Monthly Archives: August 2014

Early diagnosis is improving cancer survival but half are spotted too late to save lives

Update 22nd September 2014: Chris Smyth gives the negative spin: Half of cancers spotted too late to save lives

Chris Smyth in The Times 26th August reports: Early diagnosis is improving cancer survival

Waiting times for tests really matter and affect outcomes. The GPs letter can help by the addition of “Urgent Suspected Cancer” (USC) but on many occasions the GP is aware that the symptoms might be cancerous, but is not necessarily suspicious in that the risk might be less than say 30%. Whatever, if GPs are the gatekeepers for the Regional Health Services, then they must be doing something right, despite the recent adverse publicity. There is a real risk however, that different Regions will have differences in outcomes in the next few years, as waiting times, access, and choices, are becoming very different…

Cancer patients’ chances of living at least a year after diagnosis are improving, according to fresh data that suggests Britain’s survival rates may be catching up with the rest of Europe.

The importance of discovering the disease as soon as possible is underlined by detailed figures that show a “massive difference” when cancer is diagnosed early. Bowel cancer patients are more than twice as likely to survive if their disease is diagnosed early, while lung cancer patients’ chances of survival increase more than fourfold….

Many GP cancer referrals too slow, NHS England data suggests

GPs who fail to spot cancer could be named. No government could have designed a better perverse incentive to over investigate and over refer.

GPs failing to carry out crucial tests for cancer

 

Advertisements

A poem a day will keep your loss of empathy at bay, doctor

Daisy Goodwin in The Sunday Times 24th August opines: A poem a day will keep your loss of empathy at bay, doctor 

Poetry helps reflection and personal insight. The problem with being a doctor can be that you find yourself too busy to reflect.. When I retired I really missed the black humour of the coffee room, and poetry, like the black humour, can often help us to see things from a different perspective. Perhaps you are wondering how all doctors could get hold of a copy of “tools of the Trade”? it is available from the Scottish Poetry Library..

What makes a good doctor — is it diagnostic skill? Or a steady hand (useful if you are a surgeon)? Or the patience to fill in Sisyphean mountains of forms? Or the ability to be able to deliver bad news? ….

….How do you teach doctors, who want to save lives, to accept that their powers are finite? One way is through poetry.

This summer all the medical students graduating from Scottish universities have received a book of poems called Tools of the Trade, an anthology edited by two GPs and paid for by private donations.

The foreword says: “Being a doctor is a privilege; it is also very demanding and can be stressful, and to be able to look after others, we need to look after ourselves. We offer you this little book of poetry, Tools of the Trade, as a friend to provide inspiration, comfort and support as you begin your work.”

The editors felt that poetry was the most effective way to support these bright but immature young people who were going to be sent out from the classroom onto the wards. When you are a chronically sleep-deprived junior doctor you need something fast and powerful to sustain you in your humanity; a couple of lines of poetry can be a talisman against despair. And Scotland isn’t the only place where poetry is being prescribed…

Empathy and a thorough understanding of molecular biology are not incompatible, of course, but I think as patients we need to understand that doctors need compassion too.

Medicine used to be called the “healing art” and I think it is interesting that these moves to put poetry into the lives of medical students come from doctors. They know only too well how hard it is to retain your humanity on the last surgery of a Friday afternoon, or in A&E after the pubs close. They also know that despite all the breakthroughs in technology, all the robot surgeons and the wonder drugs that, as the poet Andrew Greig puts it:

The hard art
Lies in knowing when to stop.

Danger of boys’ rugby exposed. Should participants in sporting activities be insured or face co-payments?

The Sunday Times (Sarah Kate-Templeton) on 24th August 2014 reports: Danger of boys’ rugby exposed

A LEADING public health expert says she would have prevented her two sons from playing rugby if she had known at the time about the risk of serious injury described in her new book.

In Tackling Rugby: What Every Parent Should Know, to be published next month, Allyson Pollock, of Queen Mary University of London, warns that schoolboy rugby players have a one-in-six chance of serious injury every season.

“Imagine as a parent you were told that, over the course of a season, the average risk of serious injury to a player is 17%, or one in six, and that in some schools it is as high as 33%, one in three,” she said. “The decision to allow your child to play might alter.”…

…Dan James, 23, a former England youth player, committed suicide at the Dignitas clinic in 2008 after he was left tetraplegic from a spinal injury.

The Rugby Football Union said: “Player safety and duty of care towards players is at the core of all the training we deliver to coaches, referees and medics. Like many recreational activities there is an element of injury risk in playing rugby, but we do not believe that this is disproportionate to other sports played by young people.”

People die in lots of sports, from skiing to surfing to cycling and rallying. The rate of injuries in rugby seems high, but there is no national register of sports injuries as yet. Such a register could compare risk per outing.

It is interesting to know that the regional health services insure all sporting participants without any premium increase. There is no “extra” premium to take part in Rock Climbing or Rugby rather than tiddlywinks….. Surely it is time for the sports clubs to cover their members in some way. The reality of rationing health services overtly demands some sort of  contribution. Alternatively a co-payment on consumption would seem fair…

Update 6th Nov 2014:

Melanie Reid in The Times opines in her notebook:

Sad to say this, and perhaps only a mother who has sat too long in A&E on a Saturday afternoon could, but the glorification of Sam Burgess proves that rugby simply doesn’t get it. Burgess is the wrecking ball of rugby league who has just switched codes to union. He is being talked up as a future star of England on the strength of the physical punishment he can inflict and withstand.

He is regarded as a hero — some might use another word — because in his last league game, in Australia, despite fracturing an eye socket and cheekbone in the first minute, he played on for 79 more and his team won its first championship for 43 years.

Commentators speak reverentially of the four plates in his cheekbone. He’s so intimidating, they say. King of the “big hit”. In fact pound for pound, they gasp, no other players can “hit” like he does. They drool at the thought of the collisions to come.

Rugby is the greatest of games but the culture of the big hit is destroying it. There are not enough adolescents with freakish bodies to sacrifice. There are too many ruined bodies and frightened mothers. The England player Joe Launchbury, a man built like a tree, is out for six weeks with a neck injury.

Ten days ago, in a single match, Scotland’s new captain, Grant Gilchrist, broke his arm and four of his Edinburgh team mates left the field with a broken jaw, a fractured cheekbone, knee ligament damage and concussion.

That’s one third of a professional rugby team, men trained to withstand injury, seriously injured. Is that what we want?

Letters Nov 4th:

Sir, Melanie Reid is right in her condemnation of the “big hit” in modern rugby (“Rugby score: broken jaws 2, fractured cheekbones 1”, Notebook, Nov 4). The rugby authorities and particularly the “law book” authors would do well to give serious thought to her article.

At any one time about 25 per cent of players at the top level are unavailable for selection because of injury. Assuming that an individual player is injured for 25 per cent of the season and that the season lasts 32 weeks, he would expect to be out of action for eight weeks. At a rate of four weeks per injury, he would expect two injuries per season. Further, assuming a senior career of 12 years, he could expect 24 injuries of this severity over his career. The authorities should properly consider the long-term effects of these injuries on the quality of the player’s later life.

John Owen
Trefriw, Conwy

Sir, Having watched a good Ulster team being outmuscled by an immense Toulon team recently, I share Melanie Reid’s concern about big hits in rugby.

Could we learn from the airlines with their cabin baggage templates? Put a gate at the end of the players’ tunnel, and if you do not fit through you don’t get onto the pitch.

TJ Robinson
Banbridge, Co Down

 

“Physician Assistants”, as proposed by ministers, trained for 2 years, will increase inequalities and litigation. Back to Health Post workers?

Chris Smyth in The Times reports 22nd August 2014: Patients will soon be treated by less-qualified doctors’ assistants in local surgeries and hospital emergency wards under government plans to relieve pressure on the NHS.

Science graduates with two years’ intensive training — compared with the seven years it takes to become a doctor — will qualify as a new class of medic known as “physician associates”.

They will carry out many of the same roles as junior doctors, including examining patients, ordering and interpreting tests, admitting and discharging to hospital and deciding on treatment. They cannot prescribe drugs but will prepare prescriptions for doctors to sign off….

Talk about an admission of rationing by undercapacity. The one thing that a Doctor does that no-one else does is “make a diagnosis” and is then insured for getting it wrong…. When I did a period of voluntary work overseas in Nepal there were “Health Post Workers” who acted as doctors for rural areas, often up to a week’s walk from a doctor’s location. The Ministers seem to be in favour of moving back to the third world standards.. It will certainly foster a two tier health service, and increasing demand for private practitioners and Private Medical Insurance. Physician associates will not reduce inequalities, but increase them… In a world where the doctors are pilloried for being unable to cope with an infinity of demand, perhaps some of them will volunteer!

Health experts’ food poverty warning

Doctors may face ‘tougher sanctions’

The risks in having babies in rural areas – midwifery-led units questioned by consultant.

A letter to the Western Telegraph is reproduced (I gather it was edited down, and was originally stronger) from Miss M R Howells, recently retired Obstetrician and Gynaecologist:

IT WAS only a matter of time before a senior officer of Hywel Dda University Health Board tried to deflect blame for closing Withybush Obstetric Unit and SCBU from itself to Royal Colleges and clinicians ( Bernadine Rees, ‘£300K cost of judicial review’, Western Telegraph, July 30).

Let us be clear, Mrs Rees; the Royal College of Obstetricians and Gynaecologists was not involved. It was ‘quoted’ in the original consultation document, but not invited to participate in the consultation. When convening a Scrutiny Panel, Mark Drakeford was informed that the College would provide two senior fellows to advise if requested. No such request was made. Instead, two clinicians were involved, one a paediatric professor working in London, not rural Wales, and a gynaecologist from Swansea, who has not worked in obstetrics for many years.

Mr Drakeford also ‘quoted’ the College, stating Withybush was “too small to remain open” in a letter to the Patient Participation Group of St Thomas Surgery. The views of Pembrokeshire clinicians, GPs and specialists, familiar with the local problems and overwhelmingly opposing the closures, were ignored, a slap in the face for your own clinicians. No wonder morale is at rock bottom.

We await with dread and trepidation the first adverse event following the closure of the obstetric unit at midnight last Sunday.

Meanwhile, patients, their relatives and friends, face thousands of extra miles of travel, and staff are left with long journeys to provide the best service they can under difficult conditions.

The most up to date facilities in the world are useless if you cannot reach them in time ( “Bosses are totally prepared for the move”, Western Telegraph, July 30). The Health Board alone bears the responsibility for the decision.

M.R.Howells

Travel time from home to hospital and adverse perinatal outcomes  (British Journal of Obstetrics and Gynaecology BJOG 2010) Women who take 20 minutes or more to get from their home to hospital by car at full term are more likely to suffer from adverse neonatal outcomes suggests new research published today in BJOG.

South Wales Programme midwifeled units paper (Welsh Government)

“Time to clarify maternity services policy” (Mike Broad – 7th February 2014  in Hospital Doctor)

Hywel Dda under pressure as doctor says ‘Glangwili will not cope’ once Withybush has been downgraded..

Midwives and patients warn of ‘devastating’ staff shortages

Furness – the chronology of endemic denial. “Loving the NHS to Death”

In a letter to a colleague Miss Howells says:

“Perhaps worst of all, Powys free standing midwifery led units (FMLUs) are being held up as paragons of maternity virtue, with high numbers of home births, only 4 per cent transfers and no “risk” to mothers and babies. Whatever the cause, Powys’s perinatal mortality (PNM) is the highest in Wales according to the All Wales Perinatal Survey, apart from Cardiff and Vale. Whereas Hywel Dda’s is the in the 4 lowest. The actual Powys transfer rate is 24 per cent (the 4 per cent quoted was the number of the mothers the midwife compiling the stats considered to be “dire emergencies”, but surely any transfer in labour is an emergency, why else would you do it, it’s hardly optimal management.) 24% is more in line with the published literature. As the Powys stats only went electronic in 2011, I am quite concerned how many of the other stats were given this “personalised” treatment. The low PNM in the FMLUs themselves is probably due to all antenatal stillbirths (SBs) being counted as obstetric cases, as Powys only allocate place of birth at onset of labour, so SBs (rightly) immediately become obstetric cases, and also because the pts are transferred to several obstetric units, some in England, Hereford and Shrewbury/Telford, as well as Neville Hall, Bronglais and Merthyr, so that any death on arrival in those units accrues to the obstetric unit, not the FMLU. The PNM ought to be very low in  units which de facto select only low risk women, don’t count the antenatal stillbirths and also have a really low deprivation index, unlike bits of Pembrokeshire.

This is not meant, as it may sound, to rubbish Powys service. They don’t have a DGH, and no doubt do the best they can with the resources they have. What worries me is the drive by HDda to introduce a service for spurious reasons based on their stats, which will initiate a deterioration in our PNM to the levels of Powys, and there doesn’t seem to be anyone out there listening. The WAG seems to think it has the support of the local clinicians, but Pembrokeshire obstetricians and paeds, both in post and retired, are strongly opposed to the moves, so we are not sure where this impression has come from. And this is not just guarding the patch. Contrary to health board opinion, the clinicians in the 3 units have always worked together. If there were a sensible way of merging, we would have done it long ago, and been on a 1 in 8 or 9 rota, like the physicians. It is just too risky.”

Update – Letters in The Telegraph 30th December 2014 from Dr Essex and Mr Spencer:

SIR – The conclusion that doctors are rarely necessary at the delivery of babies will keep me busy for years to come. As a paediatrician who specialises in disabled children, I have produced thousands of reports, forensically analysing events around the delivery of babies who were allegedly damaged at birth.

I have spoken to many parents who feel that they were ignored or were bullied by midwives into not accepting a doctor’s assessment and help. Their babies have been left profoundly and permanently damaged, or even dead, by these perceived attitudes.

Many junior doctors and medical students have told me that they are routinely belittled and bullied by midwives on the labour ward. Some midwives seem to consider it a professional failure to summon a doctor, and often do not call until it is too late.

These attitudes cost the NHS millions of pounds and heartache for parents. The only sanction is the recommendation that the midwife concerned be sent for further training on how to interpret the tracing of the fetal heart rate. This does not address underlying attitudes that are likely to be exacerbated by midwife-led units.

Dr Charles Essex
Leamington Spa, Warwickshire

SIR – A normal delivery is a retrospective diagnosis. Even in the most risk-free and uncomplicated pregnancy and labour, things can go suddenly and catastrophically wrong. Consequently, any one of “all the myriad interventions that doctors relish” (Letters, December 6) may be the only way to rescue the baby or even the mother. Such intervention is not always available in a timely manner at home.

I am not in disagreement with the provision of home delivery, but we have a national shortfall of 3,000 midwives.

It is rare to be sued for carrying out a caesarean section, one of the commoner “myriad interventions”. The reverse is certainly not true.

Peter Spencer FRCS FRCOG
Bury St Edmunds, Suffolk

 

 

 

Stem cell therapy will cure cancer and make blind see

Josephine Moulds reports in The Times 20th August 2014: Stem cell therapy will cure cancer and make blind see (with apologies to The Times for reproducing the “good news” in full)

A revolution in British healthcare can be accelerated if class-leading research gets the right funding

On the twelfth floor of Guy’s Hospital, next to the Shard, is a gleaming laboratory with panoramic views of London. To the untrained eye, it looks rather like a room full of photocopiers, microwaves and washing machines — but the equipment in here sets pulses racing for the scientists who come to stir, spin, modify, test and manufacture cells within its spotless glass walls.

This is the heart of the cell therapy string of the government’s Catapult programme, which invests in areas of leading academic research, in this case designed to drive the growth of a revolutionary form of treatment that proponents say will cure cancer and make the blind see.

Chris Denning, professor of stem cell biology at the University of Nottingham, says: “If we can achieve even a fraction of what we hope with stem cells, then it will be a revolution for healthcare. It will give us a whole new set of tools to treat diseases like cancer and repair damaged organs, such as the eye, brain or heart.”

British universities are recognised worldwide for producing some of the best research in this field, but the race is becoming more crowded. “China is an emerging area,” Professor Denning says. “It is snapping at people’s heels. [The UK is] among the best in the world, there is no question, but there is no space to rest on our laurels. We need to keep at the forefront, otherwise we will get overtaken.”

There are fears that Britain is failing to translate its research into moneymaking businesses. Michael Hunt, the chief executive of ReNeuron, one of the few cell therapy companies based in Britain (see box), says: “The UK has a strong presence and history of stem cell research and cell biology research. At the moment, it has a bit of catch-up to do to translate that research into therapeutic candidates that can be taken through clinical development to the market. We [at ReNeuron] are very, very alone as a pure cell therapy business that has the aim of doing just that.”

The problem is that academics have little incentive to undertake the daunting task of translating an idea that works well on paper into a therapy that can be administered to a patient.

Andrew Baker, president of the British Society for Gene and Cell Therapy, says: “Scientists are judged on the quality of their papers; that is often linked to fundamental research findings.

“You don’t get major brownie points or publications if you translate the finding. From a tactical point of view, scientists think: ‘Why am I going to spend five years doing this trial?’ ”

This is where the Catapult programme comes in. Keith Thompson, chief executive of the cell therapy Catapult, says: “Sometimes it’s seen as the boring slog of science, turning the idea into something that you can make routinely. But unless you do this stuff, a) you’ll never get the therapy to the clinic and b) you’ll never keep it for the UK.”

One of the biggest hurdles facing fledgeling cell therapy companies is the lack of precedent. Even the relatively simple task of developing a business model is a lot more complicated when nobody has done it before.

Mr Thompson says: “Health economics are basically built up around interventions from a drug that often will have some sort of lifelong therapy, whereas a stem cell-based cure might give a lifelong cure.

“How do you cope with something like that? If you cure somebody from blindness, they are going to have a lifelong benefit from that. How do you price that? And how do you pay for it? You may have to pay for it over a number of years.”

Delivering these therapies is far more complex than shipping containers of tablets around the world. Many cell therapies are developed from the patient’s own cells, such as the replacement windpipes developed by Videregen (see box).

Mr Thompson says: “If you’ve got a trachea, it’s got a very, very short shelf life. How do you get the cells from the patient, grow the new trachea and get it back to the patient? You are talking very short supply-chain delivery times — 24 hours is not uncommon. That brings in a whole range of complications, integrating manufacturing with clinical use.”

The lab at Guy’s can be used by SMEs and even large companies to manufacture cells. The equipment is of the highest specification, but the facility also has lower-spec machines, so that companies are able to replicate the processes in their own facilities. Mr Thompson has ambitions to provide an even fuller service to cell therapy companies that wish to come to the UK. The Catapult has put a bid in to government to fund a 5,000 sq m manufacturing hotel, where companies could lease space for final, large-scale clinical trials and initial market supply.

“As the thing takes off, we would then expect the company to build its own facility and take its people with it,” he says. “We are designing the facility in a way that will be highly replicable. The expectation is that the company would want to do it relatively near by, so that the staff it had would move with it.”

This is the beauty of pouring money into cell therapy at an early stage. Small businesses attracted to the UK by the facilities on offer are likely to stay put as they grow, because of the regulatory headaches they would face if they tried to move abroad.

Mr Thompson says: “Because these things are complex to make and there is a lot of knowhow in it, and they are regulated, it means that once you build these places and therapies get licensed in them, they don’t move very easily. So it’s really important to have a strategy which embeds these things into the UK very early on.”

Every big pharmaceuticals company has monoclonal antibodies in their portfolio. They generate revenues of $45 billion a year and the market is growing at 5 per cent to 7 per cent a year.

“These things are a roaring success,” Mr Thompson says. “The trouble is that so much of the manufacturing of that and exploitation has gone offshore. One of my aims, by putting down manufacturing and supply chain routes, is to keep the long-term value as much as possible in the UK.”

Companies that develop intellectual property with the help of the Catapult must then negotiate over how that IP is meted out. Mr Thompson says that a company might want to keep the IP specific to the disease it is seeking to cure, while the Catapult will try to hold on to generic IP.

“If we managed to get some IP around a scale-up system that reduced the cost of goods for everybody, we would want to try and disseminate that across the board non-exclusively.” The Catapult could use IP to generate revenues, which would help to support the centre, but its primary concern would be to make sure that it is used.

It is able to have this open approach to IP because of relatively secure government funding. The coalition has committed to provide the Catapult with £10 million of funding every year for the first five years of its existence, and it is believed that that will be renewed regardless of the general election result, thanks to cross-party support. The Catapult, in turn, is expected to find an additional £20 million a year from private investors and grants from the European Union and others.

Mr Thompson says that continuing government funding is important to ensure the longevity of the project. “I’ve been around in biotech for a long time. I’ve seen institutes start up with a bit of seed money and, frankly, they often lose focus on what the mission is and focus on trying to bring in the money.”

Steve Bloor, the chief executive of Videregen, won a £1.9 million grant from the government’s Technology Strategy Board and then raised £1.3 million from private investors. He says: “It is very difficult to get large amounts of investment capital or equity capital for these types of contracts, in contrast to the US, where there is much more freely available capital. We are in danger of losing out to places like the US and Korea, Japan and China. The money is over there.”

The Catapult is seen as crucial to attract academics, companies and investors to the UK to build a vibrant cell therapy industry. Professor Denning says: “The US has put vast amounts of money into this area, so has China. This is more a question of if we don’t do this we’ll end up buying back the technology from other countries in the future. Unless we do this, we won’t keep up.”

In numbers

$12.2 billion estimated size of global market for stem cell technologies by 2018
£9 million spent by the cell therapy catapult on its lab at Guy’s Hospital, London
60,000 stem cell transplants performed each year on oncology and blood-based disorders
$900 million revenue generated by cell therapy products distributed by biotherapy companies in 2012
2,500 ongoing regenerative medicine clinical trials around the world
15 per cent trials sponsored by industry

Stroke fatalities linked to weekend nursing shortage

Chris Smyth reports 20th August 2014: Stroke fatalities linked to weekend nursing shortage

Hundreds of stroke patients are dying because hospitals do not have enough nurses working at weekends, a comprehensive study suggests.

Patients were significantly less likely to die in stroke units that had more nurses on duty at the weekend, the analysis of data from the bulk of English hospitals has found.

The conclusions will provide further ammunition for health chiefs trying to persuade NHS staff to move to a seven-day service, but the study also found that having more doctors at the weekend did not seem to improve survival rates. Researchers said it was “surprising” that evidence on the effects of weekend staffing was still so poor.

Sir Bruce Keogh, medical director of NHS England, wants more senior staff on duty seven days a week after previous research suggested that patients were 16 per cent more likely to die if admitted at the weekend.

In the latest study, researchers tried to investigate this “weekend effect” by looking at data on 57,000 patients admitted to stroke units in more than 100 hospitals over the course of 18 months. They too found that patients were 16 per cent more likely to die within a month if admitted at a weekend, although this fell to 5 per cent after adjusting for sicker patients at the weekend.

Some hospitals had five times as many nurses per patient as others on Saturdays and Sundays, and there was a clear relation between nursing numbers and death rates. Patients in a unit with 1.5 nurses per 10 patients faced a 15 per cent chance of dying, compared with 11 per cent in a unit with 3 nurses per 10 patients, equivalent to one extra death for every 25 patients admitted.

Benjamin Bray, clinical fellow at King’s College London, who led the study, said this could be because basic care was more likely to be missed when nurses were busy. He urged hospitals to review nursing numbers, suggesting in PLoS Medicine that a lack of nurses could explain the “weekend effect”.

Death rates were no higher, however, in hospitals where doctors did not make ward rounds at the weekend. Dr Bray said this did not necessarily mean doctors should stick to working Monday to Friday, as they could help in other ways such as getting patients home quicker.

Peter Carter, chief executive of the Royal College of Nursing, said it was “unacceptable” that death rates were higher at the weekends.

A spokeswoman for NHS England said: “Hospitals should use the evidence to set staffing levels that meet the needs of their patients.”