Paying for the hours

Unfortunately I have realised that my inflated monolith of a salary will soon be worth no more than a few million Zimbawe dollars thanks to Gordon’s recent discovery that tax and spend policies lead to an end to Tory Boom and Bust increasing inflationary pressure. So I hopped in the Lambo with Lola and hot-footed it down to London to Damien Hirst’s gallery where I was able to pick up a rather tastefully embalmed surgeon for a fraction of the cost of the real thing. I am hoping to put it on the door of my office to discourage any of the squitty juniors from coming to ask my advice.

On the way back we were passing the DCMS when I saw David Lammy deep in thought. I bet he was worrying about THIS problem-how to save the Wardington book of hours for the nation. Thinking it was a book of my hours which my secretary (no doubt jealous of Lola) had sent to Mrs Hewitt, I nearly made him an offer on the spot, but when he explained what it really was, I decided that I didn’t like the idea of opening Sana Towers to the public, so my accountant wouldn’t let me buy it.

But why don’t British museums sell some of their works of art to finance acquisitions. There are hundreds of thousands of pictures and sculptures in this country that never see the light of day. Why not pawn a few to pay for something that the curators are actually prepared to hang. Surely we don’t need to keep them all in case some junior minister wants to hang it on the wall of his grace and favour apartment to impress the chicks.

The Imperial War Museum has got the idea. They recently sold a rare Messerchmitt 163 (German)to pay for an almost unique DeHavilland DH9 (British). This sounds like a good deal especially as it looks like they may have enough parts to make 2 of the DH9s!

Maybe some of our other museums should follow suit. I’m sure this must happen on a small scale, but we never seem to get to hear of it

Speechless

CRETINS

hat-tip ferret fancier

Playing GoD

Today the HFEA issued a decision on pregestational diagnostics or PGD. The press release can be read HERE. In short it says that we should look at the possibility of allowing families with high risk of having children with inherited cancer genes to screen embros to select out those with the abnormal gene. This seems like a very humane and sensible thing to do, and having seen young men and women die of these cancers, and women forced to have bilateral mastectomies and oophorectomies (surgical removal of the breasts and ovaries) at a young age because of their high risk of cancer, I am immediately sympathetic to this decision.

But…on the other hand I wonder. I am inherently and rather uncharacteristically Luddite about this sort of technology. What sort of a world will we move into when we can select particular characteristics for our children? Is it right to be creating embryos and then discarding them? Who will have the rights to these discarded embryos? How do we make a moral difference between selecting for cancer or for cystic fibrosis, or for blondeness, blue eyes or being gay, even (if such a gene is ever found). We are entering a new world with different ethics and values, and with less of the great mystery and magic which makes me glad to be alive.

What joy will there be in the birth of a child we have designed? Will it be the same as the new car we ordered from the catalogue, or the flat we buy off plan? How disappointed will we be when they don’t turn out to be perfect (because they won’t)? Playing with our genetic makeup gives us the illusion of power, but it is just that, an illusion. In the end we will all die, and some will die younger than others. I think perhaps I would prefer the unknown.

But I think if I was a carrier of the BRCA1 or BRCA2 genes, which give a very high lifetime risk of breast cancer (36-85%) and ovarian cancer (16-60%), or the HNPCC gene, which gives an 80% risk of colon cancer, I would probably have the test, and I would probably take up the offer of PGD. Does that make me a hypocrite or a pragmatist?

Both, I suspect

But on a health economic assessment I’m sure this procedure offers value for money, as the cost of PGD will be much less than the cost of treating the subsequent cancers. So on purely economic grounds I can support it unreservedly and leave the moralising to others. So there we are, problem solved. Easy, this ethics business.

If you’ve got IT, you’ve really got IT

Anyone who was in any doubt about the wisdom of letting this government introduce ID cards should read THIS post from Dr Crippen. As those of you who take any medical interest will know the government has recently introduced a computer application system for job applications for junior doctors: MTAS. This has been controversial enough, and the implementation could perhaps most kindly be described as a complete unmitigated disaster. Now we learn that someone in the DoH forgot to password protect the applications. So all the information in them (Address, phone no, sexuality, criminal record etc) was available for anyone to read on the web. Channel 4 have more details . This is what will happen if the ID cards bill goes through. Don’t let them do it

Topping up again

In an interesting new take on the approach to top-up payments in the NHS, reported in the Times HERE, A leading insurer has started a policy in which patients will be able to pay an amount equal to their age per annum, for which they will bee guaranteed access to £50,000 worth of cancer drugs if they are licensed but not available on the NHS. An interesting proposition? Well yes, but lets look at the exclusions. If you have cancer-not eligible. If you are over 65-ditto If any relative has developed cancer under 65 ditto. So in fact I think this is a bit of a loss leader to try and get people to take up their more inclusive policies, when they realise how little advanced cancer treatment is available on the NHS. But of course they have a real incentive to promote the top-up approach as it will potentially save them huge amounts of money compared to wholly private treatment

Including my fees!

Lola-break out the Lafite 61. I think I may need a drink. Speaking of top-ups lets go for a spin. I may have to sell the Bentley

Did he take the truth with him to Gloucester?

The Telegraph today has early publication of the Dr Foster Hospital Guide entitled The NHS: The truth , which has rated every hospital in the country according to a standardised mortality ratio (SMR). While I am delighted to see that my own hospital ranks highest in the region and amongst the best in the country, I have to say I am deeply sceptical that one can read anything into these results. There are so many factors that go into the SMR, many of which are irrelevant to the Hospitals, that they cannot really be said to reflect an individual hospital’s performance. Indeed a cursory review of the Dr Foster database shows that only about half of the consultants in our department are listed, and about half of these have the wrong specialty attributed to them. Only a small thing, but it makes me question the accuracy of their data collection.

SMRs of course are part of the funding formula used to divert money away from areas with healthier populations to those with worse health outcomes such as Birmingham and the Black Country. This formula is probably more responsible for the meltdown in our local health economy even than financial mismanagement by our local PCTs and Trusts, or even the Department of Health. So they are hugely relevant to how our local healthcare is delivered and funded.

But maybe we would be better off having worse outcomes and more money?

But I want to pay…

I would recommend reading THIS short document from Doctors for Reform illustrating a number of ways in which top-up payments are being introduced by stealth into the NHS system, also commented on by the good Dr Crippen. I have experienced several of these in cancer treatment, most notably in relation to the funding of three new drugs, bevacizumab (Avastin), Cetuximab (erbitux) and erlotinib (Tarceva). All are expensive. All are effective in a proportion of patients. None of them are cures. Exhaustive cost-benefit analysis has been applied to each treatment by the National Institute for Health and Clinical Excellence (not-so-NICE), and they have all been found to cost more than the notional threshold of willingness to pay (Currently approximately £30,000 per quality adjusted life year gained (QALY). Their efficacy is not in dispute.

So what are we to do? Here in the real world these treatments, despite being standard practice in Europe and the USA, are not economically affordable by the NHS, though they are all funded by ‘proper’ insurance companies. But why shouldn’t people be allowed to pay for them? At the moment in our region we have received advice from the Department of Health that patients may not pay for top-up care. If they wish to go private, all of their care must be given privately, which means they have to pay consultants’ fees and a 100% markup charged by private pharmacies for dispensing the drugs. Interestingly this opinion is disputed in the Doctors for Reform paper.

And should we tell our NHS patients about these treatments or not (assuming they don’t ask)? I have previously always found it rather difficult to say ‘here is the best treatment, but we’re going to give you the 2nd best’, but now I wonder: shouldn’t everyone know what their options are? probably they should, and I am much more open in my approach to this issue, though I generally try to discourage people from taking the private route unless they have insurance. Unsurprisingly, the Primary Care Trust do not want us to advertise these treatments to patients, but they have recently produced a standard letter explaining the above. But before we get to the stage that we can have a sensible discussion in the clinic, people have to accept the principle that the highest standard of care is not necessarily a right. I don’t think we have reached that point.

They go up diddly-um up

I admit it, I was a great fan of Biggles. Not only that but I am desperately hoping my children will be as well, so that I have an excuse to get them out of storage! So I was very pleased to see THIS amazing story. I don’t remember Biggles flying the DH9, as I’m sure that he preferred the Sopwith Camel, or the occasional foray in an SE5, but I’m sure that he would have been impressed that these guys, having found the aircraft in pieces in a maharajahs elephant shed managed to reconstruct the DeHavilland DH9 bomber, a wooden aeroplane of which no other examples survive, without even the benefit of any technical drawings. I am all the more amazed because I saw pictures of the bits in a display at Duxford before they had been reconstructed and there was no wood there-only the metal parts had survived the years. It did not look like an embryo bomber, and I would have fancied my chances of matching their efforts with the contents of my shed, given enough time and effort.

Rather more worrying they apparently had enough parts left over to build another ‘plane, and this one they’re going to try to fly. I think I’ll let Algy or Bertie go up first. Not that I’m windy of course

A difficult farewell

One of my longest standing patients came into the hospital last month. He had oesophageal cancer, and has had several courses of chemotherapy, which have given him a very good quality of life for 3 years. When I first met him, I told him that I expected his prognosis to be between 6 months and a year, so he had been lucky. Unfortunately he was now at the stage where his cancer was progressing rapidly and there was nothing more I could do to reverse that process. He was dying.

We had become friends over the last few years , and I found that I could talk to him quite easily about what was going on, and was able in a small way to make his last few days easier. Among other things we discussed a “do not resuscitate” order (he laughed). Although I was not there when he died, I was quite close at hand. His family were with him and he died peacefully and painlessly.

This is what my work should be. I have helped someone with a terminal illness to enjoy 2 years that they would not otherise have had. I had reduced his chemotherapy schedules to minimise the impact on his lifestyle, an experiment with which I was quite uncomfortable at the time , but which was undoubtably the best thing for him. Instead of a protracted deterioration over several months, he was well up until 3 days before he died. Unfortunately things do not always go so well.

His wife wrote me a very kind letter thanking me for my help. So far I have not been able to reply, and I don’t know why. I suppose it is a form of grief reaction-denial. I certainly don’t like to believe that he has died. But I think it’s more than that. I think perhaps he made me believe that I had some power to control the uncontrollable-he gave me a false sense of my own power or ability which has now, inevitably, as it was always going to, gone. Perhaps it is that for which I am truly grieving.

And yet, when I ;ook back on the last 3 year I realise that this was a story with 2 sides. From the start we had an unusually balanced doctor-patient relationship: Whenever I was struggling, he would often offer me solutions. We were both prepared to make compromises to find the best way forward. We had what is politely described as “full and frank exchanges of views” on several occasions, but always with indefatigueable good humour. When he was dying, he made my job easier by laughing. I think perhaps that he gave me more than I gave him, and maybe I’m guilty about that.

But I know that in years to come I will remember him when I am talking to patients about their prognosis, and that his story will give hope to many of them. And that I will remember him when patients are telling me about the impact of their treatments, and I hope I will listen more. And perhaps when it is my turn to die, I will remember him and find the courage to laugh in the face of death, and make life easier for whoever is with me.

And now perhaps I can write that letter

And another thing…

Praguetory and Iain Dale remind me that I missed out one part of the constitutional vandalism inflicted on us: The Prime minister, not content with giving himself effective personal control over the executive and legislature as well as a strong hand in appointing the judiciary has also appointed a toady/crony, elevated to the peerage following substantial donations to the labour party, as the governments senior law officer who would have to decide whether or not to bring charges against him if he were ever caught recommending people be… elevated to the peerage for making, er, substantial donations to the Labour party.

Surely, surely we won’t allow this to happen

And with the quality of members TB has put in the house of Lords isn’t it about time we removed the phrase “elevated to the peerage” from the language-perhaps you have suggestions for a replacement. My starter for ten is “plummeted to the peerage”