Wednesday, 11 March 2015

ABPI Sponsorship of NHS Debate: What's the Catch?

I am looking forward to the #GuardianLive debate tonight where the three main political parties will discuss the future of the NHS. Guardian’s health correspondent Denis Campbell will chair, and guest speakers will include Norman Lamb MP, Minister of state for care and support, and Liz Kendall MP, Shadow minister for care and older people. Should we be surprised that such an important debate is being sponsored by the Association of the British Pharmaceutical Industry (ABPI)?
The relationship between healthcare and industry (both pharmaceutical and medical devices) has always been an important but difficult one. Mass production of Penicillin during World War Two would not have been possible without the hand of industry. Lifesaving medication like Aspirin and Beta blockers have been developed and produced by industry. Similarly, none of the devices that cardiologists implant routinely, coronary stents and pacemakers for example, could have been developed without close collaboration between industry and clinicians.
Yet relations between healthcare and industry are at a low point. Many conflicts of interest arise when pharma influences healthcare delivery. The NHS drug budget is approximately £10 bn per year and rising. Looking at just the top 10 prescribed drug classes by cost, more than £3bn was spent in England alone on branded drugs where in most cases equally effective cheaper generic alternatives are available. Overdiagnosis (by changing diagnostic criteria or incentivising doctors to diagnose), lowering the threshold for treatment (as with statins, for example), and limited evidence that ‘innovative’, more expensive treatments work, all favour industry’s agenda. Many of these damage the NHS which strives for universal delivery of cost effective and evidence based treatments. The National Institute for Health and Care Excellence (NICE) has been set up to strike a balance, ensuring that effective and affordable treatments are available to everyone. How the different political parties will overhaul NICE following the election is of huge interest to all (see this excellent Guardian article, sponsored by ABPI).
Data transparency in clinical trials carried out by industry is an important issue. It has been estimated that only half of all registered and completed clinical trials are published. Positive trials are twice as likely to be published than negative ones. One example of this is the failure of the pharmaceutical company Roche to disclose all trial data concerning Tamiflu to the Cochrane Collaboration. The UK government has spent £500 million stockpiling Tamiflu on the basis of data that is not complete. Patients giving their consent for use of their personal data in these trials are seldom made aware of this. Studies suggest that only a fifth of all new drugs brought to market offer any advantage over existing therapies.
Key themes for tonight’s debate include:
·        If the NHS has finite resources, how should they be spent? Is it more cost effective to outsource services?
·        How can we improve access to innovative, new drugs to improve patient care?
·        Patient data: who should have access, and why?
It is easy to see how the ABPI view on these may differ from that of most NHS clinicians. The relationship between clinicians and industry is an essential one. But there are serious tensions as well. I hope the debate tonight reflects these.
Vinod Achan

Tuesday, 3 March 2015

Michael Sheen speaks in support of the NHS

Actor Michael Sheen gave one of his finest performances yet in support of the NHS this weekend. He spoke in Tredegar, Wales, birthplace of Aneurin Bevan, architect of the NHS. Sheen’s speech, delivered with impressive force, should be an inspiration to all those defending the NHS. Here are some key extracts:

·       In 1945, Aneurin Bevan said, “We have been the dreamers. We have been the sufferers. And now we are the builders”. And my god how they built and what they built. Every bit as much a wonder of the world as any architectural marvel or any natural miracle. The National Health Service. A truly monumental vision. The result of true representation, of real advocacy. A symbol of equality, of fairness and of compassion. The nation that swept the post-war government into power was made up of a people that had faced the horrors and hardships of the Second World War. And bound together as one community, they had been sustained and inspired by a feeling of comradeship, and sense of responsibility for their fellow man and woman. Compelled to help those in need and those in hardship.

·       In his book ‘In Place of Fear’, Bevan said, “The collective principle asserts that no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means”.

·       We do not turn our backs on those facing hard times. We do not abandon them or exploit their weakness. Because they are us. If not now, then at some point and inevitably, they are us. We are not afraid to acknowledge that we can be ailing. That we can find ourselves weak. We do not shy away from that hard truth. We embrace it because in that way, we are always strong. We leave no-one behind. We only say we cross the finish line when the last of us does. Because no-one is alone. And because there is such a thing as society.

·       It’s no surprise that people feel disengaged with politics. Never an excuse not to speak up for what you think is right. You must stand up for what you believe. But first of all believe in something. Because there are plenty out there who believe in grabbing as much as they can. They won’t say it. They are too smart for that. No one says they want to get rid of the NHS. Everyone praises it. It’s as powerful a symbol for goodness that anyone has.

·       This is beyond party politics. This is about who we want to be as a nation. Too many people have given too much and fought too hard, for us to give away what they achieved and be left with so very little.
For a full video of the speech see here:

For more on Aneurin Bevan, see here.

Vinod Achan

Thursday, 15 January 2015



A surge in hospital activity over winter months is predictable, yet this winter we face unprecedented challenges at the frontline. There is much talk of an A and E (Accident and Emergency) ‘crisis’ but A and E represents only one of several interfaces within the healthcare structure.  Consider the following simplistic bathtub model of hospital flow to look at how primary care, secondary care and social care interface with each other.

1. The hospital is a bathtub. If the size of the bathtub reflects the number of hospital beds, we have in the UK the smallest bathtubs in Europe (half as many beds per head of population compared to France; see here to compare).
2. The water level in the bath is determined by patient flow into the hospital (via the tap) and out of the hospital (via the outlet pipe). The tap in turn is determined by a number of factors including the following: access to primary care, telephone advice (NHS 111), and patient choice (to attend the ED rather than see a GP).

3. Flow out of the hospital on the other hand depends on patient recovery, access to rehabilitation beds and social care.

4. There is an additional re-entry circuit: when flow through the backdoor is obstructed and social care is unable to cope, outflow is diverted back to inflow (the hospital readmission).
Recent changes to the NHS have had an impact on this model at both ends. 

Recent changes mean that the tap has been turned to full. The number of district nurses, who play a crucial part in keeping people out of hospital, has fallen by 40% over the last decade. General practice, the jewel in the crown of the NHS, is also vital to keeping people out of hospital but now being stretched to breaking point. Recent changes following the Health and Social Care Act 2012 have distracted GPs from their clinical work and led to older GPs seeking early retirement.  Patients are finding it harder to access primary care and opt instead for the emergency department (ED).  NHS 111 is sending larger numbers of patients to the ED (see below).
At the same time, the flow of water out of the bath is being blocked. Social care cuts have made it harder to get patients home.  Many smaller cottage hospitals, rehabilitation facilities, and nursing homes have been closed.
At the easiest of times, hospitals are run at 100% capacity for maximum efficiency. But open the taps to full by overwhelming primary care, then plug the outlet pipes by cutting social care and rehabilitation beds, and the bathtubs of the NHS, no matter how efficient, will overflow when winter arrives.
Vinod Achan
Vinod Achan is a Consultant Cardiologist and Consultant Lead for Emergency Angioplasty at Frimley Park Hospital (now part of the Frimley Health NHS Foundation Trust)


Monday, 24 November 2014

Why Do Doctors 'Fail'? A British Perspective

Atul Gawande's first 2014 Reith Lecture is eagerly anticipated by many including myself. He is an excellent surgeon and author, as well as an eloquent speaker, and his views on why doctors fail are of enormous interest to all of us. Nevertheless I can't help but feel that a British answer to the same question might be rather different to his. 
In a short preview on the BBC Radio 4 website, he explains that there are three reasons why doctors fail. 1. Ignorance. 2. Ineptitude, the failure to apply our vast knowledge of disease and its treatment effectively. 3. Hubris, the failure of doctors to realise their limitations.
I have no idea what course his talk will take tomorrow (I will have the radio on at 9AM) but I hope he will take into account the following point.
In most societies, doctors 'fail' to deliver the best possible care to all their patients due to a lack of resources, constraints placed upon them by systems they work in, and political factors. In the US, resources are concentrated on the few who can afford excellent healthcare while a large percentage of uninsured are 'failed' by their healthcare system, government, and possibly doctors. In the UK we choose to distribute those limited resources more fairly, so that access to healthcare is universal and not determined by privilege.
Where we 'fail' to consistently deliver the best possible care to every single patient due to limited resources (and the data suggests the NHS is a doing an excellent job compared to other healthcare systems in the world), please do not mistake this for ineptitude.

The real challenge for doctors in the future will be how we deliver existing treatments to everyone in the world cost effectively. This is in fact an area in which the UK leads the world. A shining example of this is the way the NHS delivers 24/7 heart attack care to everyone at no cost to the patient (see here). A system which cannot allow this to happen is the real failure in medicine. 
Disclaimer: Dr Gawande was an undergraduate at Stanford and then a Rhodes Scholar at Oxford. I was an undergraduate at Oxford and then a Fulbright Scholar at Stanford. Dr Gawande was named by Time magazine as one of the world's most influential thinkers. I was not.

Sunday, 13 July 2014

House of Commons Debate: Ethics of Wearable Technology

I had the unexpected privilege last week of being invited to a House of Commons debate on the ethical impact of wearable technologies. The debate took place in Committee Room 10, was organised by The Debating Group and sponsored by CIPR. As a cardiologist with an interest in how these technologies are impacting wellbeing and healthcare, I was interested in how other professionals perceive these technologies.
The motion was: Wearable Technology is an Ethical Nightmare for PR, Marketing and Communications Professionals. Stephen Davies argued in favour of the motion. Stephen Waddington opposed. Much to my surprise, the motion lost by an almost 2:1 vote.  
For me, the debate is really about how Big Data will impact the future, and the ethical challenges this presents ('The Data Dilemma'). As individuals we continuously produce unique datasets. How this data is captured and utilised will present huge opportunities and challenges in the future. Teasing apart this 'jungle of data streams' will not be straightforward.
Supermarkets monitor our shopping habits and can predict our interest in health, our relationship status, whether or not we are trying to lose weight or get pregnant and so on. Internet search engines monitor our browsing habits and again predict our interests and activities. All this data has huge value but also the potential to cause harm if shared without our knowledge. In Japan, billboards are using facial recognition technology to target specific adverts to potential customers. As you board a flight, a flight attendant wearing Google Glass will know more about your various habits than the person you might be travelling with.
There are huge benefits to be reaped from Big Data. There are also huge challenges, and in particular ethical challenges, to society and organisations harvesting this highly personal data. Continuous personal health data (generated by wearable tech) combined with genomic data (owned by organisations like 23andMe), and shopping habits could be used to accurately predict our future health. Is this information that we want to share without restriction?
Clinicians are already using implantable technologies to monitor heart rhythms and predict the risk of cardiac arrest and/or stroke. Genetic  and blood testing for cancers is commonplace. All of these present ethical challenges which clinicians deal with on a daily basis. As the amount of personal health data being captured and shared rises exponentially, the ethical challenges can only increase. One of the key questions will be: who owns our personal health data (see Maneesh Juneja's excellent blog)? To suggest that there will be no ethical nightmare seems shortsighted. 
Vinod Achan is a Consultant Cardiologist with an interest in Digital Health, Wearable Tech, and the ethical implications of Big Data. The photograph of me speaking at the debate was taken by Kate Matlock.

Thursday, 5 June 2014

Defending the NHS

The NHS is under a sustained attack both from media and government.  I wrote about this a year ago (see here) and very little has changed.
One effect of these attacks is to demoralise NHS staff who deliver an excellent service despite shrinking resources and falling pay. The other is to destroy public trust in the NHS. Both pave the way for a takeover of the NHS by alternative healthcare organisations.
There are many reasons why we should defend the NHS to the hilt. Here are my top five:
1.      The NHS delivers universal comprehensive healthcare. It delivers not just a basic acceptable standard of healthcare, but the best possible healthcare for everyone regardless of income. This means that when you fall ill, the NHS takes you in and does its best to fix you regardless of your income or employment status. A recent analysis by the Commonwealth Fund (see here) shows that contrary to media reports, the NHS ranks overall first amongst 11 other healthcare systems (and first or second in almost all categories including effective care, safe care, equal access, efficiency). All of this it achieves with the lowest expenditure per head of population (and lowest % GDP expenditure).

2.      More equal access to healthcare improves healthcare outcomes. Life expectancy is worst in unequal societies. In the US, heart attack patients with no health insurance have a 30% higher chance of dying than someone who is insured (see here).
3.      The NHS is the most cost efficient healthcare system in the world (apart from perhaps Cuba). Administration costs were 5% but are expected to approach 20% of the NHS budget as market forces dominate. Also the bargaining power of the NHS allows it to negotiate the best possible prices with industry. Privatisation of the NHS is NOT going to reduce healthcare costs as a % of GDP.
4.      The NHS embraces effective, proven technologies and can implement them nationwide in a way that no other healthcare system can. Primary angioplasty (emergency coronary angioplasty and stenting) as a treatment for heart attacks is an excellent example of this. See here for details.
5.      The NHS has always had an international reputation for training nurses, doctors and other healthcare professionals. Anyone who dismantles the NHS should not underestimate the effect this will have on training future nurses and doctors.

Friday, 2 May 2014

Five Point Plan to Support the NHS

The NHS faces serious financial challenges in the near future and is being portrayed in the media as an organisation on the verge of collapse. What is not emphasised is that the NHS provides effective universal healthcare at a much lower cost compared to other healthcare systems.

The NHS budget for England is less than £70 billion. A challenge to save £20 billion from 2011 to 2014 was set by NHS England. Amazingly, the NHS responded with an underspend of £1.5 billion in 2012/13. Despite these increases in cost efficiency, huge challenges loom large for the NHS. Acute trusts in particular face hardship.

The NHS is being ground down but there are many ways in which we might support the NHS during this period of austerity. The following are some suggestions that spring to mind.

1. Financial support for the NHS needs to increase, not shrink. Government spending on the English NHS is shrinking from 6.5% of total GDP (2009-10) to 6.2% (2015-16).
2. The continuous 'redisorganisation' of the NHS must stop. The estimated cost of disbanding PCTs and setting up CCGs as a result of the 2012 Health and Social Care Act was £1.5 billion. Integration and cooperation rather than competition needs to be the driver for change. Unless the NHS remains the preferred provider for most aspects of healthcare, time-consuming tendering processes and marketing campaigns are likely to increase not reduce costs (with the largest cost increases seen in administration and not clinical care). When profit making services are cherry picked by private providers, acute care (which struggles to make a profit) will face further hardship.
3. We must look at how we work with the pharmaceutical industry. The NHS drug bill exceeded £10 billion in 2013. A concerted campaign across the NHS to use themost cost effective drugs (and in particular generic rather than branded drugs)could save £1 billion, for example. The NHS needs to exploit its huge purchasing power (with hospitals and GP surgeries working together) to negotiate the lowest possible prices with big pharma. 
4. We must address the PFI problem. PFIs (Private Finance Initiatives) are extortionate mortgages taken out to build hospitals. Approx 120 current NHS PFI projects have a capital value of £12bn but will eventually cost the NHS £79bn in repayments. Total annual PFI repayments in 2012/13 reached £1.8bn and will peak at £2.7bn in 2029/30. At least one hospital has collapsed because of crippling PFI debt.
5. We must harness the power of technology to our advantage. At present, contracts binding the NHS to single IT or technology vendors are expensive and fraught with risk when contracts end. Open source software and hardware designs which allow compatibility across the whole NHS should be standard requirements, for example.  

These are my five suggestions. What would you add to this list?

Vinod Achan
Vinod Achan is a Consultant Cardiologist and the Clinical Lead for Primary Angioplasty at the Surrey Heart, Stroke and Vascular Centre, Frimley Park Hospital NHS Foundation Trust.