Eating disorders

This article: ‘Shocking figures reveal one in three hospital admissions for eating disorders are children’ is currently buried at the bottom of the Mail website. To the right of it are the normal too fat / too thin / too old / too ugly stories that form the staple diet of the Mail website. Needless to say the Daily Mail misses out on a chance to reflect on the media’s impact on these ‘shocking figures’ (a phrase the Mail normally reserves to describe a group of women not conforming to their strict body expectations).

They report that the survey found that more than half blamed their condition on family traumas, whilst 3% said they were influenced by ‘size zero models and skinny pop stars’. The missing percentages are not mentioned.

Just over a week ago the Daily Mail put this picture onto their website:

They accompanied it with accusations that the dress Katy Perry was wearing was  ‘clinging in all the wrong places’ and included the words ‘girth’ and ‘protruding belly’.

Thankfully a commenter underneath the Mail article has posted this under today’s article:

Eating Disorders

Sick and Wrong

I think I should apply for a job as a Daily Mail writer. It seems so easy. In order to write a Daily Mail article one merely needs to follow this three step process:

1. Take a standard Daily Mail premise (i.e. “Asylum seekers are evil…)

2. Find a random statistic and throw it in.

3. Conclude that some part of the country in hideously broken.

This explains why the Daily Mail-o-matic is so astoundingly accurate.

So this story and editorial comment has a simple point to make: life-saving cancer drugs are being denied by NICE (National Institute for Health and Clinical Excellence), whilst at the same time the NHS wastes £21billion (yes billion) on ‘failed schemes to tackle inequality.’

The headlines are great aren’t they: Betrayal of 20,000 cancer patients… and NHS waste betrays our cancer patients.

I’m a huge fan of Warner Brother’s Looney Tunes Cartoons (Bugs Bunny, Daffy Duck, Road Runner etc.) and it’s a intriguing fact that they employed joke writers who got paid $50 for each gag that was then included in a cartoon. I’m beginning to wonder if the Mail employs headline writers on a similar basis; £1000 for ‘NHS Waste’ – £2000 for “cancer” etc. If so, they’re really earned their money. As usual, the article is almost entirely untrue. I think what depresses me most is the comments section of Mail articles. People actually believe this stuff. This is the main reason why I am very grateful to angrymob for allowing me to contribute articles. It’s extremely therapeutic to me to be able to respond – it is a shame that the angrymob readership is not as wide as the Wail, but it is a start. “You shall know the truth and the truth will set you free” as a wise man once said.

£21 Billion

I read this article because of the reporting on the workings of NICE but what really caught my eye was the £21billion claim. It’s classic Mail really; billions of pounds wasted on tackling inequality. Because we (Mail Readers) all know that tackling inequality is part of the evil-socialist-not-really-British-human-rights-nu-labor-agenda. It’s almost like subliminal messaging only with the subtlety of a bulldozer. The reason this line caught my eye so much is that there is no way it could possibly be true. And the writer must have know this – this can’t just be an error or a misunderstanding – it’s so off-the scale wrong that it’s obvious after about 2 seconds of thought.

Last week it emerged that £21billion – a fifth of the entire annual budget – was spent on failed schemes to tackle inequality.

It took a little bit of research to work out what on earth this referred to and having found the answer, I have to admit I am impressed by their creativity. This figure is derived from a National Audit Commission report entitled “Healthy Balance” which looked at public health spending in England. As an aside, this is the short summary of the report:

The health of people in England has improved over the past ten years. Life expectancy has increased, infant mortality has fallen. Government targets to cut death from heart disease and stroke by 2010 have already been met. But if the big picture is positive, stark problems remain. Inequalities in the health of people from certain areas and social backgrounds has stubbornly resisted improvement, and has even increased in some cases.

So, public health programs from the government have been very successful but health inequalities remain a challenge. This is how they get to say that schemes to tackle inequality have ‘failed.’ So what of this £21 billion spent – from the article is seems this is a specific budget on schemes to tackle inequality – bureaucracy and PR are the sorts of things this statement conjures in my mind, certainly no actual healthcare. The reason I knew this was a lie, is the simple fact that this is impossible – there is no way the NHS could spend a fifth of its budget this way – it’s just untenable and hence the writers must have know it was false. So I found the figure of £21 billion buried in the article. What it comes down to is this; The government provides funding for the NHS in England by providing funds to PCT (Primary Care Trusts) who then control the money and ‘buy’ services from GPs and Hospitals (and other providers). The money is allocated on the basis of population size. However it is not distributed evenly as social deprivation has a strong correlation to healthcare needs and hence healthcare spending. How money is allocated is complicated – much of it is targeted or ring-fenced by the government and some of it is determined on a formula to allow for variations in need. Of the English NHS budget (around ~£70 billion) £21 billion is allocated according to this formula. What that means is this is not money spent on inequality measures but allocated on the basis of differing needs. And what’s it spent on? Well, everything the NHS does – hospital beds, operations, GP service, prescriptions etc.

As I said, it is impressively creative. A blatant lie, but a creative one.

NICE

The National Institute for Health and Clinical Excellence has a very difficult brief. They are charged with creating clinical guidelines based on the best available evidence in order to improve healthcare across the board and also to assess new therapies to see if they are both Clinically effective and Cost effective.

There are a lot of new cancer therapies that the drug companies keep bringing out. These drugs are often very clever and stem from a much better understanding of cancer biology at the molecular level. All of these drugs are very expensive.

In order to determine whether these drugs should be available on the NHS, NICE asks too questions; Does it work? (Clinical effectiveness) and Should we spend money on it? (Cost effectiveness). The second question is often the problem and as a clinician I have an instinctive distaste for the concept; my patient is ill, I want to make them better, this works and I don’t care how much it costs… However, whichever healthcare system you work in there are limited resources and hence the need to ask if therapies are cost effective. This is done using a methodology called QALYs (http://www.medicine.ox.ac.uk/bandolier/booth/glossary/QALY.html)

The concept is that a year of life lived at 100% health equals one QALY, whilst a year lived at 20% health equals 0.2 QALYs. The advantage of this approach is that is enables very unlike things to be compared such as therapies that treat disabling conditions against life-saving procedures. Ultimately it is impossible to put a value on human life. It is truly absurd. However in clinical practise where there is a limited pot of money – as there inevitably is, somehow we have to decide which treatments to use.

The interesting question is how much should the NHS spend per QALY gain?

To try and give some meaning to that here are a few examples (caution: the figures are made up by me to provide context)

Hip replacement
Patient aged 65
Life expectancy 15 years
QALY score without treatment; 0.4 x 15 years (i.e. an arthritic hip seriously decreases the individuals quality of life)
QALY score after hip replacement; 0.8 x 15 years
(Quality of life increased from 0.4 to 0.8)
QALY gain (0.8 x 15) – (0.4 x 15) = 6
Cost of Hip replacement £3000

Cost per QALY gain: £500

Neonatal care
Premature babies are extremely expensive…
28 week premature baby (born 3 months early)
Life expectancy without treatment: 0
Life expectancy with treatment: 70 years
QALY score with treatment: 0.8 (some prem babies achieve approximately full health, some never do, the range is massive)
A ’28-weeker’ would typically be in a NICU unit for 12 weeks at a cost of around £10,000 / week
QALY gain: 0.8 x 70 – 0 = 56
Total Cost: £120,000
Cost per QALY gain: £2150

Monoclonal antibody based chemotherapy for kidney cancer

Patient aged 38
Life expectancy without treatment: 3 months
QALY score 0.7
Life expectancy with treatment: 27 months
QALY score 0.5

QALY gain: (2.25 yrs x 0.5 QALY/yr) – (0.25 x 0.7 QALY.yr) = 1.125 – 0.175 = 0.95
Cost of treatment: £40,000 / year – total of £90,000

Cost per QALY gain: £95,000

[As I said, the figures are used purely to give context and I made them up myself. They are approximately accurate and there are studies out there that formally perform these calculations and then NICE makes a recommendation based on them.]

So what threshold would you put for deciding whether a treatment is cost-effective?

NICE typically works to a threshold of £20,000 – £30,000.

Ultimately we have to have a way of decided what to fund and what not to. Whilst the QALY method is undoubtedly crude, I don’t think there is a better one.

So let’s look at the NICE decisions, The Mail is complaining about – I looked up the NICE rulings on two of them:

Sorafenib

This is a drug for advanced HCC (a type of primary liver cancer). NICE concluded that the drug does improve life expectancy – the median survival advantage is 2 ½ months. So patients given this drug improve their prognosis from 14 months to 16 ½ months. At a cost of £51,900 per QALY gained.

Lepatinib

Lepatinib is used for advanced breast cancer. However it is only suitable for a minority of patients with this disease. The conclusion was that Lepatinib is clinically effective and improves mean survival from 17.6 weeks to 27.1 weeks. At a cost of £67,847 per QALY gained.

Why this article makes me so angry.

There is a vitally important debate underlying all of this. The question of what we as a nation and a society are prepared to spend on healthcare resources is vitally important. It is very difficult to decide whether end-of-life drugs are useful or not and there is no doubt that an extra few months spend with loved ones is extremely valuable.

However every £1 spent on one of these massively expensive drugs which have very limited benefits is money that cannot be spent on other healthcare spending. I think that part of the answer is that we should, as a nation, be prepared to spend more than we do but that’s my personal view. I also think that whilst drug companies are entirely legitimate in seeking to make a profit, some of the mark-up on medical products is simply immoral. What angers me is that this kind of article with all its inaccuracies has two effects; firstly it makes proper debate much more difficult and secondly it induces significant (and usually misplaced) anxiety in cancer patients and their families. And that to me, as a simple clinician is evil.

More Lies about the NHS

There must be something wrong with me. I read Richard Littlejohn’s column from 30th November (Thank heavens my sick mum wasn’t at the mercy of the NHS) and I didn’t get angry.

Was this because I agreed with what RLJ had to say?

No.

Was this because RLJ extensive research had led to a well thought-out argument that I found interesting?

No.

Was it because his column contained some facts for a change?

No.

So why wasn’t I angry?

Simply because it was RLJ being RLJ and I’m told you shouldn’t shoot a duck for quaking.

Normally this kind of thing makes me really very very angry. I have a small confession to make at this point. I am an unrepentant apologist for the NHS. I work in it, I am aware of its limitations and issues and I could write long articles on what’s wrong with it. I don’t for three reasons. Firstly, the NHS is much – and unfairly – maligned. Two, the problems of it are almost always different to the issues raised in the press. And thirdly, and much more importantly, the NHS is an amazing thing and whilst it does have issues they are, in the real world, a price well worth paying for comprehensive healthcare. I am proud of the healthcare the vast majority of patients receive and the work we do in the NHS. It is hugely frustrating to see this constant abuse in the press. And it’s not just about the shear insult of this but every week I have to deal with the anxiety created in patients before they even make it to the hospital door. Of course, it is not surprising that anyone who reads our papers is scared of being admitted to hospital.

So, let’s summarise RLJ argument;

1.His mother was involved in a traffic accident and was well looked after in a hospital in the states.

2. The NHS might have killed her because all British hospitals are dirty and you will pick up a deadly disease in you are unfortunate enough to be admitted one.

3. American Healthcare is great and insurance works while the billions we spend on the NHS are a waste as there’s no good outcomes or accountability.

If I only I knew where to begin with this. I must warn any brave readers that in order to write this I have done some actual research and have provided references at the bottom so that all the facts can be checked. That’s right – this article ought to come with a health warning to anyone who reads RLJ regularly; WARNING, the following contains actual facts and not RLJ delusions.

MRSA

I think I want to begin by talking about MRSA. To be fair to Littlejohn, almost no one in the press gets this right. My own personal rant is that MRSA is NOT a superbug. (E.coli 0157 now that’s another matter…. sorry, getting of the point). MRSA stands for Methicillin resistant Staphlococcus aureus. Staph. auerus is an extremely common bacteria, it is on the skin of at least a third of the people who read this article. It can be treated with various antibiotics including penicillins. Methicillin is not used in the UK – it is most closely related to Flucloxicillin (a type of penicillin). MRSA is Staph aureus that is resistant to flucloxcillin. This is not a major problem, as the vast majority of strains of MRSA are fairly weedy and are sensitive to multiple antibiotics and are fairly easy to treat. It is quite misleading to say that someone died of MRSA – they died of Staph. aureus infection and the MR bit or otherwise is usually irrelevant. Hospital-acquired infections are common and in general have nothing to do with hospital cleanliness. I know, what a ridiculous thing to say! Well, firstly the majority of infections that patients get come from their own skin. The main reason why people get infections in hospital is not because they’re in hospital but because they’re ill. By definition the people in hospitals are those that will be most vulnerable to picking up infections. This is why hospital cleanliness matters because it is about minimising the risk to vulnerable people. However, and this is the key, even if the hospital walls, floors, ceilings and beds were entirely sterile it would not stop people getting infections.

So what’s all this fuss about MRSA? The answer to that is multifactorial. I think there are two important reasons. Staphlococcus aureus is a very clever bug and can infect multiple sites in the body; it can cause skin infections, urinary infections, pneumonia, septicaemia (blood infection) to name but a few. The other reason is that the methicillin-resistant strains of Staph aureus are only found in hospitals or other institutions. Places where antibiotics have been used. And hence there is an assumption that MRSA has been acquired in hospital. MRSA infection can certainly be reduced by increasing cleanliness but to some extent that’s irrelevant, remember that most infections come from skin (and it’s impossible to ever fully sterilize a patient’s own skin). Do you really care whether you have a MRSA or an MSSA (common-or-garden Staph. auerus) infection, if I can treat it for you either way? There is no evidence that MRSA strains are more deadly that non-resistant strains.

Here’s some facts you’ll never hear in the press:

1.      MRSA is a worldwide problem. (Probably the greatest problem is in Japan for various historic reasons).

2.      MRSA became endemic in UK hospitals in the early 1990s.

3.      MRSA-related deaths are falling.1

4.      MRSA is a major problem in the USA. This is a quote from a CDC report. (The CDC is the Centre for Disease Control and Prevention – one of the world’s leading authorities on infectious diseases).2

“Hospital-acquired infections from all causes are estimated to cause >90,000 deaths per year in the United States and are the sixth leading cause of death nationally. Nosocomial infections increase patient illness and the length of hospital stays. The direct cost has been estimated to be >$6 billion (inflation adjusted)  costs of longer inpatient visits are shared by hospitals.”

So, please, can we move on from the myth that NHS hospitals are uniquely dangerous because only we have MRSA and it’s a superbug?

The US Healthcare system and its costs

So let us look at the US healthcare system. The top hospitals in the USA are amazing and provide amazing healthcare, many of them are world centres. However there are a few minor points worth noting. Healthcare in the US is astoundingly expensive.

Here are some interesting statistics;

46.3 million3 – that’s the number of Americans with NO healthcare coverage. (15% of the population). In the event of an emergency they do indeed get treatment – but it is strictly emergency only. So cancer surgery is not covered, on-going asthma care is not covered. People with bad asthma need on-going treatment to control their disease. Without this hospital admissions are common. Emergency cover will patch them up (usually) and chuck them out to come straight back in again the next time. The frequency and severity (i.e. whether it is life-threatening or not) of attacks can be reduced with good on-going treatment. Not available to 46.3 million Americans unless of course they pay for it themselves.

The leading cause of bankruptcy is the US is healthcare costs4 – even people with healthcare insurance struggle – limitations on cover, the deductible (i.e. how much you have to pay yourself). Imagine recovering from a serious illness to then lose your home.

£92.5bn – the cost of the entire NHS for the financial year 2008-95

$596.6bn – the combined cost of the US Medicare and Medicaid programs6. That’s £360bn. Medicare provides healthcare coverage for the elderly and Medicaid for the poorest. The majority of uninsured people are too well off for Medicaid but can’t afford insurance or their employer doesn’t provide it. Both of these programs still involve premiums and co-payments in addition to the government £360bn. Medicare has about 45 million people enrolled and Medicaid 50 million. So, in summary; the inefficient, expensive NHS covers 60 million people entirely for £92.5bn, whilst Medicare/Medicaid provides basic coverage (but not without co-payments) for 95 million people for £360bn. In fact, the US spends more per population on a basic healthcare system that only covers the oldest and poorest than the UK government spends on a healthcare system that looks after everyone. In UK terms that would equate to the government spending around £120bn for basic (so-called safety-net) coverage of less than 20 million of the UK population.

And here’s the real shock; for all the money they spend, the US life-expectancy is less than that of the UK.7

I am seriously impressed by anyone who’s still reading at this point. And this is part of the problem, the sort of trash that the Daily Mail puts out is much easier to read than the complex facts that actually reflect the truth of healthcare. There is so much more I can write – about unnecessary and invasive tests, about the benefits of preventative medicine but I think I should stop now.

The NHS is far from perfect but it is very very good. It is also unbelievably cheap for what we get for our money – worryingly to those who work in it, it is the most efficient healthcare system in the world. The problem is that for ideological reasons (i.e. Government=bad) The Daily Mail and those like it want to force us to take on a US-like model of healthcare. They’ll get their 5* hotel room hospital beds and everyone else will suffer. We will see the poor and the elderly left to die quietly or to live with their debilitating disease as the insurance companies make a fortune. And if the American example is anything to go by, ultimately we all end up paying more for sub-standard healthcare coverage for the most vulnerable.

I want to apologise for the length of this article but someone has to stand up to the constant lies of the Daily Mail. The NHS is an amazing thing and whilst it does have issues they are, in the real world, a price well worth paying for comprehensive healthcare. I am proud of the healthcare the vast majority of patients receive.

Dr alienfromzog BSc(Hons) MBChB MRCS(Ed)


References:

1.      Department of Health: http://tinyurl.com/6kjbue

2.      Centre for Disease Control and Prevention paper: http://tinyurl.com/ybvp2p3

3.      US Census: http://tinyurl.com/ln5a2q

4.      Baltimore newspaper article: http://tinyurl.com/ylg2fet

5.      HM Treasury corrected figures: http://tinyurl.com/yzme4ng

6.      Official financial report of Medicare and Medicaid; http://tinyurl.com/yguq2wn

7.      World Health Organisation figures: http://tinyurl.com/yguq2wn

Paul Dacre Must Die

The Daily Mail are a fucking disgrace of a newspaper. I hope Paul Dacre dies a slow and painful death and that people queue up to shit on his grave. The current top story on the Mail Website (betting it will be front page news tomorrow with a special defecation from Littlejohn who must be drooling reading this one) is this: ‘Mapping out the strain on your NHS: 243 sick babies treated in one London hospital ward…. and just 18 mothers were born in the UK‘. Naturally this story has already found its way onto the Stormfront forums and will no doubt be picked up by the BNP and other racist organisations gathering ‘evidence’ of how the poor white child is neglected in favour of the ethnically diverse child.

I’ve scouted the website of the hospital involved – London’s Chelsea and Westminster – and cannot find a copy of this map or any press release relating to it so I cannot verify any information or put it into any real context – exactly what the Daily Mail wants. The whole article concerns a map made to celebrate the diversity of mothers that give birth in the hospital. It seems to involve mothers being asked to put a pin on a map to show their original birth place. The Mail does not specify the timescale over which the data is collected, nor does it specify whether all mothers were asked or whether the hospital went out of the way to collect data only from foreign mothers.

The whole article is just whinging at the fact that people from other countries have given birth to children in a British hospital. We don’t get given any further information than that because the Mail knows that the headline is enough to get the usual idiots foaming at the mouth about ‘immigration’ and ‘loony-left madness’ etc.

As for those wankstains moaning about the cost to the taxpayer – £1400 a day according to the Mail, not a figure they provide a link for – I may complain about paying taxes as much as the next guy, but you know what, I get a warm feeling when I see this map. I pretend that all of the tax I’ve paid this year has gone on just saving one child’s life and it somehow makes it all worthwhile. A fellow human being has given birth to a child and thanks to the NHS it has survived. It is a triumph for humanity over arbitrary borders, of compassion over hateful ‘not in my country’ types who would pull up the drawbridge and say ‘fuck you’ to the rest of humanity even if they were sick children who would die without our assistance.

When you read this Daily Mail headline – and if you dare, the whole article and comments – it is easy to forget that Sue Reid – the author of this disgusting piece of hatred journalism – is actually talking about the lives of sick babies – something supposedly sacred. Here they are described as a ‘strain’ and used as an example of ‘the changing face of Britain’.

Personally I celebrate the fact that ‘The 243 mothers are from 72 different nations. They include Mongolia, the remotest regions of Russia, Japan, Africa, South America, swathes of Asia, Australasia and even Papua New Guinea’. I think it speaks volume about the value that we as a nation place on human life; that we are in the majority a nation who doesn’t worry about the nationality of a child that might die but instead save it – regardless of whether we can wring the money out of the parent.

I just pretend that none of my taxes go to treating a single sick Mail reader. And I consider them all to be sick for wanting to enrage themselves with such hateful bullshit each day, and for treating the lives of a few sick children as a burden which we must get rid off.


Update:

Thankfully Five Chinese Crackers has had the patience (and past experience with Sue Reid) to properly look into this story and has an excellent post on this, please go read it because Sue Reid really is a piece of shit. He also includes the following press release issued by the hospital that demonstrates just what a complete farce the story is, although I suspect the damage has already been done. If Littlejohn uses this story tomorrow (if he can even be arsed to shit out a column that is) then he really will demonstrate that he is never about ‘reporting the facts’ as he so laughably puts it. Here is the press release (massive hat-tip to 5CC for this):

‘Chelsea and Westminster Hospital is a specialist referral centre and cares for patients of many different backgrounds, reflecting London’s very diverse population.

‘Of the 550 babies admitted to our Neonatal Intensive Care Unit (NICU) every year, a very small number of these are overseas patients. In 2009, there have been just two overseas admissions.

‘The map was placed in the NICU nearly four years ago to provide the families of the babies we care for, as well as staff, with an opportunity to indicate their background if they wished. It is not an indication of country of residence or citizenship.

‘It was intended to illustrate the diversity of staff working on the unit and the families of the babies we care for, to encourage everyone to reflect on different cultures, in a fun and informal way.

‘Chelsea and Westminster Hospital’s NICU provides intensive care, high dependency and special care facilities for babies and is a specialist referral centre for neonatal surgery.’