunities for more individuals to reap the benefits of the arts, in all its forms. This has the potential to enhance life for us all: doctors, patients, public, and society at large.

  1. WHO. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948.
  2. Bircher J. Towards a dynamic definition of health and disease. Med. Health Care Philos 2005;8:335-41.
  3. Saracci R. The World Health Organization needs to reconsider its definition of Health. BMJ 1997;314:1409-10
  4. Department of Health. (1999). SavingLives: Our Healthier Nation. London: Stationery Office, (Cm 4386): 159pp.
  5. Smith R. Spend (slightly) less on health and more on the arts. BMJ. 2002 Dec 21;325(7378):1432–3.
  6. Gordon-Nesbitt R. Exploring the Longitudinal Relationship between Arts Engagement and Health. Available at: https://longitudinalhealthbenefits.wordpress.com/ accessed 20/09/15
  7. Arts Council England, The Value of Arts and Culture to People and Society: An Evidence Review (London: Arts Council England, 2014).
  8. Bygren, L. O., Konlaan, B. B., & Johansson, S. E. (1996). Attendance at cultural events, reading books or periodicals, and making music or singing in a choir as determinants for survival: Swedish interview survey of living conditions. BMJ: British Medical Journal, 313(7072), 1577.
  9. Bygren, L. O., Johansson, S-E., Konlaan, B.B., Grjibovski, A.M., Wilkinson, .V., & Sjöström, M.‘Attending Cultural Events and Cancer Mortality: A Swedish Cohort Study’, Arts & Health, 1, no. 1, March 2009, pp. 65–6.
  10. Iwasaki, Y., Mannell, R. C., Smale, B. J., & Butcher, J. (2005). Contributions of leisure participation in predicting stress coping and health among police and emergency response services workers. Journal of Health Psychology, 10(1), 79-99.
  11. Särkämö, T., Tervaniemi, M., Laitinen, S., Numminen, A., Kurki, M., Johnson, J. K., & Rantanen, P. (2014). Cognitive, emotional, and social benefits of regular musical activities in early dementia: Randomized controlled study. The Gerontologist, 54(4), 634-650.
  12. Petrie, K. J., Fontanilla, I., Thomas, M. G., Booth, R. J., & Pennebaker, J. W. (2004). Effect of written emotional expression on immune function in patients with human immunodeficiency virus infection: a randomized trial. Psychosomatic Medicine, 66(2), 272-275.
  13. Department of Health. Report of the review of arts and health working group. London: Department of Health, 2007.

Finding the words

Making and documenting good decisions about CPR (cardiopulmonary resuscitation) and treatment escalation plans, that are truly shared decisions, is a challenge. I find that the challenge comes from a number of factors: intrinsic difficulties of talking about the possibility of death in a largely death-denying culture; the great diversity of beliefs, wishes, and level of preparation for such decisions amongst patients; difficulties in facing my own mortality and the ways in which personal situations may affect my professional abilities; navigating tensions between hope and acceptance; and additional complexities that stem from having such conversations in the context of an emergency hospital admission. In the midst of a busy shift, faced with distressed people who are in pain, sometimes it is hard to find the words.

A number of recent cases have highlighted concerns about the process of resuscitation decision making and documentation. In particular, people have been distressed by the fact that DNACPR (do not attempt cardiopulmonary resuscitation) orders have being placed in their records without an explicit discussion with either them or their family. The High Court Ruling on R (David Tracey) vs 1) Cambridge University Hospitals 2) Secretary of State for Health forced the medical profession to face up to residual paternalism in this area of practice, and to make changes. It prompted some important reflections amongst individuals, teams and institutions and I have seen a noticeable difference in practice since the ruling, which reinforced the legal duty to discuss decisions about care with patients, particularly DNACPR decisions.

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DNACPR discussions provide an opportunity to engage patients in informed decision making. This requires an awareness of what CPR is and what determines success. Unfortunately there is a wide gap between the practice and success rates of CPR on television, and reality [1,2]. Worse still, this gap has widened in recent years [3]. With this backdrop, it is essential that discussions between healthcare professionals and patients and their loved ones are open, honest, realistic, supportive and clear. A number of reports have questioned whether the processes and documents we use currently are adequate to support such discussions. For example The Health Select Committee’s enquiry into end-of-life care reported:

“We recommend that the Government review the use of DNACPR orders in acute care settings, including whether resuscitation decisions should be considered in the context of overall treatment plans. This Committee believes there is a case for standardising the recording mechanisms for the NHS in England.”

This has led to the development of a newly designed Emergency Care and Treatment Plan. The Resuscitation Council (UK) is currently holding a public consultation on this document and the information provided alongside it. Documents and guidelines have an authority and power that should not be underestimated; their language and structures shape our behaviour and frame our interactions. It is essential, therefore, that the panel considering new documentation on decisions regarding treatment during serious illness get it right. But what does ‘right’ look like? I have read the proposed document and it is has clearly been drawn up with good intentions. There are several aspects which would improve clarity and communication. However, the language used at the heart of the document leaves me concerned. I can see the benefits of widening the question beyond a yes/no decision on CPR, to encompass overall priorities for treatment. But, for me as a potential patient, and as a doctor in its’ current form the wording doesn’t capture the essence of these decisions in a way that will positively support clarity of communication.

Following discussions on CPR and other interventions, what I hope to capture in my documentation is the values of the patient, and any lines that they do not wish to cross. The current proposal requires a decision between three options:

ECTP options

Although I could fit in any discussion to these categories I worry that they do not prompt and support relevant choice and accurately capturing the priorities of patients and their families. Most people’s priority is to get better, but this is not always possible or realistic. Who would not want to ‘consider’ all treatment to prolong life if framed in this way? I am concerned that the  alternative options are too broad and therefore do not really help in this area of complex decision making. Although of course the document would be part of wider, more detailed discussions, these key headline categories could be a hindrance rather than a help in this process. I have suggested that the panel consider stronger wording and tentatively suggested:

  • The over-riding priority is to prolong life, and all treatment options, no matter how invasive would therefore be accepted.
  • The priority is to prolong life, but not at the cost of quality of life. Some interventions would not be accepted (see below for specifics).
  • The over-riding priority is quality of life, therefore interventions which may prolong life but at the cost of quality of life would not be accepted. Care should be focused on symptom control, comfort and dignity.

These are in some ways subtle changes, but for me these statements are clearer and give a better sense of priorities, prompting documentation of more specific details. They also bring to the fore the real chance of harm from invasive interventions and ensure this forms part of decision making. I do not imagine everyone will agree, and I don’t think this formulation is perfect. I would be very interested to hear what others feel about the proposal. 

The consultation closes at 9am on 29th February. Please consider submitting a response, particularly if you are a patient or carer. We need many voices and perspectives to make sure we find the right words and get this right.

  1. Harris, D., & Willoughby, H. (2009). Resuscitation on television: Realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama. Resuscitation,80(11), 1275-1279.
  2. Hinkelbein, Jochen, et al. “An assessment of resuscitation quality in the television drama Emergency Room: Guideline non-compliance and low-quality cardiopulmonary resuscitation lead to a favorable outcome?.”Resuscitation 85.8 (2014): 1106-1110.
  3. Portanova, J., Irvine, K., Yi, J. Y., & Enguidanos, S. (2015). It isn’t like this on TV: Revisiting CPR survival rates depicted on popular TV shows.Resuscitation, 96, 148-150.

Parallel lives

parralel clouds

I am immeasurably proud of the NHS: the most successful model of healthcare the world has ever seen. If anyone within my earshot suggests that privatisation would be a step forward they rapidly regret it. But even I sometimes get a wake up call: a stark reminder of the absolute necessity of the NHS, and the horror we may face if the political right’s dream of marketised healthcare is realised.

On a recent shift as the Medical Registrar I received a call from an A&E doctor who wished to discuss a patient who had suffered a stroke. I was surprised as all patients with strokes are channelled into the acute stroke pathway: assessed and treated by a dedicated team and admitted to a specialised unit for consideration of thrombolysis; specialist investigations; and early physio, speech and language therapy. However the A&E doctor explained the situation and I agreed to admit Maria*.

I sat by Maria’s bed in the Medical Assessment Unit, and listened as she told me her story. She was a UK citizen who had been living and working abroad. Whilst at home one day she had suddenly experienced weakness on the right side of her body and her speech had become slurred. She was rushed to hospital and diagnosed with a stroke. In the healthcare system she found herself in she was not assessed for and offered thrombolysis. She had to provide a payment method as soon as her initial assessment was complete and the bills began mounting from there. With every test and treatment she was offered she faced an impossible decision: could she afford what was being offered in monetary terms; and could she afford not to have it in health terms? This trade off had devastating effects. She did not have intensive physiotherapy, speech and language therapy. She did not have relevant investigations. She did not receive the best, evidence-based treatment.

By the time she received advice from the British consulate, and was helped to return to the UK for ongoing care, she was significantly disabled. On arrival to our hospital she had dense weakness with stiffening of the limbs leading to pain. She was wheelchair bound and struggled to get from chair to bed without assistance. Her speech remained impaired, making it difficult to communicate her wishes and needs. We admitted her to a medical bed, and the next day the specialist stroke team began working with her to regain as much function as they could. She has a long journey ahead.

If Maria had been at home in the NHS she would have had world class healthcare. She would have been assessed for thrombolysis. She would have had early physiotherapy, speech and language therapy and nutritional interventions. She would have been able to focus all her energy on her recovery and not worry about mounting debts. She would have embraced every test and treatment offered by her medical team, who themselves would have been focused entirely on her needs, not the financial state of their department. 

I watched in horror as the NHS was dismantled by stealth through the Health and Social Care Act. I wrote fervent letters, I shouted, I demonstrated, but to no avail. I often wondered why there was so much apathy from doctors of my generation. A recent article, by a Guddi Singh, who I went to medical school with, suggests some reasons including: a lack of understanding of health politics; being fooled by government rhetoric on the “choice” and “clinician-led” agenda; fear of rocking the boat, especially with a lack of organisational support (from the BMA and RCP who were noticeably silent about the proposed reforms); and a wish to just get on with the job. Doctors have a proud history of advocacy, but this side of our role does not get enough attention in modern medical school curricula.

We have only begun to see the effects of the devastating changes of the Act. As the NHS is systematically cut, ground down and sliced into pieces for private gain it will only get worse. I never want to work in a system in which the first person a patient in need sees is a cashier. I never want to work in a system in which patients trade financial ruin against health and wellbeing. I never want to make decisions about a patients’ care based on cost, rather than need. I never want to see another patient like Maria, and I never want her story repeated right here in the UK.

This can’t be the future. We can’t let it happen. I will be joining Guddi’s call to action and fighting tooth and nail to keep the NHS in the hands of the people, rather than the corporations – the friends of the political class. Markets are not the answer to questions around sustainable provision of high quality healthcare.

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Read more about the devastating destruction of the NHS, watch slices of public services being handed over to private companies, and see the impact of these changes on services you and your family may one day rely on.

Stop NHS privatisation.

Join us.

* names and other details changed to protect confidentiality

Lonely this Christmas

I love Christmas. But I occasionally find myself in a moment of loneliness in the midst of all the crowds and music and noise. When I see pictures of friends with their newborns, home just in time for Christmas; hear couples conspiring about the perfect present for each other; or catch the refrain of a song and am reminded that no-one is thinking “all I want for Christmas is you” the sparkle loses it’s shine. Being in the ever diminishing demographic of single 30-somethings can be lonely. But these moments are fleeting. I’m soon reminded of how much love surrounds me as my Mum calls to double check when my train is getting in, my brother texts to ask whether vegetarians eat gravy, and my friends email checking who is bringing the Gin at New Year. I know how lucky I am and how full of people my life is, and I was reminded of this on my last day of work before the Christmas holiday.

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Ron* was a patient I had previously met in clinic. He had severe COPD and lung cancer for which he’d opted not to have treatment. He was admitted the week before Christmas with breathlessness and we were treating him for an infective exacerbation of COPD. We were fully staffed and the team had the ward under control so there was time to do what I wish we could do more often: sit and chat. Ron was recovering slowly from his exacerbation but still feeling very breathless. He couldn’t walk more than a couple of steps before having to stop and rest. I suggested he would probably need to stay with us until after the weekend, and asked what his plans were for Christmas. He didn’t have any. No family. No friends. He, like so many other invisible members of our communities, would be having Christmas dinner for one. He had, over the years, lost those he cared for and been left alone. I said it was just as well he didn’t have plans as he may need to stay in hospital for Christmas this year. He agreed all too quickly.

I used to think it would be the most awful thing imaginable to be in hospital at Christmas. And for some this is true. But hospitals are bright, warm places, full of caring people. Every member of staff working this Christmas will do their best to spread some cheer, and give out an extra ounce of compassion to those they see. And for those people who have no-one; who might otherwise be alone, ill and afraid; hospital might be the best place to be.   

The NHS is there when no-one else is. It is part of, not only an ideal, but a reality of which we should me immensely proud: the welfare state. As a country we do not value our state services enough. They are not perfect, but they are wonderful.

I worry about the increasing pace of NHS privatisation. Who will be there for those who have no-one in a profit-driven system?

All I want for Christmas is the NHS to survive. Perhaps 2014 is the year to take action to make sure this happens…

Keep our NHS public

Can we find the spirit of ’45 in 2013?

Today marks a defining moment in the history of Britain, but looking around you wouldn’t believe it. Today, April 1st 2013, sees the The Health and Social Care Act (HSCA) come into force.

The death certificate of the NHS, issued by the National Health Action Party

The death certificate of the NHS, issued by the National Health Action Party

Some still believe that those opposed to the HSCA are over-dramatic, reactionary or naive. They will probably dismiss the National Health Action Party as extreme and publicity-seeking as it has issued a death certificate for the NHS, citing the cause of death as the HSCA 2013, with contributing causes including Thatcherism and the failure of New Labour. But it is difficult to see how anything but extreme statements and gestures can capture the attention of the public. Our generation is standing by as the NHS is quietly privatised and I for one am ashamed.

In 1948 the Attlee Labour government founded the NHS “the greatest gift a nation ever gave itself.” Since then it has been gradually eroded and dismantled. The King’s Fund’s infographic depressingly visualises various points of attack by multiple governments, starting with the creation of the internal market in 1989 when Margaret Thatcher signed the paper “Working for patients”. New Labour also have a lot to answer for; their PFI legacy crippling many Trusts today. But no previous government has actually tried to privatise the NHS, knowing that there would be a public outcry. Cameron and Clegg have privatised by stealth; clouding their agenda in a language of ‘choice’ ‘clinician power’ and ‘patient centredness,’ and ensuring that the reform documents were so long and complex that no-one, including most Ministers, understood them. The British media failed to report the warnings of individual doctors, nurses and other healthcare workers, and the demands of traditionally silent bodies such as the Royal College of Physicians to drop the Bill.

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The most worrying aspect of the reforms that come into force today are the Section 75 regulations, which state that all NHS services must be put out to competitive tender. This is not just allowing privatisation, it is mandating it. And all these profit-motivated private firms will be operating under the ‘brand’ of the NHS, so patients may not even know. Until the inevitable problems start to surface and it is too late.

Screen Shot 2013-04-01 at 18.34.44As I watched the welfare state being dismantled around me this week, I went to see Ken Loach’s film The Spirit of ’45 at The Barbican Cinema. It was a poignant reminder of a time full of hope and promise, and was a stark contrast to what I see today. In 1945 there seemed to be a collective vision of a society that could pull together for the benefit of all, with at least some people from all social classes believing that the State was a force for good, and that it had a responsibility to provide and protect the simple things most of us spend life striving for: purpose, dignity in work, family, safety, health, wellbeing, shelter, and comfort. 

Particularly powerful were interviews with doctors and patients who remembered a time before the NHS, when healthcare was only for the rich. In The Spirit of ’45 Dr Jacky Davis and Dr Jonathan Tomlinson, doctors working in the NHS today, talk eloquently about the doctor-patient relationship and about their fears about the future. Marketisation and competition change the relationship of doctors and patients to salesmen and consumers. I am no salesman and never will be.

The day after I saw The Spirit of ’45 I was on call in hospital. I was asked to speak to a patient about her medications before she went home, and quickly scanned through her notes before going to speak to her. She had had a tough few weeks, having been diagnosed with incurable (but treatable) lung cancer – only two weeks from having a chest x-ray revealing an unexpected abnormality to tissue diagnosis and treatment plan. This rapid diagnosis and treatment was an example of what happens every day in the NHS, and is a great example of the efficiency of our healthcare system, but it had left her little time to process the news. She was anxious about her medications prior to discharge so I spent a few minutes clarifying them and reassuring her.

As we ended the conversation she said thanks, and then hugged me tightly. It was nhs logoan unexpected level of physical contact and gratitude for a conversation that could only have lasted ten minutes. But it made me think. She wasn’t really thanking me. She was thanking the NHS: there for her from cradle to grave; at the most difficult time of her life; no questions asked; free at the point of need. Patients in the NHS are taken under the wing of an institution and cared for under an ideology. Today that ideology has suffered a fatal wound. Health is not a commodity, and markets will not make our NHS more efficient, more equitable or of higher quality.

Nye Bevan said “The NHS will last as long as there are folk left with the faith to fight for it”. As Owen Jones says “It is with huge regret that I must say that – however much faith we have – we did not fight to save it. The question now is – do we have enough faith to bring it back to life?”

As I look around the political landscape I fail to be inspired or energised by what I see. Attlee had vision, drive and a belief in the people.

I am looking for the Spirit of ’45 in 2013. Let me know if you find it.

Discharges in the dead of night

NHS Hospital discharges: thousands claimed to occur overnight

The news this week has been full of horror stories of patients being discharged from hospital in the dead of night. “Where is the compassion?” they cried, “How could they, the supposed caring profession?”  The stories began after The Times discovered, via Freedom of Information requests, that 100 NHS trusts sent 239,233 patients home last year between 11pm and 6am

The immediate response of the press was to paint a picture of an army of ambulance drivers booting out frail 90 year olds; dumping them at their front doors, alone in the dead of night. This dramatic depiction fuelled discussions on various forums and news programmes. The callers on Radio 4s “Any answers” actually made me turn the radio off.

My major concern is that this data was released without proper analysis. As usual in the reporting of science news, and particularly health-related news, the headlines were more important than the content. It took me two minutes to think of a list of possible contributing factors which may have led to these numbers of supposed patient discharges overnight:

  • Deaths are often coded as discharges. These may happen overnight.
  • Sometimes patients self-discharge, especially those admitted due to intoxication. On sobering up they may decide that at 5am they’d rather sleep off the rest of their hangover in their own bed. Good for them.
  • Many patients are offered the chance of discharge after a period of observation in a short-stay ward. Such patients are not really “admitted” in the traditional sense, merely held somewhere outside A+E due to the constraints of the 4hour rule, often awaiting test results.
  • Patients may leave the hospital hours before the discharge is “declared” by the ward. Sometimes this is due to the ward staff prioritising patient care over paperwork, and only getting around to logging the event later. Sometimes this is a more overt tactic to prevent more ward admissions when ward staff are under pressure. This may not be best practice, or good for patient flow, but is better than what has been imagined by reporters.

It is disappointing that those at The Times didn’t construct a similar list, and is part of a worrying trend of negative NHS stories despite high patient satisfaction. In my more cynical moments I wonder about influences on reporters and editors and links between media execs, politicians and those with interests in private healthcare.

“Patients should only be discharged when it’s clinically appropriate, safe and convenient for them and their families.” says Sir Bruce Keogh. Absolutely. I know no-one working in the NHS who does not “believe in the principles of holistic care – thinking about the patient as so much more than a bed filler and considering their lives outside the microcosm of the hospital.”

There may be a very small number of cases which fit the picture painted by The Times, and each of these is a failing of the system, which requires investigation and action. But please can we stop the media driven NHS-bashing? Those of us who work in public service endure long hours in difficult circumstances, but do so because we care. Nurses, doctors, occupational therapists, physiotherapists, pharmacists, discharge co-ordinators and matrons spend our working lives assessing patients to ensure that at the end of their medical investigations and treatment they are safe for home. When they are not we engage social services to put in place care to achieve a safe discharge. I worry that the profit motive, competition and privatisation will bring pressure to change this, but for now compassion remains at the heart of what we do, and no-one vulnerable and alone is going home at 3am on my watch.

BBC article: Overnight discharges from NHS hospitals to be examined

Sensible analysis by FullFact.org

The Dangers of DIY Diagnosis

I spend all day talking to patients about their health and disease, explaining the rationale for tests and discussing the possible outcomes of different treatment strategies. This is often difficult and complex. I struggle to articulate risk, uncertainty, and the art of medicine; the shades of grey that are a day to day reality, and which medical school does not necessarily prepare you for.  I was therefore outraged when, on my way home after a hard day at work, I saw this advert on the Tube:

An advert on London Underground for an over the counter blood test.

I should sue Myrios for emotional distress: I almost fell onto the tracks. What shocked me was the cynical, and cheerful, exploitation of people’s worries about their health.

On their website Myrios say “with all conditions, preventative medicine is key, so it is important to check your health and well-being periodically.” I have no objection to this statement and wholeheartedly endorse the “prevention is better than cure” message. But to suggest that this can be achieved by having a random panel of blood tests is outrageous.

The advert offers testing for a number of ailments, ranging from anaemia to syphilis. Below I offer my initial reaction to each of these, and a reason why you should not buy the test (I suggest you spend your hard-earned money on a giant Easter egg, lunch and an exhibition at the Tate Modern, a subscription to the LRB, or a nice bottle of red).

What concerns me about this advert, and others like it, are the ethics of marketing to vulnerable individuals and the validity of consent to the tests.

I imagined I was one of the patients I often see in clinic and typed “do I have lung cancer?” into Google. The top hit (if you don’t have the wonderful Adblock installed) is Insight Medical offering “peace of mind” from a CT scan of the Chest. This test could indeed reveal a Lung Cancer, and if detected early the outlook is better. But the test involves exposure to radiation, and should only be offered to those with the right risk factors and symptoms or signs to make sure the potential benefit outweighs the known harm. In this context, the test will be offered by a Respiratory Physician, for free on the NHS.

An example of a particularly advanced CT scanner, capable of producing amazing images in seconds

Research is ongoing for an effective lung cancer screening programme for asymptomatic individuals, and progress has been made in the use of CT for screening (a low dose protocol). I hope that in my lifetime we create an effective programme to find early cancers, amenable to aggressive curative treatment. But disappointingly there is currently insufficient evidence that CT screening makes a difference to outcomes, even in carefully selected high risk populations, which is why it is not offered as an NHS screening programme, which are subject to rigorous controls and quality assurance.

I could go on for pages about the complexities of screening; about the need to evaluate the sensitivity and specificity of a test and to know the prevalence in the population you’re testing to have a good idea of false positive and false negative rates; about the need to have a good knowledge of the natural history of the disease you’re screening for and consider lead time; about the need for precise protocols on patient selection, frequency of screening; about  how important it is to know what the intervention will be if an abnormality is detected; about the need to have systems set up to manage and perform these interventions, with appropriate after-care. I recommend The Pod Delusion Episode 129 for a great discussion with GP Dr Margaret McCartney on this subject, and also her BMJ article.

What is not often talked about is the difficulty in dealing with incidental and indeterminate findings.  What if you go for a CT Chest looking for “complete peace of mind” and it identifies a small nodule? It doesn’t look like cancer, the rest of the scan is normal and you are otherwise well. But it’s there. And you’re “high risk” as you’re a smoker. It’s too small to biopsy and your doctor recommends “watching it” with a repeat scan in 6 months (which you pay for and have.) The nodule is unchanged and your doctor recommends a further scan at 12 months. It is again unchanged so, as per guidelines,  she recommends one further check CT at 24 months. The nodule is still unchanged so she says there is no need to watch it anymore. What started as a desire for “peace of mind” has resulted in 2 years of repeat scans (with the associated cost and radiation exposure) and the unquantifiable psychological cost of knowing there is something there. Even at the end of this period you may feel uneasy that this nodule exists and there may be longterm anxiety about it. I wonder whether a scenario like this is discussed in the consent process for the initial CT. I also wonder how many patients switch to NHS care after the initial scan, leaving the NHS to pick up the bill for ongoing care and tests. As always private companies want all the profit, none of the responsibility.

I absolutely encourage you to be an empowered patient, to take control of your health, to research your condition (from evidence-based and peer-reviewed sources) and to practice preventative medicine yourself. I encourage you to talk to your doctor about your concerns. In this model of healthcare delivery there is a partnership between the patient and physician; the physician providing the expertise necessary to evaluate and contextualise the evidence, in order to advise patients on their options. Admittedly not all doctors will respond well to this, and many are still uncomfortable with the “medical Googler” but as healthcare providers we need to get better at this – our duty of care extends to protecting patients from exploitation and worry. I expect to have more and more conversations that centre around critical analysis of evidence found on the Internet. I expect to be challenged and educated by my patients in the future, and hope to steer them far away from exploitation and harm.

Don’t be taken in by cynical marketing. If you are ill or are worried about your health see your doctor. The NHS is a wonderful system and, for now, remains free at the point of need. If you need it, use it, and save your money for enjoying life.

Below are the specific tests offered by Myrios and reasons why not to buy them. 

1. Anaemia. This is a condition in which the Haemoglobin (Hb) level is low. Hb carries oxygen from the lungs to the tissues and if it is low you may feel tired or breathless. Your GP would routinely do this test (for free) if you had these symptoms. There are many, many reasons for anaemia that would require your doctor to talk to you and examine you, in order to decide on subsequent tests.

2. Cholesterol. An important and necessary component of cell membranes, but high circulating levels of some forms of cholesterol (LDL) and relatively low levels of other forms (HDL) promote atherosclerosis and so are linked to cardiovascular disease (heart attacks, strokes). This test is offered for free in NHS Health Check schemes to everyone aged 40-74, and is part of a comprehensive assessment taking into consideration personal and family history, lifestyle factors and other risk factors.

3. Diabetes. A diabetes assessment forms part of the free NHS Health Check, and  is not just an isolated blood glucose test but takes into consideration other risk factors. An isolated single test of high blood sugar does not diagnose diabetes, so further tests such as an oral glucose tolerance test might be needed, in addition to lifestyle advice and support.

4. Glandular fever. This is a viral infection caused by Epstein Barr Virus, also known as infectious mononucleosis. It often affects young adults and is contagious. Common symptoms include fever, sore throat and swollen glands/lymph nodes. For most people this condition is unpleasant but not dangerous and they get better in a few weeks. There is no reason at all for a healthy person to be tested for this disease. A doctor can advise on when the test could be helpful (including when a simple monospot is appropriate, and when other antibody tests may be needed), as part of an overall assessment of a patients’ signs and symptoms. Available for free on the NHS.

5. Gout. A condition in which patients suffer from recurrent inflammatory arthritis. They have attacks of hot, swollen, painful, red joints; often the joint at the base of the big toe, but other joints can also be affected. It is caused by elevated uric acid levels in the blood, which crystallise in joints and cause inflammation. Unfortunately a blood test for uric acid levels is very inaccurate in the diagnosis of gout. High levels are not always associated with a patient suffering from gout, and low levels do not rule out gout. In fact in an acute attack the patient may have low levels as the crystals leave the blood and enter the tissue. A hot, swollen, painful joint needs assessment by a doctor as it may have many possible causes, requiring different tests and treatments. This is available for free on the NHS.

6. Hepatitis B and C. These are viruses which are transmitted through bodily fluids, including blood and sexual contact. They may cause chronic liver disease, which puts patients at risk of cirrhosis and liver cancer. There are vaccines available to help prevent transmission. If you think you are at risk of Hepatitis B or C you need a comprehensive assessment, taking into consideration risk factors, travel and sexual history, signs and symptoms. You may need tests for other blood-borne and sexually transmitted infections such as HIV. You may need further liver tests such as an ultrasound. All for free on the NHS.

7. Hypothroidism. This refers to an underactive thyroid gland. It has many causes ranging from iodine deficiency (rare in the Western world), autoimmune diseases, to pituitary disease. Symptoms are often vague and include tiredness, cold intolerance, weight gain, constipation and depression. These symptoms also have many other possible causes. If you think you may have hypothyroidism you need to see your doctor so that they can consider other possible explanations for your symptoms, and arrange the appropriate tests. For free on the NHS.

8. Iron, Vitamin B12 and Folic acid. These are all substances needed for many functions, but specifically as part of the process producing red blood cells that carry oxygen to the tissues. If they are low you may become anaemic. There are many reasons why your iron, B12 or folic acid level may be low, ranging from dietary deficiencies, to stomach and bowel diseases, so you need to be seen by your doctor to evaluate what the most likely cause is in your case, and they can then suggest relevant further tests. For free on the NHS.

9. Menopause. This is a normal stage in the reproductive life of a woman, when menstruation stops. During the transition some women experience symptoms for which they seek help, such as hot flushes, sleep disturbance, vaginal and urinary symptoms. There is no definitive test for the menopause, although changes in hormone levels may be detectable. There is no reason to check hormone levels in most cases. If you are having distressing symptoms your GP would want to see you to talk and support you through them. For free on the NHS.

10. Stomach ulcer. A stomach ulcer (which can actually be in the stomach or first part of the small bowel, the duodenum) may lead to abdominal pain, nausea, bloating and blood in the vomit. It has a number of causes, but by far the most common is infection with Helicobacter pylori. A small minority are caused by gastric cancer. If you have symptoms you need to see your GP to assess you and consider whether a blood test (for H pylori serology) will be helpful, whether you would benefit from a trial of treatment, or whether you should have further tests such as an endoscopy. All this is available for free on the NHS.

11. Syphilis. This is a sexually transmitted infection caused by a spirochete, Treponema pallidum. The initial stage of infection stage presents with a single “chancre” a firm, painless, non-itchy skin ulceration. Syphilis is very easily cured with antibiotics. If left untreated it can eventually spread to other areas of the body, including the central nervous system, and cause serious illness. If you think you are at risk of having contracted syphilis you need to be tested for other sexually transmitted diseases and need to be seen at a GU Medicine or Sexual Health clinic. For free on the NHS.

12. Vitamin D. Humans get this from diet and from synthesis in the skin in response to sun exposure. Severe deficiency leads to rickets, a childhood bone disease (almost unheard of now in the Western world) or osteomalacia in adults. Your doctor may test your Vitamin D levels if you have certain bone diseases (for free, on the NHS). There has been recent interest in Vitamin D and its role in multiple health problems including cardiovascular disease, asthma, MS and neurodegenerative diseases. There is a lack of evidence to support Vitamin D supplements unless a patient is severely deficient (uncommon in those with a normal diet who occasionally see the sun), therefore there is little value in testing.