Sunday, 23 March 2014

A Comparison of Healthcare in UK, US and France

 

At a time when NHS funding is being squeezed and both GP (primary care) and hospital services are coming under huge pressure, it is worth looking at a comparison of healthcare systems in the UK, US and France.
 
While France enjoys a slightly longer life expectancy than the UK, it spends 12.5% of its GDP on healthcare (£3000 per head) compared to 9.4% (£2190 per head) in the UK. France has 6.4 hospital beds per 1000 of the population (of which 65% are privately funded) compared to 3 beds per 1000 in the UK (where only 15% of beds are privately funded). 49% of French doctors are GPs compared to 30% of UK doctors.

In stark comparison, the US (whose healthcare system we risk emulating) has the shortest life expectancy despite spending 17.2% of its GDP on healthcare. Only 12.3% of US doctors are GPs.

A solution to the current NHS crisis will require many approaches. Ongoing disruption of the world's most cost efficient health service increases healthcare costs. Administrative costs now account for 30% of NHS spending. Some of that spending needs to be clawed back and spent on the frontline. An urgent priority now is to support and strengthen GPs who form the backbone of the NHS.

 
Source: OECD

Tuesday, 11 March 2014

Reshaping the NHS: talk by Sir Ian Kennedy, Annual BFSA Lecture



Sir Ian Kennedy QC spoke on 'Reshaping the NHS' at yesterday's annual general meeting of the British Fulbright Scholar's Association, held at the very impressive Two Temple Place.

Sir Ian is the Emeritus Professor of Health Law, Ethics and Policy at UCL, an Honorary Fellow of the Royal College of Physicians, and Vice Chair of the College of Medicine. He previously chaired the public inquiry into paediatric cardiac surgery at the Bristol Royal Infirmary, and was chair of the Healthcare Commission from 2003 to 2009 (before it became the CQC).

Eminent Fulbrighters in the audience included Prof John Lazarus and the amazing Katharine Whitehorn.
 
Sir Ian spoke of the differences between changes in NHS structure and culture. He described the NHS as 'a moral enterprise, short on reflection and enterprise'. Ultimately our devotion to the NHS boiled down to two things: Do we love our neighbour? And how much?

Had the NHS run its course? Of course not, he said. But he did raise two questions, both difficult to answer: Where should the money come from? What should we spend it on?

He drew from his vast experience of public inquiry into healthcare disasters to describe anecdotes of appalling behaviour by healthcare professionals, often a result of system failures. Sadly for me, he did not highlight the many wonderful achievements of the NHS, most importantly the delivery of universal and comprehensive healthcare, free at the point of delivery (1).

When asked what the NHS could be proud of, he hesitated. He might have quoted Prof Don Berwick, Harvard Prof turned UK Health Tsar, who on the NHS' 60th birthday described it as 'one of the astounding human endeavours of modern times' (2). For my summary on Don Berwick and the NHS, see here.

There was much in Sir Ian's lecture that I found useful. He emphasised the importance of Service in the NHS, and talked about developing 'a culture of service'. The key to this, he emphasised, was STRONG LEADERSHIP. How do we persuade NHS leaders to stay in post for longer (the average lifespan of an NHS CEO is 2 years)?

We need leaders in all sectors of the NHS, leaders amongst the cleaners, the porters, and so on, as well as doctors and nurses. How do we identify and develop these leaders? He spoke of  the three hallmarks of good leadership: having a vision, communicating that vision, and living the vision. For a short video on how NHS leadership at my own NHS trust is winning national awards, see here.

Sir Ian talked about putting the patient at the centre of everything. VERY IMPORTANT. Employee engagement, he also said, is the best indicator of quality of service. 

Sir Ian's talk was informative, entertaining, well received and provoked vigorous debate. The Commonwealth Fund data (3) was discussed briefly. During the Q and A, I spoke of my own experience of how the NHS has rapidly adopted new approaches to emergency heart attack treatment (4). 

I think it's fair to say that by the end of the evening in that wonderful venue, we all learnt something new about how the NHS can and will improve further.

#bfsaNHS


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. Frimley Park Hospital NHS Foundation Trust is an award winning 24/7 regional Heart Attack Centre, performing over 1000 coronary angioplasties a year and delivering emergency cardiac care to a population of one million people.

 

Saturday, 1 February 2014

24/7 Heart Attack Care by the NHS

A recent article by Richard Grant in the Guardian implies that the treatment of heart attacks outside working hours is below an acceptable standard. He suggests that "the principle of 'office hours only' applies as much to emergency medicine as it does to your local fishmongers".
 
This attack is mostly based on an article recently published in the British Medical Journal by a US group. They performed what is known as a meta-analysis of heart attack (ST elevation myocardial infarction; STEMI) patients. Data from 48 different studies (mostly patient registries) was pooled to increase patient numbers and generate meaningful data (for more information on clinical studies see here). Of the 48 studies published between 2001 and 2013, only two looked at patient cohorts beyond 2009. The majority looked at patients pre-2005 and some even in the 1990s. Also, only two out of 48 studies looked at UK patients (one of those was a single centre registry). The analysis concluded that worldwide mortality rates for STEMIs was higher out of hours (and that North Americans fared better).
 
How does this data apply to the treatment of heart attacks in the UK now? For details on how we treat heart attacks in the UK see my earlier blog here. The majority of STEMI patients in the UK are now treated by primary angioplasty, the gold standard of heart attack treatment, and the speed with which this has been successfully implemented is shown by this graph.

 
ALL patients in the UK regardless of their background, location, age and clinical condition receive an equal and excellent standard of heart attack care 24 hours a day, 7 days a week, and delivered by a consultant. A network of designated 24/7 regional heart attack centres in the UK ensures that ALL patients get the appropriate treatment as soon as possible (and yes, to all those outside the UK, it is free at the point of delivery!). This is ONLY possible because the NHS delivers truly universal healthcare across the country and NHS ambulances work closely with NHS heart attack centres 24/7 to deliver the best care for patients.
 
All this data is very carefully audited and available to the general public. The MINAP (Myocardial Infarction National Audit Project) 2013 report is available here. An example of how we deliver emergency care at our NHS trust is described on page 114. BCIS, the British Cardiovascular Intervention Society, produces annual public reports (see here). Again the UK is unique in the way it audits and publishes data of ALL interventional cardiology units.
 
The general public in the UK should know that if they have a heart attack, they will receive the best possible care (at the very highest of international standards) 24 hours a day, 7 days a week. Any suggestion in the media to the contrary is misleading at best and scaremongering at worst.
 


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. Frimley Park Hospital NHS Foundation Trust is an award winning 24/7 regional Heart Attack Centre, performing over 1000 coronary angioplasties a year and delivering emergency cardiac care to a population of one million people.

Q and A on Angina and Heart Attacks


 
The human heart pumps six litres of blood per minute around the body for an entire lifetime (and up to 18 litres per minute during exercise and pregnancy), maintaining the delivery of oxygen and nutrients to all body tissues. Three (and in some people, four) major coronary arteries (running on the surface of the heart) supply blood to the heart muscle and slowly narrow with age due to the accumulation of fat and inflammatory cells in the wall. This process known as atherosclerosis is accelerated by smoking, diabetes, high blood pressure and high cholesterol levels.

What is Angina?
As the arteries narrow beyond 60%, blood flow to the heart muscle is restricted during exercise and can produce symptoms of stable angina during physical activity. In most people, this is a central chest discomfort (described as a weight on the chest or a tight band across the chest) radiating to the shoulders and/or neck and associated with shortness of breath. Others may only experience breathlessness, jaw pain or upper back discomfort. These symptoms typically resolve with rest. Occasionally there may be no warning symptoms whatsoever.


What is a Heart Attack?
A complete blockage of a coronary artery results in a heart attack which is potentially fatal. Heart attacks are the most common cause of death in the developed world and the risk of death following a heart attack is 40% if untreated. The symptoms of a heart attack are the same as those described above but more severe and typically associated with sweating, feeling faint, vomiting and sometimes collapse. Interestingly, 25% of heart attacks do not produce any recognizable symptoms or are ‘silent’.


How do we treat Heart Attacks?
Thirty years ago, heart attack patients would spend at least two weeks in hospital and, with no specific treatment available, the probability of leaving hospital (having survived the initial attack) was only 80%. Over the last thirty years, ‘clot busting’ drugs improved survival rates to 90% but patients spent a week in hospital, often suffered significant muscle damage and often developed heart failure.

Now there is substantial evidence that the best treatment for heart attack patients is an emergency (or primary) coronary angioplasty delivered as quickly as possible. An interventional cardiologist, with the help of his or her team, performs an angiogram by passing a narrow plastic tube (called a catheter) into the circulation (through a small tube in the groin or wrist) and to the heart, obtaining detailed x-ray images of the coronary arteries. The artery responsible for the heart attack is then identified and reopened with a fine wire, balloon and a stent (a wire mesh tube to keep the artery open). Other devices to aspirate clot from the arteries may also be used in conjunction with drugs injected directly into the blocked artery. Survival rates are greater than 96% and patients leave hospital after two or three days with a lower risk of heart failure.

Heart attacks require emergency treatment and delays can result in death. At designated ‘24/7’ regional heart attack centres like Frimley Park NHS Foundation Trust, we have a ‘Door to Balloon’ target (namely, the time between the patient entering the hospital via ambulance or helicopter and having their blocked artery reopened) of 60 minutes (and in practise we average 40 minutes).


What should I do if I think I have Angina?
When symptoms are stable, in other words symptoms develop with activity but resolve with rest, urgent advice should be sought from your GP and then a cardiologist. Your cardiologist will arrange a treadmill test, an ultrasound study of your heart and possibly an angiogram before deciding on the best treatment for you. Symptoms developing at rest should be regarded as ‘unstable’ and treated as urgently as possible.

The ideal situation would be to avoid a heart problem altogether. Avoiding cigarettes, regular moderate exercise, weight control, blood pressure control and a healthy diet (in particular avoiding sugar and controlling fat intake) can help reduce your risk of developing heart problems. However a number of unidentified factors (including genetic factors) mean that no one is immune from heart disease and symptoms should always be taken seriously.


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. Frimley Park Hospital NHS Foundation Trust is an award winning 24/7 regional Heart Attack Centre, performing over 1000 coronary angioplasties a year and delivering emergency cardiac care to a population of one million people.
(Explanation of figure: A. Blocked coronary artery. B. Stent being deployed. C. Reopened coronary artery.)

Saturday, 28 September 2013

The Quantified Self: A Clinician's Perspective


Digital health was a hot topic at Social Media Week London (#SMWLDN) this week and I was lucky to be involved with a session called The Next Stage of Digital Engagement: The Quantified Self (hosted by CIPR). The session was voted runner-up by MarketMeSuite in (take a breath) The Most Slightly Terrifying and Yet Apprehensively Exciting Talk Award category.

Our chairman was Drew Benvie, founder/MD of Battenhall and author of Body Data: Applied Thinking in Quantified Self and Wearable Technology . My co-panellists were David Clare, Digital Consultant at Hotwire and author of OneMoreLifeHack, and Steve Davies, Director of Ruder Finn UK and author of Bionic.ly.




We all gave our very own and different perspectives on The Quantified Self (QS). This is the concept of self tracking body data and sharing this via social media. It also concerns the application of the web, apps and wearable tech to personal health and productivity.

Steve spoke about how he and others in the QS community are monitoring their bodily functions, blood biochemistry and genetic makeup to learn about their health. By 2023, the computing power of an iPhone will fit into a red blood cell raising all sorts of exciting possibilities for invasive body monitoring.

David spoke of how the rise of the QS movement is being driven by an explosion in DIY digital health technologies, how businesses (including the pharma industry) might tap into this body data to tailor products more appropriately, and how the QS community is growing from a small hacker community to a mainstream phenomenon.

I spoke about how patient body data is monitored and transmitted between ambulances and hospitals during the treatment of heart attacks, how cardiologists are using implantable devices in patients which can be monitored remotely, and how the QS movement may provide us with healthy body data that allows us to predict and therefore prevent illness.

During the interactive session, we touched on the concerns regarding data privacy, the dangers of over-testing and medicalization of healthy people, and much more.

The session was streamed live and is available to watch here (there are some issues with sound overlay at the start, so you may want to fast forward to the start of Steve's talk at 04:00. My talk starts at 14:00) :

http://new.livestream.com/smwlondon/events/2394741/videos/30811376



Photo of panel courtesy of @ManeeshJuneja


  


Wednesday, 28 August 2013

London's First Health Tech Forum Meet


The London chapter of the Health Technology Forum (HTF) met for the first time earlier this month and I was fortunate to speak at the event. The HTF is the brainchild of Silicon Valley health tech enthusiast and deal maker, Pronoy Saha, who has created an international network of HTF chapters based in the US, Singapore, India and now the UK. Pronoy hopes that this network of HTF chapters will answer the following question: How can technology be used to narrow the healthcare gap between rich and poor?
 
He believes that by bringing entrepreneurs, technologists, futurists, and clinicians together, answers to this and similar questions will be found in the health tech space. A feature of these meetings is the involvement of clinicians who play a vital role in the adoption of healthcare technologies.

My impressive co-speakers were Battenhall founder Drew Benvie, MedCrunch's Ben Heubl, and telehealth expert Charles Lowe. For me the talk of the evening was Drew Benvie's vision of the Quantified Self and how this will apply to digital health in the future. Continuous harvesting of personal data for maintaining personal fitness, disease prediction/avoidance and management of chronic illness is an exciting prospect. Applying these technologies to healthcare will no doubt lead to more personalised treatments during illness.
 
I spoke about how several technologies are being applied to the emergency treatment of heart attacks. These include technologies used during treatment (drug coated coronary stents, a variety of other invasive technologies, genetically engineered monoclonal antibody based drugs and so on) as well as for communication between ambulances (or helicopters) and coronary care units. A recent radio interview where I describe such a case can be heard here. Implantable devices which can be monitored remotely are routinely used in cardiology departments.
 
I also emphasised the role of the UK's National Health Service (NHS) in future digital health. The NHS is uniquely placed to apply new technologies to cost effective, patient centred healthcare. A nationwide healthcare system with comprehensive data capture has the ability to apply new treatments effectively, safely and rapidly to a huge number of patients, as it has done in the treatment of heart attacks.
 
Details regarding the London chapter of HTF are available here. Another review of this meet is available here.

Sunday, 11 August 2013

The Stenting of George W Bush: Why the Controversy?


 
A coronary artery stenting procedure performed last week on former US President George W Bush has generated controversy. After an abnormal treadmill test (done as part of a routine screening programme), he had a CT coronary angiogram which demonstrated a coronary artery stenosis. He was then transferred to an interventional cardiology centre where a stent was inserted into the coronary artery via the femoral artery. Two physicians (neither a cardiologist) claimed that the stent was unnecessary in the Washington Post. Larry Husten writing in Forbes asked a similar question. Burt Cohen writing for Angioplasty.Org gives a more balanced view. Meanwhile, on Fox News, Professor Marc Siegel struggled to get a stent out of its packaging with his teeth on live TV ('Pull the flap at the back,' I could hear many of us screaming). If nothing else, watch the video for a really good laugh.


 
 
The simple truth is that it is not possible to make any comment about this case without knowing all the details. And those details are private between the patient and his cardiologist. 
 
The debate about routine screening tests is not the focus of this post. Briefly, routine screening treadmill tests in the ABSENCE of symptoms are not recommended in the UK, but they do happen (for example, in athletes). I learnt last week that in France all men aged 65 years are offered an appointment with their cardiologist (which I suspect might lead to a treadmill test; can anyone confirm?). It is entirely possible that Bush said something to trigger concern, despite his excellent level of fitness.

In symptomatic patients, treadmill tests are not a 'rule out' test. In other words, a normal result does NOT rule out coronary artery disease. But treadmill tests are cheap, often immediate, and an abnormal result can guide further investigation. In some patients who have no obvious symptoms, a treadmill test can be used to unmask these. The value of treadmill testing (compared to more expensive tests for which patients may wait several weeks) is still being debated.
 
Once the treadmill has been performed, changes on the ECG (or EKG) can indicate ischaemia, in other words reduced blood flow to the heart muscle. Minor ECG changes may have quite reasonably led to a CT angiogram ('I think that this is normal but I want to be sure'). Major ECG changes would have led directly to an invasive angiogram.
 
An anatomically severe narrowing of the coronary artery is likely to have been stented. While 'ad hoc' stenting is frowned upon by some in the elective/stable setting, the interventional cardiologist may already have had evidence of ischaemia. The treadmill test was abnormal. Alternatively the interventional cardiologist may have performed a pressure wire study, measuring what is known as an FFR (fractional flow reserve) across the stenosis. This would have indicated whether the narrowing was functionally important.

Much attention is being paid to the COURAGE trial in this debate. This study (published in 2007) recruited 2300 patients between 1999 and 2004. Patients who had a 70% coronary stenosis AND objective ischaemia (<10% in most patients) or angina were randomised to PCI (Percutaneous Coronary Intervention; stenting) or optimal medical therapy (For more on randomised trials, click here). PCI did not provide a mortality benefit over 4.6 years.

In this study, less than one third of the patients had significant (>10%) ischaemia and so to me it is not surprising that the study did not demonstrate a benefit. It is probably reasonable to ask why patients with no angina and no significant (>10%) ischaemia were having angiograms in the first place. 38% of patients had had a previous heart attack and 85% of the PCI procedures were elective (planned). This does not reflect current clinical practice in the UK where only 30% of PCI procedures are elective (the remainder are emergency or urgent) and all patients with heart attacks are treated urgently.

We know that FFR guided PCI improves clinical outcomes in patients (11% were asymptomatic) from the FAME II trial. We now await the results of the ISCHEMIA trial where patients are being randomised BEFORE angiography. The results of this trial are therefore more likely to reflect current clinical practice.

In conclusion, I think that it is impossible (and perhaps even rash) to say that Bush's stenting procedure was unnecessary. Perhaps a more pertinent question should be this. Why was the PCI performed via the femoral artery? In the UK, 60% of PCI is performed via the radial artery.


Vinod Achan is an interventional cardiologist and clinical lead for primary angioplasty at the Surrey Heart Attack Centre. Listen to his recent interview on BBC radio regarding the treatment of heart attacks and cardiac arrests.