The GMC should fast-track 500 refugee doctors to serve in the NHS

I have had an email from the General Medical Council, the disciplinary body of the medical profession, in response to my letter of last week, in which I charged them with being professionbally negligent in failing to grant immediate temporary licenses to practice to about 500 refugee doctors. Some of these docs have practiced medicine in places like Syria. They are used to extreme situations. I asked them to fast track these doctors into the NHS on a probationary basis - that it, that after say, three weeks in practice, their peers could say if they had any problems in practicing. The GMC has referred my letter to their own complaints board. Here is my reply:

Dear xxxx

Thank you for this [email], but I did not intend to complain. I do intend to persuade the GMC that they should fast-track the foreign-registered doctors so that they can work in the NHS in as short a time as possible. The GMC must realise that the Covid-19 pandemic is causing a crisis in the NHS, with a shortage of doctors due to illness and quarantine. The shortage of doctors at a time of unprecedented demand leads to stress, and stress is known to lower the effectiveness of the immune system. This, combined with the shortage of PPE, makes doctors, although young, vulnerable to a fatal outcome when they do succumb to the disease. I hope you can see that there is a positive feedback system in play here.

You may argue, "Well, there are only about 500 foreign - registered and refugee doctors, what difference would they make?" The answer is that every doctor makes a difference. The day after I sent my last email, you restored my licence to practice. I am a retired GP, 73, with hypertension and paroxysmal atrial fibrillation, so I am not going to last for much more than a few weeks in the front line before I succumb, yet you feel the situation is desperate enough to ask me to come back into service. I am going to respond, and will apply for medical insurance soon. You want me, but you do not feel that a doctor with experience of emergency medicine in the Syrian war is going to be worth while to register? I find this impossible to understand.
I do understand that you need to check on a doctor's abilities in medicine and communication. The best people to make this judgement in the current crisis are that doctor's peers. Give them a temporary license, draw up a probationary contract, and ask the peers to judge on the doctor's value and abilities. If there is paper work to be done, do it while the doctor is working.
Please listen to what I am saying. I am not writing a professional letter, I am writing from the heart. There is a crisis happening out there, the NHS is crying out for more doctors, and there are doctors who are desperate to join the effort. Please put the official forms and protocols aside. Please rise to the occasion.
Yours sincerely


Richard Lawson

4 hour A&E targets are good for the impatient, but not necessarily for the patient

www.dailypost.co.uk

What you are about to read is probably wrong. See the foot of the page.

Sonia Powell, 73, died in an ambulance while waiting for 35-minutes to be admitted to the A&E at Morriston Hospital, Swansea. She was seen by a doctor soon after her ambulance arrived, but the A&E was very busy.

There is to be an investigation.

The question I would put to the investigation is this:

Was Sonia's ambulance asked to wait before passing her into the care of A&E in order to meet the A&E's 4-hour target?

A&E departments are required to ensure that  95% of their cases be in their department for no more than 4 hours before they are discharged or admitted to a ward.

It is often pretty demanding to meet this target. In busy times, staff have to do one of these things:

1. work quicker, which brings with it the risk of mistakes, which lead to complaints, which lead to staff being off sick or working while in a depressed and anxious state, which leads to more complaints
2. get wards to accept patients quicker, before a firm diagnosis has been made, which may mean the patient is put on the wrong ward, which may lead to complaints, which lead to staff being off sick or working while in a depressed and anxious state, which leads to more complaints
3. reduce the rate at which people come in through the doors of A&E. The way to do this is to leave patients coming in by ambulance in the care of the ambulance crews. These patients are technically not in A&E and so do not figure in the target statistics. 

I have been in this situation, on a trolley outside the door of A&E, chatting to my ambulance crew.  I was not acutely ill, and would personally rather not have been there, but a nurse from a MIU had insisted I go in order to avoid risk of a complaint, even though I had told her I was not a complainer.

My ambulance and crew were out of action during my 20-30 minute wait, leaving their colleagues on the road more busy, which brings with it the risk of mistakes, which lead to &c.

Sonia Powell was not that old. She may or may not have had multiple problems that doomed her to die. She might have died in A&E or on the ward - or she might not.

The investigation may decide that one factor in her death was the 4 hour waiting target. Or it may not.

In the end, to avoid mistakes, A&E departments do not need targets set by politicians and applied by managers. They need adequate levels of medical, nursing and diagnostic staff.

Having posted this, I tweeted this to the excellent Malcolm McKenzie, A&E consultant, who informed me most politely that what you have just been reading is wrong. However, it may be a bit right imo.

Who will pay for the PIP silicone breast prosthesis clean-up?

The current news about PIP, the now-defunct silicone breast implant manufacturer who came up with the brilliant wheeze to use cheap industrial silicone in its implants, raises interesting questions about the relationship between private and NHS medicine.

30,000 French women will have their balloons removed, but the DoH is reassuring UK recipients that there is nothing to worry about, even though it seems the PIP device is more prone to rupture, which will present the immune system with a challenge.

There is an association of 7-8 cancer cases with the PIP , including one rare Anaplastic Large Cell Lymphoma. It will take many more cases of cancer and illness to develop before the probabilities of a causative relationship becomes accepted by the academics. Studies of the carcinogenic potential of the contaminants will be needed, and all studies will cost much money. They should be funded by the insurance services of the private cosmetic surgery industry - but it would be naive to expect that will happen.

The French are using the precautionary principle, and the UK is using the HITS (Head in the Sand)  principle.

In the end, I predict that it will be advised that all the PIP prostheses will be ordered to be removed.

But who will pick up the bill?

Removal costs are about £2000, and replacement £5000. Most were put in at private expense. Removal and replacement should therefore be at private expense. But one woman said: "I was constantly unwell and the implants lost shape," she said. "They looked deformed. I went back to the clinic but they told me I would have to get the NHS to clean up the mess."


This is clearly the line that the cosmetic surgery industry and their insurers will be lobbying for.  The Tories, when they have finished being in denial,  will probably agree to the NHS doing the remediation work free of charge,  in line with their policy of dumping on the NHS while promoting and supporting private medicine.  




See also: My book Bills of Health, which showed that about 20% of NHS clinical work is devoted to treating illness caused by unemployment, poverty, bad housing and pollution.

Adopting a Peer to lobby on Health and Social Care Bill

I have adopted a Peer to lobby in the fight against the Health and Social Care Bill. 
You can too. Click here. We get allocated a Lord (or Lady) at random, and can send a letter. Here's mine:

Health and Social Care Bill

As a retired General Practitioner, who have worked all my life in the NHS, I very much hope that you will do all you can to radically amend the HSCB, making sure that the worst aspects are removed. I paste here a list, generated by Dr Evan Harris, an ex-MP, highlighting the aspects that most need to be amended. You will probably recognise this as a LibDem amendment, but the NHS is a matter beyond party politics, (I am a Green), and this is a fuller version than other lists that are circulating.

1. the removal of all references to promoting competition whether directly or indirectly.
2. any duty to promote choice being made subsidiary to duties to promote fair access, equality of outcomes, and integrated services.
3. the removal of the facility for transferring NHS assets, including land, to third party providers.
4. retaining the cap on Private patient income by NHS Foundation trusts.
5. the restoration of the duty of the Secretary of State to provide or secure the provision of, healthcare services, and the reinstatement of the power of the Secretary of State to delegate his functions to NHS commissioners and to direct them as necessary.
6. the retention of the ability of the local authority overview and scrutiny function to refer significant services changes to the Secretary of State for adjudication.
7. providing that Health and Well-being Boards (HWBs) have a majority of elected members and are able refer unresolved disputes with local commissioners to the Secretary of State rather than to a national qango.
8. the explicit prohibition of the wholesale outsourcing of commissioning work to private companies.
9. guaranteeing that commissioning groups are fully co-terminous with social services local authorities, except where HWBs and local authorities agree otherwise, and are funded solely on the basis of the health needs of the population.
10.the removal of the power to pay financial incentives to practitioners as a means of influencing their referral behaviour.
11.rejection of any personal health budget scheme which allow users to spend NHS funds on private health insurance or as a top up towards private health care or to buy services or treatments judged too ineffective or inefficient for the NHS to buy.
12.the inclusion of a duty on all NHS bodies, when arranging with non-NHS bodies to provide services, to avoid any risk of essential NHS services (including teaching and research) being destabilised in an unplanned way through loss of income or case-load,
and
13.ensuring Directors of Public Health remain independent sources of expert advice.

I trust that you will put much effort into amending this Bill. The NHS is well loved by its users, and despite its deficiencies, is one of the most efficient health services in the world.

Thank you for working on this most important matter.

Sincerely

Andrew Lansley's Health Bill picked up by Care UK

What's going on?

The below-pasted snippets from today's Daily Telegraph.

It is as if the Telegraph has had a truth drug put in its editorial tea.
Or has woken from a deep slumber.
Or maybe they just do not like anyone who says to them, "Call me Dave"

Whatever, it is a very welcome development. I feel the stirrings of hope within my thorax. Maybe the Coalition is about to execute a majestic U-Turn over the Health and Social Care Bill.


Andrew Lansley, the shadow health secretary, is being bankrolled by the head of one of the biggest private health providers to the NHS, The Daily Telegraph can disclose. John Nash, the chairman of Care UK, gave £21,000 to fund Andrew Lansley’s personal office...Mr Nash, a private equity tycoon, manages several businesses providing services to the NHS...96 per cent of Care UK’s business, which amounted to more than £400 million last year, came from the NHS.

Lansley is not alone in having some financial explaining to do.


The private office of George Osborne, the shadow chancellor, is funded by the hedge-fund bosses Michael Hintze of CQS and Hugh Sloane of Sloane Robinson...Alan Duncan, the then Energy spokesman, was heavily criticised after it emerged that his private office was being funded by Ian Taylor, the chairman of Vitol, a firm of oil traders. 

This Health Bill is rejected or questioned by almost all significant experts. There is evidence that Dave is worried about it.

We can be certain that GPs will be wheeled out in the next few days saying it is a good idea, but they will be the ones who will get fancy salaries and bonuses from running the GP Commissioning authorities.

The Health Bill will be to the detriment of the UKs health care. Nobody wants it except those who expect to get their snouts in the trough. Now we have a direct financial link between a private consortium and the Health Secretary who is passing law that will benefit that consortium, part of a pattern of links that demonstrate unacceptable, anti-democratic practices.


I have a feeling we can win this one.

I also have a feeling that there may be a General Election within a year. This is not a prediction,  unless it happens, in which case it is.

Alternative plan for NHS reform

This below is a response to Lansley's plans for dismantling the NHS. It was drawn up by Dr Tim bland, and has developed supporters through email lists. Tim is trying to get it into the letters columns of papers, without success so far. I believe this is because it is information-dense, and the media cannot cope with information. They deal with impressions.




Alternative Agenda for Healthcare Reform

4.1.2011

Letter for publication in The Guardian



Sir, Following Polly Toynbee’s comment article on the NHS published on page 29 on 4.1.2011 we are a doctors’campaign group who would like to keep the pressure up on the Government with an alternative agenda for NHS Reform. Healthcare does need reforming, but not in the destructive way the Government is signalling; so what should the government do? Unfortunately Labour is not offering a constructive alternative at the present time.



1 Put the White paper on hold and have a time of national consultation with all stakeholders. The new Secretary of State is moving “too far, too fast” with a level of reform that carries a huge risk of major failure. We need a national rethink on the way forward for the next 50 years, not the next five.



2 The coalition government needs to realise that this White Paper risks bringing about the end of the NHS as we know it by causing complete chaos followed by fragmentation and piecemeal privatisation. We should not put responsibility for running the whole NHS onto GPs, as is proposed by Mr Lansley.



3 We believe that the Government does want to retain our state-run healthcare system i.e. NHS, but that it is missing a golden opportunity to introduce changes that place more onus on individual responsibility for health and associated costs. The only way to save the NHS is to reform it. However, Mr Lansley is increasing patient expectation when he should be increasing patient responsibility.



4 A new contract would need to be established between the State and the Population for the continuation of a universally applicable, state-run, healthcare system. This would involve the Population accepting a reduced scope of NHS services, the State committing itself to long-term healthcare provision and all parties recognising that the NHS’s performance is crucial to the success of the greater project for national debt reduction.



5 Be true to the sensible, Conservative manifesto commitment to have no more major, reorganisational change in the NHS. Keep most existing structures in place and bring about rational, consensus-based, incremental change. This will be far less expensive and leave doctors free to focus on efficiency savings instead of being diverted to major reorganisational change.



6 Have a full, informed debate on the expensive, 20 year, experiment of the purchaser/ provider split, which began in 1990 with Kenneth Clarke and Margaret Thatcher. A decision needs to be made now on whether to keep it or get rid of it.



7 Abandon blind faith in the ideology that the free market will be an effective agent for “saving” the healthcare system. This blind faith is a pre-2008 idea, utterly discredited since the Banking Crisis broke upon us. This supreme faith in the free market needs to be downgraded onto a par with the many other healthcare ideologies in the intellectual market.



8 Focus on doing something urgently about the state of our hospital sector. Consultants should be given back power from managers and also the accountability that always used to go with the crucial link between each patient and their named consultant. Restore the traditional “firm system” of consultant-led teams; this could only be done by finding some way of reducing the drastic effect that the EWTD is having on our healthcare system; this would enable restoration of continuity of care in hospitals and proper training for the next generation of doctors, especially future surgeons. Do something about the national scandal of PFI costs that are bleeding the NHS dry. Get rid of the plethora of centrally driven targets.



9 Don’t force any change upon GPs that compromises their vital advocacy role on behalf of their patients or diverts their attention from patient care. Each patient has to know that his GP’s sole consideration is the patient’s best interest.



10 Make sure that the U.K retains its high level of medical training, medical research and public health, which are some of its greatest strengths.



We believe these ideas could be developed into a pragmatic, centrist philosophy for sustainable state-run healthcare that could command widespread support for many years to come. We want to bring this alternative agenda for NHS Reform to a wider, national and parliamentary audience



The NHS Twenty Ten Group of U.K. Doctors

Dr Tim Bland, GP, Chairman

Mr Wael Ismael, general surgeon

Dr Raj Patel, haematologist

Dr John O’Moore, GP

Dr Raj de Silva, neurologist

Dr Mohsen Khorshid, dermatologist

Mr Bhik Kotecha, ENT surgeon

Mr A Sivaraman, spinal surgeon

Dr Pushpa Chopra, GP

Mr Jag Chawla, ophthalmologist

Dr Ashok Kumar, GP locum

Dr Chaman Sajjanhar, GP retired

Mr Bhabu Chopra, ENT surgeon

Dr John Lee, GP

Dr Abdul Jabbar, GP

Dr S Subramaniam, GP

Mr Chitta Chowdhury, ENT surgeon

Dr Mani Subramanian, GP

Dr Badi Beheshti, GP

Mr Krishna Vemulapalli, orthopaedic surgeon

Dr Sridevi Vemulapalli, GP locum

Dr Maryline Punungwe, GP locum

Dr Pamela Punungwe, GP registrar

Dr Richard Lawson, GP locum



Dr T. C. Bland

NHS GP

Chairman of The NHS Twenty Ten Group of U.K. Doctors

Wife who retracted rape claim: Explained

There are many news reports on the case of the wife who falsely retracted an allegation that her husband had raped her, and was sent to prison.

The Guardian gives them the names Sarah and Ray.

In essence Ray was abusive and a control freak over many years of marriage. After he had raped her, Sarach called the police, and Ray was arrested and sent down. Out on bail, he manipulated Sarah, first into dropping her charges against him, and then into retracting her rape allegation against him. She phoned the police and said she had made it up. The Crown Prosecution Service then did her for perverting the course of justice, and she went down until the sensible Judge Judge (sic) released her.

As a psychiatrist and GP I have seen many of these cases. 
There is usually a manipulative male* who insists on controlling all actions of his partner. She is unable to talk to friends, especially male, but also female. She has difficulty in going out of her partner's sight. Violence and rape is common. She is miserable, and begins to think about leaving; and this is where the difficulty begins.

Say an alert GP or Social Worker notice what is going on, and offer to help. She says she needs help, but then a strange on-off pattern kicks in. She wants help, but keeps going back to him - irrationally, and to the total frustration of anyone who is trying to help her.

The Battered Woman Syndrome has been written up by Lenore Walker, a psychologist. She frames it in terms of PTSD.

I offer a simpler framework: the woman's will has been taken over by the male. He exerts control over her actions, through very extensive manipulation.

For instance, when she tries to get away, he will convince her that he is going to kill her, or her children, and/or himself. He is able to convince her time and again that he is sorry, and that he will change. So the woman, powerfully driven by misery and pain to seek to leave him, is drawn back, equally powerfully, by his manipulations.

If this state of affairs were more clearly recognised by psychiatrists, medics, SWs, police, CPS and judges, we would all be that much better off.

I ought to write to the Royal College of Psychiatrists. Maybe I will.

In the meantime, girls, if he seems to be a control freak - RUN!


*gender roles can of course be reversed

Chernobyl deaths estimated at somewhere between 56 and 1,000,000.

I spent yesterday evening watching Channel 4 "What the Green Movement Got Wrong". As an experience, it was less unpleasant than scratching my eyeballs with a Brillo pad, but only slightly so, mainly because I am not used to doing the Brillo pad thing, whereas I am only too familiar with seeing the green movement misrepresented on telly.

The programme was a reprise of Ch4s "Great Global Warming Swindle", only this time they stuck a studio debate onto the back end to try to forestall complaints. There was no attempt at balance in the film itself : it was an all-out attack on the green movement by a handful of alienated ex-activists like Mark Lynas.

Luckily the debate had FoE, Greenpeace and George Monbiot on to rebalance the outrageous bias of the programme. They did very well.

The programme was basically a paean of uncritical praise for nuclear power and GM food, both of which are necessary to save the world.

As part of the case, they claimed that the damage from Chernobyl was over-hyped. They quoted a UN report, led by the International Atomic Energy Agency, concluding that only a 64 deaths are attributable to Chernobyl.

So that's all right then. Or is it?

John Vidal has a useful survey of estimates of Chernobyl related cancer and deaths. Here we go:


Agency                                              Deaths so far    Cancers predicted           Deaths predicted

UN/IAEA/WHO Report                               56                                                  4,000

UN International Agency for
Research on Cancer                                                                                         16,000

Russian Academy of Sciences              200,000

Belarus National Academy of Sciences   93,000                 270,000

Ukrainian National Commission
for Radiation Protection                       500,000

Assuming there is no double-counting, that brings the number of deaths in Russia, Belarus and Ukraine up to 793,000. This figure is reinforced by a book  "Chernobyl: Consequences of the Catastrophe for People and the Environment," by Alexey Yablokov of the Center for Russian Environmental Policy in Moscow, and Vassily Nesterenko and Alexey Nesterenko of the Institute of Radiation Safety, in Minsk, Belarus, who examined over 5,000 scientific papers.

They challenge the UN/WHO figures on the 56 deaths among "liquidators" who went in physically extinguish the fire and clean up the Chernobyl reactor.


"The book finds that by 2005, between 112,000 and 125,000 liquidators had died."

Yablokov was a contributor to the Greenpeace review on this link.

In summary, we have a bit of a discrepancy here.

Chernobyl related deaths lie somewhere between 64 and 1,000,000.  

What is the explanation?


Part of the explanation is that the UN studies only included papers in written in English in peer-reviewed literature. Peer-review is OK, can't argue with that since we require it for climate science, but in English? Since when has it been that knowledge is only valid if it is written in English? This is an outrageous, blatantly political attempt to exclude unwanted data.

I am aware that I am beginning to sound like a climate change denier here. This is an interesting role reversal: in the case of climate science, the sceptics are in denial; in the case of radiation science, the deniers have got their hands on the levers of power.

The fact is that radiation medicine is very highly politicised, which is affecting how people view the facts.

There are doubts throughout the science, beginning with the estimation of the effects of radiation arising from the Hiroshima and Nagasaki experiments. Prof Chris Busby shows that there are two distinct modalities, one from external radiation like gamma, and another from internal irradiation, where a particle is lodged in the tissues and irradiates its environs with repeated doses of alpha. This means that the orthodox view of dose is unfounded. He likens it to the difference between warming yourself at a fire and eating a piece of coal. Chris Busby also posits a Second Event theory to explain the how the biological effects of internal radiation are underestimated by the orthodox paradigm.

There has been no methodical data collection over Chernobyl. The IAEA/UN report suggests that we will never know. Basically, it is not in the interests of the IAEA that we should. The truth is not in them. Their sole raison d'etre is that nuclear power should forge ahead, come what may. To this end, it seems very likely that they have co-opted and corrupted the WHO and other UN agencies.

Mark Lynas may say that in taking this view, I am being unrealistic.

If accepting IAEA lies and distortion, and starring in propaganda films is the way ahead for the NewGreens, then I prefer to remain an old Green, thanks Mark.

Lansley NHS Reforms: totally wrong. Grassroots-up, demand-side reforms needed

I tend not to blog about medicine much, partly because blogging is for fun, and medicine is my day job (though only one day a week, and I do that just for fun, so it is time I began blogging medicine. QED).

The NHS changes proposed by Andrew Lansley need a good firm smacking. The only thing he has got right is that medicine should be oriented slightly more to primary rather than secondary care. However, Lansley's organisational revolution is not the way to do it. Few GPs have the organisational skills to make it work, though we will be given a good media hammering in coming months by GPs saying it is a Good Idea.  These will be the GPs who stand to make a fortune by charing the new administrations.

My experience of NHS meetings tells me that the NHS is not good at organising decisions. What it will mean in practice is a hugely expensive change in letter headings from "Blogshire Primary Care Trust" to "Blogshire GP-led Patient Focussed Primary Care Trust." This is going to cost some £3,000,000,000 pounds for a pointless change, at a time when people are being thrown out of work in the name of deficit reduction.

Total madness.

And why are they doing it? In order to open the door that bit more for private "care" companies to get work from the NHS. Privatisation by stealth.

So Lansley's reforms are top-down, organisational changes designed for the convenience of private health care companies.  The NHS needs this like it needs a hole in its heart.

This does not mean that the NHS should just be left to carry on regardless. 
It does need reforming, but the reforms should be grassroots-up, not top-down.
There should be more concentration on the demand side of the equation, not just the supply of drugs and therapies.

In brief, this means improving public health with policies designed to reduce inequality, unemployment, sub-standard housing, reduce pollution, and promote social cohesion. This could reduce demand on the NHS by some 20%.

Secondly, GPs should spend a proportion of their post-grad education time simply exchanging information with each other on what works for them.

Third, all big organisations need a Suggestion Box Scheme.

Fourth, GPs need to be trained up in brief psychotherapy, clinical ecology and acupuncture in order to offset their reliance on expensive drugs peddled by Big Pharma.

I will try to explain what I mean in future blogs.

That glucosamine trial

I have read the paper on glucosamine and chondroitin by Juni et al (here, but you may need to be a BMA member to see it).

They find no significant effects from these supplements in arthritis in the papers they examined, but no side effects either.

This runs counter to my clinical experience, of patients happy to have lost their pain, and taking less erosive pain killers. Yes, I know. Anecdotal. But happy patients mean a lot to me.

I could find no obvious flaws in the paper, but then to do that you would have to be a statistician. Incidentally, a statistician reviewed the statistics of a load of papers published in the Journal of the Royal College of Psychiatrists (of which I am a member) and found that the fast majority were statistically flawed.


However, the fact that they looked at joint space deterioration is significant, even if the results were not statistically significant. NSAID painkillers make no claim to increase joint space (in fact they may decrease it).

One of the difficulties with non-patentable drugs and treatment modalities is that there is no incentive for manufacturers to pour squillions into research, as investment towards receiving 20 years of patents royalties.  So the work does not get done adequately.

Pace Juni et al, if I get a patient with year old with early osteoarthritis coming in, besides all the usual stuff - painkillers, weight loss, exercise - I will still advise him to try a 3 month course of glucosamine, drink more water, and try the effect of a magnet. I'm sorry if this will infuriate EBM zealots, but if I see him skipping in in 3 months with a smile on his face, pain free, and not taking analgesics, I cannot see that as a bad thing.  Meta analyses are useful, they have their place, but they are not Holy Scripture.

H5N1 in Indonesian pig population. Ideology to blame.

Great. H5N1 bird flu has jumped to pigs.  Just in case this gives you a So What? reaction, we are not talking here about the Swine Flu A(H1N1), which was all the rage in 2009, with huge vaccination and public health measures until it turned out to be quite minor, of interest now only to conspiracy theorists who think that it may have been dreamed up by Big Pharma as a measure to boost profits from sale of Tamiflu and vaccines.  (My opinion is that the response of the public health authorities was fairly correct, and that we should all count ourselves lucky that it turned out to be so mild).

No, we are talking about H1N1 Avian flu, which kills about 60% of the humans it infects. Luckily, it has great difficulty in spreading from birds to humans, and from human to human. You have to be pretty close to an infected bird or human to catch it. The epidemic of H5N1 in birds has been tailing off in Indonesia since 2007, but it is present in 7% of the pigs. Unfortunately they are mainly symptomless carriers, so we don't even get to identify which ones are infected without a test.Fortunately, it does not yet seem to pass from pig to pig.

So why is it significant that it has found its way into pigs? Pigs are a reservoir for the virus, and in pigs it can shuffle its genes around until it comes up with a winning combination that enables it to spread from pigs to human and between humans. Pigs are closer to humans than birds, physiologically. So far it has not done the transmission trick, and it has been in Indonesian pigs since 2005. It has so far developed the capability of binding to protein in the noses of both pigs and humans.

Maybe we will get lucky again, and by the time the H5N1virus overcomes its transmission problem,  it may hopefully have lost the virulence that gave it its 60% mortality rates.

If not, if it gives us another 1918 epidemic, at least we will have someone to blame - the free market fundamentalists.

How so?

Well, take a look here, at this WHO table of human deaths from H5N1.

Compare Indonesia and Vietnam.
Vietnam had a bad problem - the worst in the world - until 2005. Then they cracked it, and Indonesia took over as the main country of infection. The Vietnamese cases since 2005 were mainly from contamination from Indonesia.

How did Vietnam succeed in clearing the infection? Here's How.
After nearly two years of using mainly culling to control the virus, the Communist government last year adopted a combination of mass poultry vaccination, disinfecting, culling, information campaigns and bans on live poultry in cities.

Any rational world health organisation would have tried to replicate Vietnam's success in Indonesia. They did not.

Hans Troedsson, the UN's World Health Organisation representative in Vietnam, said the plan was "technically sound" but could not be copied or used as a blueprint by every country.
The cause of this irrationality, in my opinion, boils down to ideology. Vietnam's solution was deemed socialistic by some influential person within the WHO. Indonesia's sacred free market must not be contaminated with socialism. Instead, it remained contaminated with H5N1, which has passed into the pigs, and may pass thence to us, which may or may not have important consequences for human population numbers.


I am being very careful to remain scientific and objective here.

There is a remedy. Control the Indonesian outbreak with the Vietnamese model. Test all Indonesian pigs for H5N1 and slaughter out all the carriers. It's going to be expensive, far more expensive than applying the Vietnamese solution to the birds, but hey - that's the free market!

How to undermine Big Pharma's influence on the NHS

There is an ongoing debate on Bright Green Scotland about Caroline's backing for homoeopathy.

The question of Big Pharma has come up.

Now I am not proposing that the solution to corporatised medicine is to give everyone homoeopathy.

But one pathway to undermining the power of the pharma corporations  is

(a) to understand the financial bias that is pushing medics to prescribing expensive patented medicines.

(b) to find out whether promising lines of CAM (Complementary and Alternative Medicines)  are in fact more cost – effective.
I am thinking of

• acupuncture, 
• magnetotherapy, 
• some herbs (not “herbalism” as a whole entity), 
• clinical ecology (=food intolerance, indoor air quality &c), 
• acupuncture, and 
• certain forms of psychotherapy, (hypnosis for PTSD, Cutting the Ties to deal with toxic relationships), 
• food supplements like glucosamine, and 
• homoeopathy.

Before the opposition start accusing me of being anti-scientific, I am proposing that these things should be examined scientifically.

All of these lines I incorporated into my practice, and I had low prescribing costs. All of these CAMs have a poor evidence base, because of the economic problem associated with research - you cannot get a patent on a traditional medicine, therefore there is no incentive to spend £loadamoney investigating it.

It is up to the Government, through the MRC, to assess these treatment modalities.

On homoeopathy, the key point, as comedians and scientists never tire of pointing out, is that there is no *material* apart from sugar in the pills. If matter is the only effective agent, H cannot work, therefore it does not work, therefore studies that show it does work are erroneous. QED.  Which is a scholastic argument, not a scientific one. Scholasticism argues from authoritative principles, science argues from observation.

As I link on an earlier blog , there is some evidence from physical experiments that ultra high dilutions, if prepared in a certain way, may retain unexpected properties. If this can be established, homoeopathy could be re-examined more objectively, with less examiner bias.

Its a small point, this Homoeopathy debate, and I think Caroline is doing the right thing, especially if she calls for an audit of homoeopathic practice in the NHS.

While on the subject of undermining the influence of Big Pharma, there is the matter of preventive health too. About 1/5th of NHS spending is down to treating ill-health caused by non-green policies – unemployment, poor housing, pollution and poverty. Maybe more if social disintegration were counted. This is in my book.

Now, let’s all get going on the Resistance to the Cuts. http://bit.ly/deApQe

The BMA Homoeopathy (homeopathy) debate

The BMA is calling for homoeopathy to be removed from the NHS.

OK. I'm going to put my head above the parapet, ready for a hail of machine gun products from the anti-homoeopathy activists.

I confess that I have prescribed a few homoeopathic remedies in my in my 30 years as a GP. Just a few - pulsatilla, arnica, rhus tox, aconite. I found aconite especially useful for patient self-management of panic attacks (backed by good information) - very much more useful, and less problematic, than diazepam. I saw no harm from it.

I saw some dramatic recoveries - coincidental, naturally. I saw a particularly impressive coincidence with an adolescent whose problematic asthma disappeared after one dose of a powder prescribed by a proper homoeopathic doctor.

I have huge respect for homoeopathic physicians.  They are old-school. They engage with their patients, get to know them, and form a therapeutic relationship. The patient feels understood, and if the personal physician gives them a powder, they feel confident that they will get better. So they do.

At very least, homoeopath physicians in their natural habitat get an enhanced placebo effect.

Which would explain why published  homoeopathic trials tend to show show positive effect, while randomised double blind trials tend not to show any effect. Or are reported as not showing any effect.

With the notable exception of David Reilly's work.  David did an RCT on homoeopathic preparations in nasal allergy, and got a positive effect. His methods were criticised, so he repeated the work, taking on board the criticisms, and still got a positive effect.

Reilly has a .doc summary of the debate that can be downloaded from this page. It is fairly heavy going, with closely argued statistics so do not waste disc space if you do not do odds ratios and 95% CI's. But it does give another side to the picture about the scientific study of homoeopathy. For instance, the same device is used by H sceptics as has used by detractors of the Spirit Level - discarding unusually positive data.  


He shows a picture of two clusters of placebo controlled trials, one of orthodox drugs, and one of homoeopathic remedies. It is impossible to tell the difference in terms of significance. So the analysts (whose abstract begins with the words "Homoeopathy is widely used, but specific effects of homoeopathic remedies seem implausible." ) proceed to extract 8 homosopathic trials and 6 orthodox trials, and conclude "When account was taken for these biases in the analysis, there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions". This was then reported in an editorial under the headline as The End of Homoeopathy, a report duly amplified in the mainstream media. I confess that I picked up on this. Which just shows that if you want to really know something, you have to trace it right back to source.

I have always asked, when in the right company, that Reilly's work be replicated using two identical ultra-dilute solutions, one prepared by succussion, and one by turbulent mixing. The hypothesis is that the turbulent mix solution will perform less well if succussion is having an effect.As far as I know, this has never been done. It should be.

The response of the objectors is that it just cannot work, because there is no atom present of the original molecule.  Homoeopaths respond that the succussion (passing shock waves through the solution) process creates a "memory" in the water. Objectors ask for evidence of this memory.

Beneveniste thought he had found it, in demonstrating an effect on white cells from antibodies at homoeopathic dilutions. It seems that his effects were not replicated.

However, Louis Rey found this : Ultra-high dilutions of lithium chloride and sodium chloride (10−30 g cm−3) have been irradiated by X- and gamma-rays at 77 K, then progressively rewarmed to room temperature. During that phase, their thermoluminescence has been studied and it was found that, despite their dilution beyond the Avogadro number, the emitted light was specific of the original salts dissolved initially.

The scientific method requires that this work be replicated. It may have been; I don't know. I am coming late to this debate.


Next, this: "We discovered a previously unknown phenomenon in liquid water, which develops over time when water is left to stand undisturbed, and which made precise gravimetric measurement impossible. We term this property autothixotropy (weak gel-like behaviour developing spontaneously over time) and propose a... ( view more ) possible explanation. The results of quantitative measurements, performed by two different methods, are presented. We also report the newly discovered phenomenon of autothixotropy-hysteresis and describe the dependence of autothixotropy on the degree of molecular translative freedom. A very important conclusion is that the presence of very low concentration of salt ions, these phenomena do not occur in deionized water. Salt ions may be the determinative condition for the occurrence of the phenomena". Vybíral + Vorácek2007

Reilly quotes Professor Luc Montagnier, a French virologist who co-discovered HIV and who won the Nobel Prize in 2008, made the radical claim ( 2009 ) that some bacterial DNA sequences are able to induce electromagnetic (EM) waves at high aqueous dilutions - if they were 'strongly agitated', a step 'critical for the generation of signals'. 

He also cites "evidence of ultramolecular dilutions of histamine ability to inhibit basophil activation “in a reproducible fashion”" [ Belon P, Cumps J,  Ennis M, Mannaioni PF, Roberfroid M, Ste-Laudy J,  Wiegant FAC. Histamine dilutions modulate basophil activity. Inlfamm Res 2004; 53:181-8]

These are the tip of the iceberg of papers relating to the micro-structure of water. I have a strong suspicion that water is far more sophisticated than the simple image that we have in our textbooks of tiny bouncy balls flying around at random.

Here is a simple starter on the micro structure of water.

The study of the micro-structure of water deserves scientific study. The trouble is that, because it is outside the mainstream, the people who do it tend to work on their own, and sometimes maybe their work leaves a little to be desired in terms of perfection.  But the medical profession should never forget, and never, never repeat, what we did to poor Semmelweiss.

The essence of science is to say dogmatically, not "This is the case", but to ask, "Is this indeed the case?" In this debate, the question is, "Is it indeed the case that water has no nano-structure which is worthy of investigation?"

So there is something to the micro-structure of water that needs scientific investigation. Whether this will have any relevance to homoeopathic medicines we will have to wait and see.

What we do know is that homoeopathic physicians do meet a need. They have high patient satisfaction. Their medicines are not expensive. Above all, their medicines do not (cannot, in the view of the sceptics) cause side effects.

I do not agree with the request from my union, the BMA, to remove homoeopathy from the NHS. It should be allowed to continue, but under conditions of audit, covering all aspects of their practice: what diagnoses they are presented with, the success rates that they achieve, and their cost-effectiveness. When this evidence is collected, we will be able to make an evidence based decision on whether or not it is worthwhile for the NHS to continue to fund homoeopathic physicians.

This would seems a reasonable way to move forward on this issue.

Later blog on this.

Lansley's NHS reform: more testiculations all round

As a GP I ought to say something about Lansley's plan for the NHS.

There now follows a pause while I collect my thoughts, and search for a word that will not result in this blog being blocked by filth filters. Aha:

"Testicles!!".

Basically, it is another enormous waste of money, as jobs are shuffled around, buildings vacated, and headed notepaper is changed.

I chaired a Locality Commissioning Group in the 1990s. In those days, we had no money or powers. Now the same group will have millions, and a huge remit, which GPs will not be able to do, as they have the inconvenience of treating peoples sniffles, so they will engage managers to do it for them. SNAFU.

Yes, it is another step in the direction of privatisation. Every change brought on the NHS is about privatisation. Part of the strategy is to waste so much money on reorganisation that there is no sniffle service, so peeps are forced to go private.

I'm going to stop now. Blood pressure.

NHS management - low hanging fruit, ripe for the snip?

Everybody  is talking about public spending cuts. There is a lot more to public finances than just public service cuts, but on the other hand, there is a case for some cuts. So, let's do it.

How do we produce pain-free cuts in the NHS budget?

Managers amount to 3.1% of NHS staff. Their numbers have increased by 6.3% p.a. over the last decade, compared to 2.7% increase in other NHS staff. How do managers' wages compare with the average? On a par with doctors, sure, but rather more than cleaners.  I am in the process of trying to dig out some figures. [update 30 March: Ah, here they are, dropping like ripe plums into my hand, from today's Guardian, A select committee found that £15.4 billion, 14% of NHS budget, goes on management and admin. An expert thinks that is average for health systems, but given that costs have been rising, (see below), is was less back in the day before the purchaser provider split.

So it is on management that the axe should fall, to heal in the budget deficit that everyone agrees must be healed.

The essential managers include those that service finance, buildings, and supplies. The rest are  box tickers, meeting attenders, and such beauties "service development managers" - who are automatically surplus to requirements since there is no prospect for service development in the present climate. The product of the latter set is primarily  to annoy front end staff by continually rearranging what they are supposed to be doing. A few can remain to service the staff proposals for efficiency changes, see the comment slot below.

In last week's BMJ, there are a series of suggestions for how cuts could be made painlessly. Everyone - consultants, GPs, ancillaries  - had efficiency suggestions, but the only one who had nothing significant to suggest was the management person.

The NHS, like any large organisation, does need continually to be looking for ways to improve its way of working. The way to do this is through the good old Suggestion Box. Coal face workers can put in plans for improvements, which can be assessed by groups of their peers, and promising plans can be piloted and rolled out if successful.

On the subject of meetings, my local PCT meetings were seriously embarrassing in their pointless waffle quotient, as compared to the way local government meetings are conducted.

Tactical and strategic overview of NHS work can be made by ad hoc meetings of front line staff, each office electing a representative, and if necessary the representative meetings electing a representative, forming a communications web leading up to the Minister of Health.

The management of the NHS offers us a pair of juicy, low hanging plums that can be firmly grasped and snipped off without in any way damaging the tree.

We can assume until proved otherwise that Fallujah birth defects are due to DU

Useful list of DU sites.

It is clear that there is an increased incidence of birth deformities in Fallujah.
What is causing it? The candidates are Depleted Uranium (DU), White Phosphorus, something else, or a combination of the above.

We know that White Phoshorus was used.
Abu Sabah, a refugee from Fallujah, reported seeing phosphorus bombs: "They used these weird bombs that put up smoke like a mushroom cloud. Then small pieces fell from the air with long tails of smoke trailing behind them. These exploded on the ground with large fires that burnt for half and hour," Abu Sabah said. "When anyone touched these fires their bodies burnt for hours." Source

However, White Phosphorus, although toxic , is not known to cause birth deformities. Absence of evidence is not evidence of absence, but it is not a major candidate.

Malnutrition, particularly folic acid deficiency, is a known cause of neural tube defects, but not of the more complex defects being seen in Fallujah.

There is controversy over  DU was used in Fallujah. It is hotly denied by Richard S Lowry, a "military historian" who has written a book on Fallujah.

Others disagree:
Having seen what appeared to be a depleted uranium (DU) missile fired at a building in Fallujah on CNN during the first week of the fighting, AFP asked the Pentagon if DU weapons are being used in Fallujah. "Yes," Lt. Col. Joe Yoswa said, "DU is a standard round on the M-1 Abrams tank." Source.
That quote again:
Christian Bollyn of the American Free Press , Washington D.C asked Lt.Col. Joe Yoswa if the US was using Depleted Uranium in Fallujah and received the reply that " DU is the standard round on the M-1 Abraham Tanks" which have been used in Fallujah. source

The source continues,

It was estimated that during that assault over 10,000 tons of depleted uranium, DU, was used in the bombardment of the city of 300,000 people. Both the Pentagon and the British governments insist that the use of DU is not illegal. Source 
This 10,000 tonne figure is doubtful. It may relate to the amount used in Iraq as a whole - see below. 

ICBUW is investigating the possible use of uranium weapons during the attacks on Fallujah. Currently it seems that Abrams tanks and Bradley fighting vehicles were deployed during both battles. Both vehicles carry armour piercing rounds containing uranium and high explosive rounds which do not. However the fact that they were not facing armoured targets does not mean that only high explosive rounds were used. In fact, there are indications that armour piercing ammunition may be more effective against individuals fighting behind cover in urban areas. While is not known how widespread the use of uranium weapons was during the fighting, it seems likely that it was used to some extent.
Source

The Pentagon admits to having used 1,200 tonnes of DU in Iraq thus far.
Source

So there are wide discrepancies in the reportage. These discrepancies can be resolved by publication of the original the ammunition lists from 2004. Or let's hear from crews who were there. Most importantly, let us do a survey on the ground in Fallujah, to find out what radiation counters and chemical analysis shows.

Here is one source that could prove Lowry wrong:
Mr. Rasheed presented a video report entitled "Witness from Fallujah." And regarding DU, he said: "We detected abnormally high radioactivity by using a Geiger counter." Source.

DU is both radioactive and chemically toxic. As a chemical weapon it would be banned by the Geneva Convention, so the military have no choice of stance except Stout Denial. There is no proof that DU causes these problems, they say, exploiting journalists' ignorance of the fact that there is no proof in science, only evidence. And the evidence that DU causes problems is as widespread as the use of these weapons.


There is evidence that DU can cause birth deformities.: "In aggregate the human epidemiological evidence is consistent with increased risk of birth defects in offspring of persons exposed to DU."


What is lacking is not "proof", but the willingness of politicians to listen to doctors rather than to generals in matters relating to medicine.

The evidence needs sorting out, and the Bradford Hill guidelines need to be applied.

"Chemical Castration" should be tried for some sex offenders

The BMJ 27 February has an article titled "Chemical Castration for sex offenders: Doctors should avoid becoming agents of social control".  It refers to an article on the National Probation Service site, which sets up a service for some forensic psychiatrists to advise on medical treatments for some sex offenders. The treatments are first Prozac-type antidepressants, and second, anti-testosterone drugs such as cyproterone acetate and gosrelin.

The BMA article (which is not yet on-line, and may not be for non-BMA members) is nothing if not cautious. It uses the "Chemical Castration" label, which is an emotively charged term. It says, "although ostensibly for public protection, it also carries with it a sense of symbolic retribution...straddle(s) the border between treatment and punishment".

One of the authors of the article is Don Grubin, who is named in the Probation Service article as setting up "a national advisory service for prisons and probation aimed at increasing the availability of medical treatments for sex offenders".

I personally welcome this development as a highly sensible approach, so long as it is fully audited to test its effectiveness and safety.

Anti-androgen therapy reduces the re-offending rate from 50% to 5%, which is a pretty impressive effect.

Given the huge media profile given to sex offences against children, and the understandable emotional public reaction against paedophiles, this development is many years overdue. I wrote to the Home Office about this in 2001, and they responded with the usual pathetic Government fob off. Now they have finally come round to trying it out.

I stress that this is not an official Green Party position. There is a debate to be had, because it is vital that the medical profession does not become an arm of the State, using its knowledge to control people that the State judges to be dissenters. But I really do not think that fear applies in this case.

We already routinely practice preventive social medicine in the case of psychotic patients who are sectioned and treated on grounds of "being a danger to themselves or others". A patient with hypomania may be blissfully happy with the way things are as far as they are concerned, and may not be asking for any help, but we may judge that they are a danger to others, and restrict their liberty and treat them with antipsychotics.

This is a pretty close parallel with the situation of some sex offenders. There is a spectrum of self assessment among this group, some feeling profoundly guilty about their thoughts, proclivities and actions, while others are in denial about the damage they cause to others.

It seems not unreasonable at least to offer treatment to those who ask for medical relief from their hypersexuality, which many do. There are some cases in the literature where hormonal therapy has abolished a paedophilic drive, and the patient has experienced a reversion to happy heterosexual sex with his partner.   Given that there is no evidence of the effectiveness of  the current treatment, CBT, offered to a sample of sex offenders, and given the enormous damage that sexual assaults can inflict on victims' lives, it is unreasonable to withhold hormonal therapy from sex offenders.


The forensic psychiatrists should design a plan for rolling out this treatment in a way that is carefully audited, to establish what does and does not work with what kind of offender.

I should stress that this is my personal opinion as a psychiatrist. The Green Party has not yet considered this matter.

H1N1 mutation found in Norway. So far not a big deal.

Norwegian medics have found a mutation of the H1N1 swine flu virus.
It is not certain whether it is more pathogenic, and is not markedly more infectious so far.
Too early to tell.

Don't Panic!

I'll tell you when to panic.

Aspirin, take it with a pinch of salt, and with food

Aspirin; what to do? Everyone is in a state of total discombobulation, and to make it worse, the Daily Mail confuses primary and secondary prevention:

Growing evidence in recent months has increased the view that giving aspirin for primary prevention - where patients do have symptoms of heart disease - is counter-productive.

Wrong! Wrong again, Daily Mail, just as you were about Hitler.

Here's the distillation of 30 years in the consulting room:

A 300mg tab of aspirin is estimated to make you leak 10ml of blood on average, so the 75mg dose may (or may not, since nothing is proven in science) make you leak half a tsp.

In my practice I saw very little ulceration caused by aspirin-type drugs, and I always strongly advised patients to take them in the middle of a meal, so the pill is less likely to release all its goodness at one point of the gut.

This is just an anecdote. I can find no peer-reviewed, randomised double blind cross-over trial to refute the hypothesis that I (and my colleagues) give good advice on taking with food,
(a) because it is impossible to double blind, and
(puts conspiracy theory hat on)
(b) the manufacturers of proton pump inhibitors (Omeprazone &c) would lose out.

If still undure, just make sure you get 5 portions of fruit and veg a day, (the Australians are on 10), aim for 30 minutes' puffing and sweating exercise a day.

Oh, and don't worry.

That's it, time's up.
Next!

LSD effective in treating the untreatable

Interesting report today in the Guardian about the therapeutic use of the hallucinogenic drug LSD. Amanda Feilding, director of the Beckley Foundation in Oxford, is involved with two studies, one in Switzerland on the effect of LSD on terminal anxiety (anxiety in those with terminal illness), and one in San Francisco on its effect on creativity. There is also a report that it is effective in cluster headache, which is an agonising, disabling head pain that is very dfficult to treat.

In the 60s I met Amanda fleetingly, and listened with due medical scepticism to her account of the advantages of trepanation as an aid to brain function. (the slogan was "Get Ahead, get a Hole") . I probably made the right decision in refusing to offer this as an NHS service. Later, I was working in the A/E department where a friend came in to have the bleeding controlled from his self-trepanation. Glad I didn't do it, even though they thought the less of me for being such a conservative.

More importantly, I studied psychiatry in Barrow Hospital, Bristol in the 1970s, and in the library there I found a small monograph, a report on a world conference on LSD therapy. Barrow was, I believe, one of the centres where LSD was used in psychiatric therapy. Unfortunately I have been unable to sind the monograph since, or any reference to it.

The accounts were interesting indeed. They were from all ends of the psychiatric spectrum, from the authoritarian ("Come on John, it's time for your weekly acid trip. You cannot refuse, the doctor says it's good for you....are you hallucinating? Right, now stop screaming please and tell me about your feelings about your mother") to the humanists from California, who required the doctor to try the medicine on themselves first, and who insisted that the setting for the trip be supportive. This caused the sharpest debate among the audience ("Therapy is for patients. We are doctors, we don't need therapy").

From all these different backgrounds, an interesting consensus about outcomes emerged.
1 LSD therapy was bad for people with schizophrenia.
2 It was not much good for depression.
3 It was brilliant for people diagnosed as psychopaths (now sociopaths, or antisocial personality disorder).
Given the fact that sociopathy was, and still is, effectively an un-treatable condition, that it was a major burden to psychiatry in the 1970s (I have the impression that they are now just handed over to the courts as un-treatable), and given the police, court, and prison costs that sociopathy is responsible for, you would think that this fact would have been taken on board, further researched and developed.

You would think wronly. The idiot governments banned LSD because they noticed that hippies were getting off on it. Not just banned for recreational use; banned for scientific use also. (Pause while various expletives are considered, and discarded).

So good luck and thanks to medical LSD researchers everywhere.

[Update 16.3.13 Unfortunately I read in Jon Ronson's brilliant book, the Psychopath Test, that recidivism in psychopaths treated with LSD was greater than that treated in other ways. I would still like to see confirmation of this, a breakdown of the figures and a survey of the successes, as anything that offers change in psychopathy is worth looking at.]