THINKING ALLOWED - CONVERSATION WITH A CHESTCRACKER

WHAT AN UTTERLY HORRIBLE MESS !

2016-02-11T18:49:00.000+00:00

Today I am depressed and sad & I write this with a very heavy heart
I have resisted the urge to write or do anything about the Junior doctors' dispute apart from showing my support for the juniors in our department.
But after today's developments, I just cannot hold back any further.
The poor Syrian people and junior doctors in England have alot in common - let down by everyone around them,
a health secretary who is obsessed with a single issue and who seems to have lost the plot completely,
a trade union that since the days of Tony Blair has tried to convince everyone that the NHS is about to be sold off to big bad American Corporations and that this dispute is about privatisation and saving the NHS,
a trade union that has continued to argue for huge increases in the number of doctors paid at a premium rate at a time when the the country is indebted to the hilt
by Health Education England and their predecessors for not developing the role of Physicians/Surgeons Assistants or whatever they're called nowadays, as a separate profession for school leavers (rather than raiding depleted stock of nurses and other healthcare workers).
By educationalists and royal colleges who insisted on removal of the apprenticeship model and developing and formalising training for junior doctors ( a good thing in itself) without insisting on a decrease in the huge amount of service they were still providing -
by senior healthcare managers and public health doctors who continue to argue for fewer hospital beds and seem to missed the fact that the population is ageing fast and that these elderly people require both increased social and healthcare services resulting in a unbearable burden that seems to fallen on, amongst others the shoulders of junior doctors,

and I could go on and on.
Something had to give and I fear we are all about to pay a very high price.

PS I gave a talk to 6th formers last week and the ones who plan to do medicine are applying to Scottish and Welsh medical schools because of the doctors' dispute.

I was speaking with junior German doctors last night and their jaws dropped when I told them that the UK government wanted to classify Saturday as a normal working day for doctors in training in England.

Identifying Opportunities for Quality Improvement thru Mortality and Morbidity Review.

2016-02-09T18:00:00.000+00:00

The Problem with Incident reporting in HealthCare

2016-01-19T17:30:00.000+00:00

Breaking the Enigma Code

2015-12-16T13:33:00.000+00:00

Nice Animation telling the sad story of bravery which led to shortening of World War 2.

Hilarious Reactions to Virtual Reality

2015-11-13T17:00:00.000+00:00

2016 will be VR year - Facebook (Oculus), Samsung, Sony and HTC will all releasing VR sets and scenes like these will I suspect become common place.
But for now let us enjoy watching fellow human beings look silly - next year it will probably be you! On the serious side, these devices could prove invaluable in simulated training of manual tasks such as surgery, which is why I am very interested in their development.

Two reasons why Publication of Surgeon Specific Mortality Data is Anachronistic and just anti-NHS

2015-10-29T17:19:00.000+00:00

Since writing the post on the latest edition of the Bulletin of the Royal College of Surgeons of England, I have thought, pondered and cogitated on the subject of publication of surgeon specific mortality data (SSMD) - the theme of the above mentioned edition. (containing 2 articles which all surgeons must read, here and here). And the more I cogitate the more I realize that publication of SSMD is not 'modern' or essential as Professor Bridgewater suggests but flies contrary to the way the NHS and healthcare generally is developing. All healthcare is a team sport, and this includes Surgery . The days of conspicuous individualism, the Sir Lancelot Spratt era are thankfully long gone. Ironically, proponents of publication of SSMD will argue that one of the functions of such publication is to deter 'have a go' surgeons. It certainly is achieving that in spades in cardiac surgery where an increasingly large number of surgeons are 'not having a go' (even though they should be !) A phenomenon, increasingly occurring because of the need to adhere to waiting time targets is for patients to be seen and listed by one surgeon and to be operated on by another. So, which surgeon's SSMD should the patient look up before coming into hospital ?
This relatively recent change is emphasised in the consent form which patients are asked to sign and which contains the statement that 'The NHS Trust cannot guarantee the surgeon who will operate on you'.
In this age of Multi-Disciplinary Team Working where the decision to operate is taken by groups of individuals, publication of surgeon specific outcomes is just SO yesterday.
Patients want to and are entitled to know what the chances of a successful outcome after their surgery are. Publication of SSMDs is just NOT the way to do it.

The Stick and Bigger Stick Approach to Health Outcomes Publication

2015-04-11T19:55:00.000+01:00

The Bulletin of the Annals of the Royal College of England (RCSEng)is this month dedicated to the thorny issue of surgical outcomes reporting. The editorial team should be commended for publishing 2 very opposing views of the reporting of surgeon specific mortality data.
The first account is by 2 senior cardiac surgeons and a senior interventional cardiologist. It takes the contra view that as surgery is a team sport, whose outcomes depend on facilities of the organisation, it is fundamentally unfair to load all outcomes on the one person. This argument is backed up by several studies showing that mortality after surgery is more often related to a failure to rescue (FTR) rather than surgical ability. This ability to rescue is a strong reflection of the quality of a health organisation. They also argue that it is the natural human response for surgeons to become risk averse if their personal published mortality rises. These are very potent and well rehearsed arguments against the reporting of outcomes for individual surgeons as opposed to those of institutions. They also make the additional point that in the USA and in many countries in Europe, there is a tasty carrot or positive incentive to publicise outcomes - more referrals. In a centrally planned NHS, this is clearly not the case.
An additional point that I would make relates to the findings of a study presented recently at the annual combined meeting of the Society of Cardiothoracic Surgery (SCTS) and Association of Cardiothoracic Anaesthesia (ACTA). This study from Wales suggests that most patients waiting for heart surgery still do not make an effort to look up the outcomes of their surgeons. Ironically, because of pooling of waiting lists, many patients do not know who is operating on them until the night before. Consent forms used in the NHS state that there is no guarantee who the operating surgeon will be.
The points raised by this piece are very strong and evidence based. It is a shame that the authors let themselves down by suggesting that facilities in NHS institutions were poor, which they're not and by also suggesting that surgeon reporting was dissuading junior doctors from joining the speciality,a statement which again is not evidence based - as Professor Bridgewater suggests in his subsequent piece, entry to CT surgery training remains very competitive.
The second article is written by Professor Ben Bridgewater, a cardiac surgeon from Manchester who with Professor Sir Bruce Keogh (current NHS medical director) was responsible for the current system of outcome reporting we have today in cardiac surgery. He now works for HQIP, as the head of Consultant Outcomes Programme. Professor Bridgewater makes the usual arguments that in modern healthcare, it is impossible to argue that patients are not entitled to know the outcomes of the clinicians they are being treated by. He also reminds us that reporting of outcomes of individual doctors is now part of the constitution of NHS England. He claims, as he has done on previous occasions, that outcome reporting of surgeons' outcomes has led to an improvement in the results of heart operations in the UK resulting in British heart surgeons having the best outcomes in the world. I have always felt that the claim that reporting of SSMD (Surgeon Specific Mortality Data) improves outcomes is disingenuous - cardiac surgery outcomes have, ever since the first heart operation was performed, been improving in the UK and elsewhere where SSMD are not reported. The same applies for other branches of surgery whose SSMD are not reported.
As a consultant cardiac surgeon of 17 years and a strong advocate of patient involvement in their healthcare, I understand and empathise with points made in both articles. Publication of SSMD is here to stay. Crucial and avoidable mistakes have clearly been made in the anarchic way the SSMD publication programme has been rolled out, especially in my specialty. I know this having lived through the whole sorry saga over the past 15 years. I hope that these mistakes are not repeated in other specialties because at the end of the day what surgery in general does not need are unhappy disenfranchised surgeons and patients being denied treatment.

Chestcracker's Dictum #1 Everyone takes a hit!

2015-03-25T17:30:00.000+00:00

Heart surgery used to be a high stakes game for the patient.

It is now a high stakes game for the patient, the commissioner and the surgeon.

Long Live Equity.

The Human Cost of Scrutiny?

2015-03-24T17:30:00.000+00:00

This story appears in the health section of BBC news online today.
The BBC are wee bit late onto this story. There was an excellent article on the subject of the mental health of NHS staff published 2 weeks ago in the Lancet.
The ever excellent and compassionate Claire Gerada makes some very important points on the need to look after NHS staff.
Maybe noone should be surprised at the findings of these surveys.

Life used to be like this - you are a nurse/doctor. You therefore must be compassionate. You have been trained well. Because of who you are you must be going your best - end of story.

It certainly is not like that anymore.

How to deal with immigration from the EU - make everyone pay - a lesson from the General Medical Council.

2015-03-23T17:38:00.000+00:00

In 2008, a locum GP doctor injected David Gray, a patient with typical excruciatingly painful kidney stones, with a fatal (10 times normal) dose of morphine. This act was not intentional but a tragic mistake and it occurred because the doctor who was a German national and whose command of the English language was not good, for want of a better description, screwed up - badly.

This sad story highlighted an anomalous and fatal effect of free movement of workers within the European union - a sacred immutable right in the eyes of Angela Merkel and Brusselocrats. Ever since the inception of the National Health service in 1948 and quite possibly before then, foreign doctors working in England have come predominantly from the Indian subcontinent, part of the post war mass immigration of anglophonic ex colonial subjects. Prior to being registered all these doctors had to take and pass the PLAB exam, an assessment of linguistic skills.
When the internal market within the European Union was liberated in the 1990s and free movement of goods and peoples became a possibility, the number of European doctors coming to work in the UK began to increase. The first were the Dutch, all of whom can speak impeccable English. Then came the Germans, most of whom can also speak good English. This account of the sequence of nationalities who migrated to the UK is based on personal memory rather than an forensic examination of Home Office migration records (which probably don't exist or have gone missing) or of NHS human resources records (which also probably etc etc..). In 2008, after the onset of the worst recession affecting Europe, the numbers of doctors coming from southern Europe started to rise sharply. By the end of last year, the number of doctors coming to England for work from non English speaking Southern European countries outnumbered those coming from English speaking (and educated) India and Pakistan. I found this fact, when reported in the media, to be quite extraordinary. But after a moment's thought, and recollection of the effects of the recent recession, the rights of EU citizens and changes to immigration brought in by the current government, then maybe such a fact should not surpise anyone.
The problem with this change is that most of the doctors in the EU do not have the command of the English language that previous medical immigrants did. Initial plans to apply a test of English to European doctors (modified PLAB) before gaining access to the medical register, was deemed as being contrary to the free movement of EU citizens - irrespective of the fact that in this case failure to understand and speak the language could prove fatal.
The General Medical Council to their credit (although I suspect they may have been nudged by the government in this matter) have come up with a cunning plan. If EU law says that incoming Europeans cannot be treated any differently to British citizens or graduates of British medical schools, then test everyone, Brits, EU and non EU doctors - genius!
So now after slogging through 5 years of medical school, racking up a enormous debt and enduring endless assessments and exams, British graduates ( and all those who apply to go onto the medical register) will have to complete and pass a National Licensing Exam.
Genius - maybe
Unfair - probably
Template for management of welfare applicants - unlikely.

Anyway, post 2017 when Britain votes with its feet and says au revoir/arriverderci/Auf Weidersehen etc etc, it may all end up as being redundant and unnecessary.

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Why Healthcare Insurance to pay for NHS services is probably closer than you think!

2015-01-17T18:00:00.000+00:00

Recently, this story featured quite prominently in the UK newsmedia. The response from NHS devotees on social media and blogs was muted. Its significance, in my humble opinion may have escaped obsessees of the UK or English NHS. This is why I think so.
I sit on the cardiac surgery CRG or Clinical reference group.
Please let me explain before you surf away or fall into a deep slumber!!

In England, there is one healthcare service, the National Health Service or NHS . It is exclusively funded through general taxation, universally available and free at the point of delivery.
Despite its universality, the service has a provider/purchaser split, introduced in the 1980s by the Conservative Government of Margaret Thatcher and accepted by governments of all shades since.
Within this bifid service, healthcare is purchased by commissioners. Common types of treatments are purchased locally by Clinical Commissioning Groups or CCGs. Rarer or specialised types of treatment, so called specialist services are commIssioned directly by the centre or NHS England. Healthcare is provided by (you guessed it) healthcare providers. Primary healthcare is provided by General Practitioners (or GPs) and secondary care (which includes specialist services) by NHS Trusts. As a major constituent of CCGs, GPs therfore are paid to buy healthcare from themselves. Incidentally, the organisation and layout of the different commisioning and providing bodies undergoes expensive (and usually pointless) changes every few years (or election cycle), so by the time you get to grips with one system. it all changes again. It reminds me so much of this example of TV gold!

NHS England gets clinical advice on the commissioning of specialist services through bodies called Clinical Reference Groups or CRGs (phew - got there in the end!) There are 72 of these bodies at the last count. Each of these groups has a chairman, and a representative from each Senate Area (I won't go there but a senate area is essentially a geographical area of England and there are 12 of them).
As a heart surgeon in Sheffield, England, I represent the Yorkshire and Humber senate area on the Cardiac Surgery CRG.
When I first joined, I felt that this group of clinicians (and patient representatives) could either a) have a real meaningful influence on how cardiac surgical services develop in England OR b) form part of a cosmetic exercise to justify 'greater clinician involvement', as promised by Andrew Lansley - author of the most recent and most pointless of NHS re-organisations. After 2 and bit years I still am not sure whether a) or b) prevails.

Anyway, as a member of this grouping, I do receive and see a lot of NHS England email traffic and communications relating to specialist services. I am not privy to the secret stuff (so don't bother asking) but one does read between the lines.
There are two unalienable truths in the NHS today, whatever the colour of the leather of the secretary of state's chair.
1. - the NHS is in a financial pickle
2. - Specialist services (see above) cost far too much for the relative number of patients who require them and what they contribute to national or global health. They are a constant headache for those who need to plan the future of the English health service AND balance the books.
Funding of specialist services reminds me of what Kenneth Williams (the granddaddy of British camp comic geniuses) once said (with that very famous nasal drawl of his) on a TV chat show "doctors today are all specialists. They know more and more on less and less. Soon they will know everything on nothing" Apart from the fact that what he said is so true and that rampant specialisation is now seen as inappropriate in a world of ageing (holistically speaking) patients, the allusion to diminishing returns applies to the funding of specialist services as well - paying more and more to acheive less and less.
The deigned future of the NHS is primary care, social care and mental health making specialist care increasingly irrelevant (relatively speaking) and this is where this story comes in.
NHS England has stated that once the numbers of allocated specialist service procedures are completed, the funding will stop. It is grabbing the bull by the horns and will stunt the growth of this troublesome child with partial asphyxiation. The ivoried towers of excellence who provide these services are up in arms.
There is a problem with this approach and it is this -
Although an ageing population does need increased primary and social care, it also needs increased specialist services as well. The "ageing population" affects all of us. Take my specialty, cardiac intervention/surgery, for example - cardiac surgeons and interventional cardiologists are now operating on an exponentially rising number of elderly patients. New catheter based devices, which will make cardiac intervention possible in even older patients are coming on stream. They are hellishly expensive. Interventional Cardiology is one of 72 specialist services and yet consumes a mind boggling 15% of the specialist service budget.
By making this statement, NHS England has alerted us to the fact that they are not prepared to fund the increase in demand for these services. Rationing in this area has already started - just ask the cardiologists in Britain 4th largest city!
Concentrating these services in fewer and fewer centres to acheive economies of scale will only go so far to rectify the situation
There are only 2 ways this circle could be squared - additional funding through top up health care insurance (none of the political parties are suggesting an earth moving rise in tax dollars for the NHS - so far at least) or the acceptance of lengthening waiting lists. Since the conditions requiring many of these services have a poor prognosis long waiting lists will I am sure be accompanied by the sound of patients dropping like flies - surely politically if not ethically, socially or philosophically unpalatable.
The answer to all these questions and more will be answered after May 7th, 2015.

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The Challenge of Treatment of Patients with Aortic Stenosis in the NHS

2014-12-27T20:47:00.001+00:00

This paper from the United States is extraordinary because it deals with mortality on waiting lights in patients with aortic stenosis.

Waiting time is not usually associated with practice in the USA and the median times in this paper was an extraordinarily low three weeks. Deaths on waiting lists for the treatMent of aortic stenosis has always been a significant issue in the UK.
The conclusion of the paper was that treatment for aortic stenosis whether the surgical aortic valve replacement or the trans catheter TAVI should always be classed as emergency rather than elective.
The incidence of aortic stenosis is increasing rapidly with the ageing population. In a recent echocardiogr aphic study, 10 percent of the over 80s had significant aortic stenosis. Treatment is also very expensive. Managing these patients in a timely fashion will continue to be a challenge to all health care services including in this time of austerity and funding gaps, the English NHS.

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Mind what you wish for!

2014-10-27T17:53:00.000+00:00

Cardiothoracic Surgery in the UK is, as far as the General Medical Council and the Colleges of Surgery are concerned, a single specialty.
Trainees are exposed to both cardiac and thoracic surgery during their 6 to 8 years of training. In their final assessment, the exit exam for the FRCS(CTh) degree, candidates are tested in both. My specialist register entry states that I am an expert in Cardiothoracic Surgery.

In recent years, evidence of better outcomes when certain operations are performed in large numbers in individual units or by individual surgeons, has emerged. It is unsurprising therefore that a debate has arisen whether further specialisation should occur and the two halves of cardiothoracic surgical specialty should be separated.

Appointment of separate cardiac and or thoracic Consultant surgeons has taken place for many years in the UK. The decision whether to include one or other or both of the specialty responsibilities in the job description has been taken by individual hospitals depending on their needs
Over the past few years, job descriptions for posts that required both cardiac and thoracic input have not been approved by the Society for Cardiothoracic Surgery. This sadly has taken place without much debate unlike the situation in the US where the impact on trainees is being debated. This was never considered in the UK. As a consequence, pure thoracic consultant posts have remained unfilled as they have proved unpopular with many British trainees.
To compound matters, the Clinical Reference Group in Thoracic surgery has stated (?suggested) that from 2016, all cardiothoracic surgeons in England must practice only cardiac or thoracic surgery. For the uninitiated, a Clinical Reference Group is the group of clinicians who advise NHS England on commissioning for Specialist Services. There are over 70 specialist areas and a similar number of CRGs.

This suggestion for accelerated reform has angered many of the units where the majority of lung operations are performed by surgeons who perform both cardiac and thoracic. In fact more lung operations in England are performed by cardiothoracic surgeons rather than pure thoracic surgeons. The additional difficulty of organising on call rotas for both specialties has also been ignored. There are not enough doctors around for separate thoracic and cardiac consultants to be on call. Currently, in many units in England, cardiac surgeons who have not carried out any thoracic procedure for years are on call for thoracic emergencies.
The adverse effects of increasing specialisation in medicine and surgery on both training and planning of health services has been recognised. The latest review on training, entitled 'The Shape of Training' as well as speeches by Simon Stephens the new CEO of the English NHS have featured such difficulties and downside of super specialisation.

The pursuit of perfect outcomes is commendable but a full debate with consideration of all possible unintended consequences should not and cannot be avoided.

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UK Falls Behind in Genomic Medicine Race.

2014-10-25T17:15:00.001+01:00

The great Norman Shumway, the true father of heart transplantation, had many witty sayings. One that particularly appealed to me was 'the future of transplantation is xenotransplantation and always will be' reflecting his belief that the interspecies immune hurdles would never be conquered in a clinically meaningful way. The reason this famous Shumwayism appealed to me was the fact that he often visited me in the lab when I was working in the lab at Stanford Universiity in the early 1990s on a xenotransplantation project!

The future of medicine IS genomic medicine - and will become the present long before xenotransplantation ever will. This paper published recently in the JAMA, describes the findings of 2 recent studies and speculates how genomic or more accurately exomic medicine may be used in every day practice in the near future.

Both of these studies come from the U.S. and this should surprise no-one. This contrasts with the protracted and top heavy way genomic medicine is still being organised within the NHS in England as described in this painfully long document published by NHS England - another example if ever we need one of how the UK is falling behind its competitors in the hi tech world of specialist services.

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How An Engineer designed his own insides and saved his own Life - Ultimate Shared Care

2014-10-18T15:48:00.002+01:00

Amazing story. Patient deciding and designing his own treatment is the purest of all shared care decision making.

Patient Centredness, Ethics and Why You can' have them.

2014-10-18T15:41:00.002+01:00

Two articles in a recent issue of the British Medical Journal illustrate different ways hospitals and healthcare institutions can introduce interventions to improve patient outcomes. The need for a response to poor cardiac surgery outcomes in one hospital in the Netherlands proved to be the impetus to radically change the way the institute and its employees deals with patients is described in the first.

In the second, Daniel Sokol, a lawyer and medical ethicist makes a very strong case for all hospitals or healthcare institutions that treat patients to have a clinical ethics board. Both accounts strike a chord with me.
As a cardiac surgeon who was appointed at around the time the Bristol Heart Surgery farrago blew up, the response of this one institution in the Netherlands, contrasts very sharply with the local and national response in the UK. The proposed national reconfiguration of paediatric heart surgery units in England has, after more than 10 years, become mired in a legal cul de sac because many of the units that were told to stop operating on children rightly pointed out that this radical top down response lacked evidence.
The other effect of the Bristol saga was the introduction of the reporting of surgeon specific data. In my opinion, far more patients' lives have been lost than saved as a result of the current risk aversion of many British heart surgeons. In an earlier edition of the BMJ, Mr. Stephen Westaby also gives other very strong valid reasons why in his personal view publication of individual surgeons' results is so wrong. Many patient advocates argue strongly and cogently in favour of publication of surgeon specific outcomes. The process despite taking years to come to fruition was however designed badly with no checks and balances to ensure that care of risk patients would not be prejudiced - which is exactly what has happened.
One reason some (disingenuous) surgeons give, for turning down (usually elderly) patients for a cardiac surgical procedure, is that it is unethical to do so. This takes me nicely to the second article on clinical ethics boards.
I used to be a member of a clinical ethics board and the work we did was indeed very useful and contributed to excellent patient care.
Even if they so wished many surgeons would not be able to consult a clinical ethics board because as Daniel Sokol tells us, most hospitals do not have one. In the modern NHS, whose motto should be Top Down or Bust! , healthcare institutions would not set up such boards unless they are told to do so by NHS England or the regulators - CQC or Monitor- - and as they do not feature in the Bristol, Shipman or Midstaffs stories, NHS England, Simon Stevens or Jeremy Hardy are high unlikely to pronounce on the matter. When every institution has to look up for instructions to do or start absolutely anything it should surprise no one that patient and staff engagement are so poor in the National Health Service. As long as there is this perception that a universally available national health service can only be affordable and safe using this aggressive top down approach paired with local paralysis, nothing is going to change any time soon.

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The Effect of Feminisation of Medical Training

2014-09-27T20:06:00.002+01:00

As honorary senior lecturer at the University of Sheffield, I am often involved in the assessment and examination of medical students.
I was recently attending a refresher course on OSCE (Observed Structured Clinical Examination) assessment of medical undergraduates. This formal instruction for examiners is, we were told, now mandated by the General Medical Council .
The talk together with demonstration videos of how to and how not to carry out a proper valid OSCE assessment was very helpful and informative.
The speaker was a medical education specialist from the medical school. Many of her senior colleagues are also women. It struck me as I listened to her presentation that, in addition to a steep increase in the number of female medical graduates, there has been a gradual feminisation of medical training in the UK. I suppose that this should hold no surprise to anyone as the number of academic medical women involved in designing curricula and assessments has inevitably increased. This, I hasten to add, is no bad thing. On the contrary, it is to be welcomed. Feminisation of undergraduate medical training has led to an increase in patient centredness of what is expected from modern doctors (what old timers used to call the touchy feely bits!) - a quality hitherto lacking in medical training.
Whether this approach to medical training occurs in all of the countries of origin of the large numbers of foreign graduates who work in the NHS is debatable. This should be a matter of some concern if the predominance of foreign born doctors who fall foul of the General Medical Council is to be reversed. There is no doubt that this new approach to undergraduate training is extended into postgraduate training and foreign graduates who come to the UK for their postgraduate training learn fast. The doctors who are at risk are those who do all their training elsewhere and come to the UK for their tenured job. It is this group who require an intensive and prolonged induction prior to entering medical life in the UK with all that British society expects from its doctors.

High Fidelity Surgical Training

2014-09-20T19:13:00.001+01:00

This is an excellent example of high fidelity simulation of a difficult surgical procedure.
As one surgeon in the video says it is now unacceptable for a surgeon to go through a learning curve whilst operating on patients. A smart device like this not only recreates the procedure but cleverly, is able to give feedback to the surgeon.
Much more of this is required. Surgeons are clever and resourceful. Colleges of surgeons should be encouraging and incentivising young surgeons to do what this clever chap from Holland has achieved.

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Required - a National Framework for Heart Valve Disease.

2014-09-16T17:48:00.000+01:00

The National Service Framework for Coronary Disease, published in March 2000, transformed the management of patients with coronary disease in the United Kingdom.
The newly elected Labour government with health secretaries Frank Dobson and (soon after) Alan Milburn had introduced a culture change to the UK National Health Service - the concept of expert led, protocol driven, and well funded bodies that would drive improvement in healthcare from the top. These bodies included NICE and the precursor of the CQC - the commission for health improvement or CHiMP. Accompanying these new bodies were the necessary appointment of 'top docs' or health Tsars. The newly appointed Heart Tsar was Dr. Roger Boyle. His Opus Magnus was the aforementioned NSF for Coronary Disease.
The NSF and what followed later in primary and public health with successful antismoking interventions, Statin prescribing and in specialst care with the setting up of Heart Attack centres has made the UK the best place in the world for the managemnt of patients with coronary disease.
The same cannot be said however for patients with heart valve disease. Disorders of the heart valves may not be as prevalent as those affecting coronary arteries (which incidentally is on the wane) but as a(nother) disease of ageing, heart valve disease is rapidly becoming more common. A degree of aortic valve stenosis is found in one tenth of all people in their 80s - a rapidly expanding demographic. Diagnosing significant heart valve disease is probably easier than diagnosing coroanry disease. All you need is a medical history and a stethoscope (and an echo machine). A heart valve National Service framework would increase awareness of the symptoms of heart valve disease amongst patients and primary care physicians and provide the funding for a big expansion in echocardiographic services that is urgently required in the English NHS. It would also provide some sensible direction to the planning of the management of these patients - i.e. cardiac surgery or the newer (very expensive) catheter based devices. It should, in conjunction with the National Institute of Health Research, commission urgently required research into the science of the commonest of the diseases affecting the population - aortic valve stenosis and mitral valve regurgitation.
In recent years a new British Heart Valve Society has been set up. (declaration of interest as treasurer). Members are predominantly professionals - cardiologists and cardiac surgeons interested in the management of patients with heart valve disease.
Heart Valve Voice is a new (industry backed) body of experts and patients whose main aim is to increase awareness of heart valve disease and to lobby politicians. They have produced this excellent infographic showing the results of a small but targeted Europe wide survey. The results are eye-opening and confirm the need for such a venture.

Valve Infographic

The Problem with a growing Complaints System

2014-08-29T21:34:00.001+01:00

http://m.bbc.co.uk/news/health-28965026

The fact that the number of complaints in the English National Health Service has risen sharply should not surprise anyone. After years of terrible headline stories about Midstaffs, and other institutions followed by the Francis report and Keogh reviews, anything else but a massive increase in complaints would have been an abnormal response from users of the National Health Service. There are many, including victims and relatives of victims of poor practice, who feel that what the NHS needs to get it back on the straight and narrow is such an increase and more.
This rapid increase cannot however be sustained .
Increased complaints and an undoubted increase in funding for the NHS by whoever is elected next year makes my heart sink.
The expected response from a service that is hooked on process will I fear produce a megamonster that will eventually strangle its parent and make efficient working increasingly difficult. This is clearly self defeating and will threaten to produce a service that is less and not more safe.
I am not advocating that complaints should be discouraged or ignored but that the response of the NHS should be smarter. There surely must be good examples out there in the world outside the NHS bubble from whom lessons could be learnt.

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Medical Super Specialisation is good AND bad for patients!

2014-06-07T20:00:00.001+01:00

Surgeon volume and early complications after primary total hip arthroplasty | BMJ

This is an interesting article suggesting that if a surgeon specialises in one type of operation and therefore carries out a large number of them per year, his patients are less likely to suffer complications.
In an age when patient outcomes are important, this strengthens the case for further specialisation in different disciplines of surgery. In my specialty, cardiac surgery for example, there are moves now for surgeons just to specialise in surgery of the mitral valve or surgery of the aorta. If I was a patient with mitral valve disease, I know who I would want to operate on my mitral valve .
There are however tensions and problems associated with increasing specialisation.
These tensions were eloquently pointed out decades ago by none other than Kenneth Williams, camp comic extraordinaire from the 19870/80s.
It is said that many of the problems faced today by hospitals, the NHS and healthcare systems in general are due to the fact that in an ageing population, patients suffer not from a single illness but with multiple problems. Specialisation in the specialty of medicine has meant that General Physicians, doctors who had experience in all medical problems and who until 1980s were the commonest type of consultant in a hospital just do not exist anymore. When an old person gets admitted to hospital they are moved from 1 specialist ward to another (or pillar to post) with no one doctor or team taking overall care. In America, where specialisation began much earler than it did in the UK, the problem is now being addressed by the creation of Hospitalists - these essentially are doctors who act as GPs for the patient throughout their journey thru the different specialties in hospital.
In the UK, early specialisation in training, a recent trend, is now recognised as not being good for health of the nation. A recent review entitled the Shape of Training has recognised the problem and has come up with a number of solutions. When I read the report, it seemed that I was being transported back to the future. The solutions certainly vindicate many of the complaints of recent developments in training, not just by whinging old timers like myself but by many junior doctors.
So, despite the good outcomes and benefits associated with specialsiation, there are costs when it comes to the common good - a perennial tug of war in healthcare!

tags: total hip arhtroplasty surgeon volume cubic spline curves

Posted from Diigo. The rest of my favorite links are here.

When Modern Tech Makes it all Worthwhile.

2014-05-17T17:25:00.000+01:00

I was listening recently to 8tracks online radio in my car. It is one of the better online radio stations because it is intuitive to use and allows you to create libraries of tracks you like and are able to share with others. If you love music, online streaming stations, which include Bloom FM and others are must have apps on your smartphone. The combination of these apps on your phone, a unlimited data contract with your mobile phone provider and the ability to link via bluetooth with your in-car audio is one of modern life's great treats
During a recent drive home, I heard a beautiful piano tune called I Giorni by Ludovico Einaudi. It seemed immediately familiar to me. Mr. Google subsequently informed me that it has been used by the BBC for one of their own ads to highlight Arts programmes. It has also been used in a television ad in India for Airtel, a mobile comms company.

Anyway, enjoy.

Is this a Wonder Prosthesis?

2014-05-16T17:30:00.000+01:00

Reduced anticoagulation after mechanical aortic valve replacement: Interim results from the Prospective Randomized On-X Valve Anticoagulation Clinical Trial randomized Food and Drug Administration investigational device exemption trial

Cardiac surgeons, industry and increasingly patients with heart valve disease, are always on the lookout for the perfect heart valve prosthesis.
There are 2 main types of prostheses that are used to replace diseased valves, mechanical and biological.

Mechanical are now (after the Bjork Shiley disaster of the 1980s) ultrareliable and as stated by the wife of a patient of mine recently, will last 400 years. The big disadvantage of this type of prosthesis is that every patient with a mechanical prosthesis has to be anti coagulated for the rest of his or her natural life. If not they are at risk of valve thrombosis, where the valve literally seizes up (rapidly fatal in most instances) or thromboembolism where small clots form in the hinge area of the prosthesis and then fly off to various other organs, most seriously the brain causing a major stroke.
Taking anticoagulants (warfarin being the commonest) is a real bind for the patient because they need to have frequent blood tests and because the treatment is affected by other medications, foodstuffs and alcohol intake. In addition, the thinning of the blood by anticoagulant drugs makes the patient susceptible to serious bleeding complications.
The alternative type of prosthesis is a biological one i.e. one that looks like a natural native valve. In the absence of other medical disorders, the patient does not need to take warfarin - which is great news. The bad news (there is always bad news!!) is that these types of prostheses do not last forever and degenerate over time. If you have decades of life ahead of you then it is likely that the prosthesis will need replacing at some point with a potentially dangerous second heart operation .
The study highlighted above compared bleeding (caused by warfarin) and thromboembolic events (caused by NOT enough warfarin) following aortic valve replacement with a relatively new design of mechanical prosthesis in 2 groups of patients - one group took a smaller dose of Warfarin to achieve an INR (bleeding test) of 1.5-2 and the other took a higher dose of warfarin to achieve an INR of 2-3. The (unsurprising) finding of the study was that the patients who took the lower dose of warfarin had significantly fewer bleeding complications. The cost of taking a lower dose of warfarin was according to the authors non-significant - i.e. a small increase in thromboembolic complications.
Now it may have been non-significant (a statistical outcome suggesting that there is a 95% chance that difference occurred by chance) for the authors but not for the 1 or more extra patients who suffered a stroke.
This new prosthesis may very well be different and cause fewer strokes than the other mechanical prosthesis on the market, but I'm afraid this study does not prove it.
What is required is a head to head comparison with 1 or other types of prostheses in common use - a so called Randomised controlled trial where allocation of the valve is completely random and where the amount of warfarin given (i.e. the INR test) is the same for all patients in the trial. Such trials are hugely expensive but until it is done, claims to be different remain in my opinion unconvincing.

Opening the Doors on Animal Testing

2014-05-16T10:18:00.000+01:00

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I am so pleased that we are where we are in the UK with animal testing. I used to get depressed and angry in equal measures at the frequent stories of harassment and violence by anti-vivisection demonstrators 20 or so years ago.
It is to the credit of Tony Blair and Sheffield's David Blunkett (home secretary at the time), who changed the law making such violence a very serious offence, that we are in the happier position we are in today. Openness is good and will only strengthen the backing of the public for sensible animal testing. This is crucial if the wish of successive governments that Britain must remain at the forefront of biomedical research is to be realised.

Atrial Fibrillation - Common & Serious.

2014-04-27T12:30:00.000+01:00