Right folks, no sitting on the sidelines. Your healthcare is far too important. When I shout in social media about the damage being done to the NHS by this current UK government, I sometimes get the impression that some of you out there either think this is all a fuss over nothing, or is about self-interest on the part of the medical profession. Jezza is RELYING on you thinking that - he's spent considerable time on media manipulation and spin, and is currently being opportunist in times of austerity, to help consolidate that impression.
Don't let government grind down those trying to secure the welfare of you and your nearest and dearest. The NHS is a superb healthcare provider (as judged by independent assessors) but this Tory government would much rather use ill health to line the pockets of private healthcare companies at the expense of those who can't afford private healthcare, and with cavalier disregard for uniform quality of care. Public sector healthcare professionals are those who stand in their way and therefore must be vilified (to undermine public confidence in them) and demoralised so that they move abroad or out of the public sector. It's hard to think of one group of healthcare individuals or NHS providers which has escaped a campaign of negative propaganda.
As is my usual habit, I'll illustrate my point with a tune. Forgive my mixing of metaphors but this one's doing the rounds, and deserves to become viral:
So... since posting earlier today, the youtube account which uploaded the above video has been terminated.... which has forced me to send you to a site I don't usually insert links to, but needs must so:
"Science is temporary, changeable, constantly revising itself, like a transient fad."
Is that your impression?
This summer I finally got around to reading Ben Goldacre's Bad Science. It's been out since 2008 but, since I figured I'd already come across plenty of bad science from the late 1980's onward (and before, but I likely didn't recognise it prior to that), it didn't seem a priority read for me. It should have been, not least because then I would have been strongly recommending it for the last 6 years to all my friends whose field of study was in the arts rather than in science. You know who you are... get it and read it!
It's accessible, funny and useful, and focuses particularly on health sciences. It tackles head on many misconceptions about science, and particularly its often woeful handling in the media (which reinforces general misconceptions) - alongside ruthless exposure of things masquerading as science such as homeopathy and 'nutritionism.' It equips anyone to understand the basics of the scientific approach to gaining reliable knowledge, and demolishes the notion that it can only be understood by a select few boffins with big foreheads, white coats and big egos. Particularly, it squashes the media-fostered impression that scientific findings are merely pronouncements of the opinions of experts (with one expert opinion as valid as another, instead of identifying the charlatans). Goldacre points out that, while science can be 'temporary' or 'changing' as it pushes at the limits of knowledge, "Archimedes has been right about why things float for a couple of millennia... and Newtonian physics will probably be right about the behaviour of snooker balls forever." Yet, perhaps because of how the cutting edges get reported, the notion of changeability permeates (in the imagination of many) back to the core findings. The book has a particular focus on medical science and should increase your ability to separate dangerous fiction/fantasy on health issues from fact. If you haven't read the book, do so - seriously.
Contrary to the opinion of some (especially those readily embracing post-modernism), science can't be arrogant - any more than your lawnmower is - it's a tool. The irony is that the scientific method functions by actively seeking to prove its findings wrong. Sure, scientists can be arrogant (you might call some tools too but that's in a different sense entirely), and so can professional gardeners, and sportsmen, but most of us can tell whether someone's done a botched job with the lawn, or the penalty kick... if we actually look... Most of us can also recognise it's not a good idea to bring the mower indoors to hoover the carpet. So it is with science. Goldacre provides plenty of examples - some humorous, some tragic - but crucially he does not leave the reader with just a list of anecdotes; rather he gives those not versed in science a few simple tools to allow them to assess claims and recognise quackery for themselves.
Time for a musical interlude (click the arrow)
Trust yourself_New Pony
I trust myself reading scientific claims, and I trusted myself reading Ben Goldacre's book too. I don't accept everything he says (of which more later) but he says so much so well that you really should read it too, if you're as slow off the mark as I've been.
A land of wolves and thieves.
One of his first targets is 'Dr' Gillian McKeith (more recently infamous from her appalling appearances on TV show I'm A Celebrity, Get Me Out Of Here), who styled herself as a scientific authority on nutrition, posing amongst scientific props, and making pronouncements which schoolkids should recognise from biology lessons as being ridiculous. Just one example is her claim that we should eat spinach and darker leaved plants because "they really oxygenate your blood" as they contain more chlorophyll. Goldacre is pretty direct in pointing out the nonsense:
"Is chlorophyll high in oxygen? No. It helps to make oxygen. In sunlight. And it's pretty dark in your bowels. [Ed - maybe Dr McKeith has never heard the phrase 'stick it where the sun don't shine.'] In fact if there's any light in there at all then something's gone badly wrong. So any chlorophyll you eat will not create oxygen, and even if it did, even if Dr Gillian McKeith PhD stuck a searchlight right up your bum to prove her point, and your salad began photosynthesising, even if she insufflated your guts with carbon dioxide through a tube to give the chloroplasts something to work with [ie as fuel for photosynthesis of which oxygen is a byproduct] and by some miracle you really did start to produce oxygen in there, you still wouldn't absorb a significant amount of it through your bowel, because your bowel is adapted to absorb food, while your lungs are optimised to absorb oxygen. You do not have gills in your bowels..."
He then goes on to disclose the nature of her PhD. It's from a non-accredited correspondence course college, which sells its own range of vitamin pills through its website, although her management website had incorrectly stated it was from the American College of Nutrition - she claims this was a mistake which was someone else's fault although one of her books carried the same 'mistake'. Goldacre also highlights that she has fallen foul of the Advertising Standards Authority, and has been obliged to cease referring to herself as 'doctor' in her promotional material.
He also targets the widespread marketing of all sorts of medications on the basis of misleading data, including fish oils to improve children's academic performance, and herbal medicines to treat whole range of false 'diseases', sometimes whilst denying access to proper evidence-based medicines for diseases which are very real, including HIV/AIDS - as occurred scandalously in South Africa- or the case of MMR vaccine in the UK. He points out that Christian groups seeking to help have sometimes got in the way of effective programmes to reduce the spread of disease. But he does this whilst being sensitive toward the "Christian value system."
The sins of the Pharmaceutical Industry, in hiding or misrepresenting scientific data for commercial benefit, are also tackled, but he's merciless in pointing out the even graver abominations of the Homeopathists. The claims of the latter, advocating dilutions of poison for health benefit, are examined closely - as is the nonsense of water having a (selective) memory.
Goldacre points out potential problems with patient advocacy groups, or pressure groups, seeking funding of drugs of questionable benefit, and the harm this can do to society as a whole in the context of a finite healthcare budget. It can undermine appropriate priority-setting (as of course can politicians rushing to put out fires lit on various TV and radio shows, creating other catastrophes or inequalities in the process).
In my view, some of the most valuable content in the book is the exposure of just how badly the media handle scientific subjects, and how this reinforces widespread societal notions that science is impenetrable to all but a few boffins. As he puts it:
"Science is portrayed as groundless, incomprehensible didactic truth statements from scientists, who themselves are socially powerful, arbitrary, unelected authority figures. They are detached from reality; they do work that is either wacky or dangerous, but either way, everything in science is tenuous, contradictory, probably going to change soon and, most ridiculously, 'hard to understand'. Having created this parody, the commentariat then attack it, as if they were genuinely critiquing what science is all about. [Ed - sounds like Richard Dawkins' approach to Christian faith]
Science stories generally fall into one of three categories: the wacky stories, the 'breakthrough' stories, and the 'scare' stories. Each undermines and distorts science in its own idiosyncratic way."
If the above is your impression of science, you need to read this book. (Did I say that before?)
It seems that viewing figures/circulation are the altar on which proper coverage is sacrificed. Sometimes promotional activity is thinly disguised as news; sometimes the most unscientific matters are presented as if scientific (eg a finding that Jessica Alba has the perfect 'wiggle'). Personally I find it really frustrating how frequently the media report "breakthroughs" which are nothing of the sort, or at the very least have still to complete the peer review process which is crucial to determining whether something is actually significant progress.
This week they were at it again, misrepresenting scientific work on black holes, and again creating the impression that this was all just a matter of 'boffins' arguing/speculating and no way of the rest of us knowing (or caring) what the facts actually are. Science got it wrong again, and all that. Who knows what to believe of what these guys/gals tell us. You crazy science guys...
The article confuses speculative hypothesis-building (albeit using maths) and feasibility testing with areas of widely established scientific fact (like the existence of black holes, and the 'Big Bang').
Equally frustrating is the superficial attempt to achieve "balance" in reports, where the balance is just a matter of finding two experts with differing opinions, even if one is a complete maverick, or totally lacking in credibility in the discipline. Goldacre goes as far as leaving blame at the door of the media for the harm to children as a result of what he terms "The Media's MMR Hoax." Stories around mercury in your fillings also grab his attention.
In a chapter entitled "Why Clever People Believe Stupid Things" Goldacre shows well the reasons why we should beware of making assessments based just on intuition, when more robust and reliable methods are available to determine what is or is not the case. Let's use them when they're suitable to the task in hand.
OK - there are a few instances where he doesn't live up to the standard he sets for others - like lumping creationism in with Creation, and potentially forcing a false dichotomy between a belief in Creation, and scientific revelation. In Chapter 5, he throws in a rather lazy "just as the Big Bang Theory is far more interesting than the creation story in Genesis..." This is so vague as to be worthy of the same kind of (appropriate) criticism he dishes out to journalists and cosmetics or homeopathy peddlers. 'Far more interesting' in what sense? As (part) mechanism of the early universe and its subsequent development, sure. As study of the mythology of ancient cultures? No. As having something pastoral to offer people under oppression (as were the first hearers of Genesis)? No. As impacting on the existence or otherwise of God or gods? No. As providing an understanding of the development of JudeoChristian thought (whether you espouse that theology or not)? No. In fairness, he doesn't indulge in a parody of religious belief which is then up for critique, but he might be better either avoiding the subject or handling it better than your average Daily Mail journalist handles science.
Interestingly, Goldacre gives a favourable description of an external reference for ethics - the Declaration of Helsinki. He refers to it as "the international ethics bible." Of course, ethics is a tricky matter to subject to 'empirical testing' in the usual scientific sense. So scientists tend to go with what a bunch of us thinks best. Let's call it conscience. Not scientific at all, but highly necessary.
Perhaps difficulties accessing science is not all the fault of the media. Maybe scientists could be a bit more imaginative and creative in writing and communicating. Maybe they/we could reference the world of literature or the arts, if the journal editors/peer reviewers will allow them/us. The first two references (of over 300) in my own MD research thesis from 1995 are to ancient literary texts*, but arguably you have more latitude with a thesis for a higher degree than with scientific journals. However, it's recently come to light that a bunch of Swedes have taken the concept of literary reference to a whole new level...
Of course, looking at the affiliation of the senior author (Weitzberg), it's no surprise to me to find such a great contribution coming from an intensivist ;-). We intensivists are frequently engaged in blowing in the wind with mechanical ventilators. Usually it's oxygen-enriched air that's delivered, but occasionally we supplement high levels of oxygen with inhaled Nitric Oxide, as I did recently to a patient with critical oxygenation. (I didn't think of adding spinach to the patient's tube feeding regimen).
It is a significant feat, tho, to get Dylan into Nature... after all, Dylan himself did write in one of his songs "Nature neither honors nor forgives"...
A report from Gawker suggests that the concept is getting competitive:
There's also Professor Kenneth Chien's 1998 publication in Circulation, entitled "Tangled Up in Blue: Molecular Cardiology in the Postmolecular Era." And in 2010 Weitzberg followed up his earlier publication with The Biological Role of Nitrate and Nitrite: the times they are a-changin' in the Journal Nitric Oxide, and in 2011 Dietary Nitrate - A Slow Train Coming.
As journals are increasingly electronic, who'll be the first to get an audio track piggybacked on their paper?
I think Ben Goldacre would approve of a couple of Dylan quotes of my own.
"You got unrighteous doctors dealing drugs that'll never cure your ills
When you gonna wake up?..."
It's not individual scientists that we should be trusting, it's the scientific method which ultimately keeps them honest, or exposes them as wrong. And the method is transparent to all, not just the scientific community. The second quote is from Dylan's song on the Golden Rule:
"Don't put my faith in nobody, not even a scientist."
I guess we could add a line to the Word of Bob...
"no red-top journalist, and no way a homeopathist."
Tom Waits has a fitting tune which we could dedicate to those who continue to exploit others with homeopathy in the face of evidence that it doesn't work.
"A rat always knows when he's in with weasels...
They all have ways to make you pay."
*Leviticus 17 v 11 & Deuteronomy 12 v 23.
The opinions which follow are my own, and are not representative of any organisation.
Any system can be improved, and I agree with some of the comment on A&E targets but, apart from that, wot a load of tosh this report is. Does anyone else who works in the NHS recognise the description (check the link) as even remotely close to getting to the real issues? Let's take key points.
1. "The NHS "became too powerful to criticise." Where exactly does that power reside? Who/what wields power wrt the NHS? Politicians & journalists, I would suggest. The former spend their lives in fear of being doorstepped by journalists who conveniently only tackle one media-selling issue at a time, with the luxury of never having to be accountable for juggling competing and relative priorities. Besides that, in answer to the quote above, there has been no shortage of criticism.
2. "If you criticised the NHS the attitude was 'How dare you?'" Whose attitude? It really credible that this has been a significant obstacle to quality assurance? I suggest that the obstacles have been elsewhere.
3. I'm all for making access as easy as is affordable to the public purse, but really… the Sainsbury's/Tesco argument being trotted out again??!! This is supposed to be a quality-assured service, not a business competing for sales of microwave dinners or smoked salmon. People's lives, and the quality of those lives, are at stake. In any case, if Tesco goes belly-up tomorrow, another will rise to take its place. What will replace a system free to all at the point of need?
4. "Working people need to be able to see their GP in the evening or at the weekend." I have some sympathy with this, but why are "working people" generally not working in the evenings or weekends? Could it be because (i) generally it costs more to employ them to work weekends or evenings and/or (ii) the services they provide are considered non-essential in the evenings or weekends? Last time I checked Drs & nurses are working people too. Many of us already work evenings and weekends for essential acute/emergency care, and have been doing so for decades. (Some of us spent a substantial period of our career working those unsocial hours for 1/3 the "office hours" rate. NB NOT time and a third; one third). Should taxpayers' money be used to fund a more costly service for things which aren't sufficiently acute to require consultation or treatment in the evenings or weekends?
5. "A chillingly defensive culture in which even the most 'alpha-male surgeons' felt frightened to speak out for fear of ending their careers." Is Northern Ireland really that different to England in this respect? I don't recognise this scenario at all.
Thirty years ago junior docs were among the lowest paid staff in the hospital for their out-of-hours work, and frequently worked in excess of 100 hours/week. In addition to the hours the NHS was prepared to pay us to work, we put in additional unpaid, unsociable hours to get the job done. That was what many of us understood to be professional behaviour. However, when it became too extreme, and there weren't enough docs employed to cover the work, some sought to be paid (at 1/3 office hours rate) for the extra unsociable extra hours we were expected to work. I recall sitting with 2 colleagues in a meeting with a senior hospital administrator who told us in no uncertain terms that if we didn't drop the subject, we would suffer when it came to references etc and future employment. We were too naive to realise that administrators didn't write or influence junior doc references. Thankfully the process is now less dangerous for patients in terms of junior doc hours, more just and transparent. That was a result of people speaking out. Journalists assisted in that process. Thankfully I have since had (and continue to have) the privilege of working with some outstanding healthcare managers, and have held several managerial roles myself.
As a Consultant, I have worked with quite a few 'alpha-male' surgeons. I have yet to meet one afraid to speak out on issues of quality or safety out of fear of it ending their career. Indeed many who are not alpha-personality, or male gender, speak out. We have had all sorts of ways to make representation both within our healthcare institutions, and beyond them - regionally and nationally. The issue is actually being taken any notice of! Consultant colleagues describe recurring experiences across multiple specialities of being convened in 'expert groups' whose views are only welcome when they conform to the political ideology being pursued. The minutes (when it suits to take them) of such meetings can bear little relation to the views expressed or expert conclusions reached. Such groups tend to be disbanded if they prove to be 'inconvenient.'
Politicians are in the business of wielding power and influence. They have strategies they wish to pursue. Many of these may genuinely be better for society, but it is hard to separate this from the fact that their life-blood as politicians is success at the next election. They have a fixed term in which to appear to have been responsible for improvement. Some of the issues may be highly complex and there is limited time to educate the public on them and implement change - so there is a tendency to oversimplify and 'sell' their proposed solution. Professionals who disagree with their strategy are a real thorn in their side, and particularly when those professionals are held by society (ie the voters) to be credible and trustworthy experts in the territory which politicians wish to change. The public sector is expensive to run, and there is huge pressure to cut costs. I imagine this is an issue in teaching, as well as in healthcare. If the professionals can be discredited, or the service portrayed as needing overhauled, this plays into the hands of those who can then ride in as "white knights." Be aware of who's claiming who is naughty or nice, who stands to benefit, who might be harmed, and who might be being misled.
Be astute, people. There can be great distortion in the media of what constitutes deficient care. There are also shifting goalposts as knowledge increases. And when the spotlight is turned on one thing, be careful about what might be going on in areas left in the dark.
Clinicians aim to practice evidence-based medicine (when the evidence is there), and may be held accountable for deviations from it or for negligence. Yet politicians, and civil servants less accountable to the public, may make decisions and run with ideologically-based strategies which could cause harm to a great many more people, seemingly with impunity. Government has recently proposed making 'wilful neglect' by healthcare staff in the NHS a criminal offence. If suitable standards against which to measure neglect are applied, I'm all in favour BUT it should also be applied to politicians and civil servants who implement strategies without expert advice or, worse still, ignore expert advice.
Do you think these points I'm making are just a demonstration of the "defensiveness" of the NHS? If so, then the argument isn't that the NHS is defensive, as is alleged, rather it's that health care workers like me who are working within it are being defensive. Well does that actually hold water? I've already alluded to the fact that nurses, doctors, physios, pharmacists, often criticise the service from within, and professional bodies regularly produce new and better clinical standards at which to aim, as knowledge increases - which includes ability to measure in ways not feasible in the past. So healthcare professionals are not defensive of bad practice or poor standards. It's just that they may not agree with those outside the service on what are the biggest issues.
When are we going to have a grown-up discussion about what the taxpayer can afford in terms of public services? By necessity this involves looking at hard at prioritisation (rather than privatisation) and economies of scale. Are varicose veins sufficiently important that they should delay/displace gall bladder ops, or hip or cardiac surgery. Should enormously expensive and proliferating cancer therapies which prolong life for a few weeks/months at dubious quality be funded at the expense of delaying potentially curative surgery or medicine? Should we have lots of little grocery stores scattered across the country - all very nostalgic, and we know that nice Mr Swinson who serves us our cabbage (and we don't want aubergine, fresh mint, or coriander that often) - or should do we want a service which can cover the full range of what we need, which necessitates concentrating resources in a smaller number of larger institutions. Is there any point having a room labelled "A&E" close by if, when you go there after an accident, it turns out that it doesn't have full X-ray & CT scan facilities to determine whether or not you require emergency surgery; or has no on-site capacity to provide emergency blood transfusion, or does not have surgeons who carry out the emergency procedure you might need, and who do it sufficiently often to be competent at it.
"You'd better watch out, you'd better not cry
You'd better not pout, I'm telling you why..."
The NHS is potentially a bottomless pit. Santa Claus might be coming to town in the next 48 hours but the elves don't do interventional radiology, provide full trauma services, full diagnostic work-ups and modern interventions for acute coronary syndromes. And Santa's sleigh isn't big enough to bring them all down every chimney anyway. It's a finite public purse, people. This is a more useful analogy with Tesco/Sainsbury, or indeed Harrods, than the ridiculous one still being advanced by those who delude themselves and others that competition is the best way to run public service.
Does being able to visit the GP when it's a bit more convenient justify what it will do to the need for recruitment of more GPs (or else reduce their availability at other times)? Are they going to ask them to work more hours? Government direction has been to reduce the hours consultants work - many of us have had the experience of being asked to reduce the hours in our job plans. The word on the street is that Government wants changes to contracts which will increase the cover and yet be 'cost neutral.' How does that work?
In 2003, government decided that it wanted a new contract for hospital consultants (implemented 2004). There were many assumptions that consultants were not working hard enough, and that a new contract would be more transparent, and they'd be more accountable. Sure, there were a very small minority who were double-jobbing (doing private work during NHS sessions) or 'consulting' on a boat or golf course somewhere, but the vast majority of consultants were working way beyond (old) contract. It was a concept known as professional behaviour. The bottom line is that more work was being done than government would believe. (They were told). Imaginary stereotypes were too firmly rooted. Since the new contract, consultants' work has been much more closely monitored and work directly related through job planning to pay. So when hospitals planned their work, they ended up needing more planned sessions than government anticipated. Government then complained that they didn't see an increase in productivity associated with the increased cost of the new contract. This of course comes as no surprise to the medical profession who tried to tell ministers that they were previously working beyond contract. Even National Audit Office conclusions have failed to take this into account:
"NHS consultants play a key role in the NHS. Given the size of the pay increase given to consultants under the 2003 contract, it is reasonable to expect Trusts to have made more progress in improving how consultants are managed and realizing the expected benefits of the contract."
"Trusts need to get consultants strongly involved in achieving the trusts' objectives as well as their own clinical goals."
Amyas Morse, head of the National Audit Office, 6 February 2013.
However, the statement above does (inadvertently?) highlight the rub - clinical priorities may be something quite different to "Trust objectives." The two can be in conflict. This is not necessarily the fault of the senior managers of Trusts - they are essentially employed now to deliver the goals set by Ministers/Government Department of Health. And, as I've said, the latter are often at the mercy of political expediency or journalistic distortion.
If a public system is working but underfunded (and ministers either couldn't or wouldn't believe that it was the case), then fixing that underfunding should not be expected to produce an increase in activity (particularly when acute bed numbers are being cut, and working practices and priorities interfered with).
There has been much talk recently of the lack of senior medical input at night in some areas of medicine, and various strategies rolled out including 'Hospital at Night." I do recall, as a junior doc, feeling huge responsibility for keeping my consultants' patients alive through the night. No-one thought it was feasible for consultants to be resident and working hard throughout the night and do a full operating list or busy clinics the next day. I mean, they were old.... Guess what, that's still not a runner, although the current government has suggested that it wants consultants present and working overnight and has announced its changes to pension plans so that they're going to be even older when they're doing it... The latest delusion circulating is that they should be able to do this with no increase in cost - and this is supposed to deliver enhanced patient safety??!! But then politicians have also advanced the notion that, whilst formal consent is required for operations on individual patients when the surgery may benefit them, and for retention of organs or tissues for educational or other legitimate purposes, it may be fair enough merely to presume consent that their organs can be taken when they die, for the benefit of others.
Just like junior docs didn't (and hopefully still don't) want their patients to fall apart overnight, I have no doubt that UK society doesn't want its public healthcare system to fall apart - nor should it be pulled apart or left to the (absent) mercy of market forces or have its priorities distorted by 'financial incentives.' Don't let Government pull apart your NHS, or allow it to fall apart.
"I wish I’d have been a doctor
Maybe I’d have saved some life that had been lost
Maybe I’d have done some good in the world
’Stead of burning every bridge I crossed."
Don't fall apart on me tonight..."
[for illustrative purposes - no copyright infringement intended - unreleased version sourced from here]