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Chair: Professor Lewis Ritchie (Department of General Practice, University of Aberdeen)
Panel: Professor Martin Cowie, Dr Miles Fisher, Dr Ian Campbell, Joyce Cramer, Jillian Riley, Duncan Petty, Gay Sutherland, and Dr Evan Harris (Liberal Democrat Shadow Health Secretary)
Question: I would like to ask Evan Harris what evidence there is that politicians have grasped the nettle about honest debate on resource allocation, particularly as it concerns cardiovascular disease?
Evan Harris: There is very little evidence. I would not argue for more and more resources now. The money that was announced in the budget is probably about as much as the service can take because there is such a shortage of things to spend it on due to the true constraint of staffing. What I do think, however, is that we can spend this money better. The refrain I always hear is that too much of the resource is going into secondary care because of the nature of the targets being set. I’m not arguing that the targets in the national service frameworks are wrong, but the ones we hear about are these obsessive waiting list targets and A&E targets—the ones with the political premium—and the resources are going into these with no evidence of benefit. There is not enough resource going into health promotion (for example, diet/exercise), prevention (screening, etc) and primary care (for example, smoking cessation clinic funding). Given the data on the cost effectiveness of smoking cessation relative to other treatments, there is a duty on the powers that be, and I don’t believe this should be politicians but public health people with control over commissioning, to put resources into those areas in preference to other things that are less cost effective.
Joyce Cramer: Issues such as smoking cessation, diet, and exercise are more public health issues than medical treatment issues. The multiple risk factor intervention trial in the 1970s enrolled thousands of patients: one group received special intervention, which included exercise and diet, and the other group received usual care. There was no significant treatment effect at the end of the study. What happened was that the entire US society began to exercise and diet so that the control group rose up to the intervention level. It is taken as a failed study but I look at it as a great success of the public health message. It shows that these things can be done over time. This does not come from the government, or even really from doctors. The media has to spread this public health message.
Comment: As this is a medical conference it obviously has primarily dealt with the medical concept of ill health, but we ought not to ignore the social concepts. It is the lower social classes who suffer more from the ill health we are talking about.
Gay Sutherland: I couldn’t agree more. In terms of smoking cessation the government’s target groups are pregnant women, people from ethnic minorities, and people from deprived sections of society, in acknowledgement of the huge differences in prevalence of smoking between the educated wealthy and the poor. But we are still struggling with how to get to these groups.
Comment: One of the issues is that there has been very little resource allocation of general practice against population need. There is a tendency not to want to practise in deprived areas so there is a clear imbalance between need and provision. The situation is worst in areas of greatest deprivation and we really have not tackled this yet.
Miles Fisher: In Scotland there has been reallocation of the cake in terms of NHS spending. Instead of basing allocation just on demographic indices, population deprivation was taken into account. As a result, a major shift in resources was made to Greater Glasgow Health Board, which has the greatest needs. The health board put the money into primary care and this is largely funding the Glasgow diabetes project, a primary care based project for the management for diabetes and other chronic diseases.
Question: On the issue of effective use of resources, I would like to ask Duncan Petty how much he thinks the prescription charging structure provides a perverse incentive to waste and perhaps also reduces our ability to monitor compliance.
Duncan Petty: There is no good published evidence about waste. There is anecdotal evidence that the longer the prescription quantity, the more waste there is, and clearly if a prescription is written for two or three months you are going to waste more if the therapy has to be changed. One of the medicine management collaboratives has done focus group work with patients to find out what they thought of the prices of drugs and whether that affected whether they wasted them or not. Basically, patients did not care what medicines cost as they were getting them free of charge. But when the cost was put into context, that the money could have been spent on their hip operation for example, then it became more meaningful to them.
Joyce Cramer: There is no evidence that the cost makes any difference to the way people use medicines. That has been studied because there are data from Canada and other countries where there is no charge compared with the USA where there are large charges. This is not to disregard the outliers, the really poor elderly patient who truly cannot afford £100 per month for medication, but on average the cost of medication is not the leading edge issue.
Gay Sutherland: On smoking cessation, NICE [National Institute for Clinical Excellence] was aware of the potential for waste. Treatment is usually given for two to three months and NICE said that it should only be prescribed for two weeks at a time, on an “abstinent-contingent” basis—that is, if the patient comes back abstinent from smoking, then they can be given their next batch of treatment. This was partly to save money but also because of the evidence that if a person smokes within the first couple of weeks of an attempt to quit they are unlikely to recover abstinence and would therefore waste three months of drugs.
Martin Cowie: Much of the structure of the health service is historically inherited. What strikes me is that we are now asking “what are the health care needs for people in the UK and how best can we match professional skills to those needs?”. Let’s try to revisit the role of these different tribes within the health care sector. I would like to ask Jillian Riley and Duncan Petty, how warmly do your respective professional groups embrace the need for change, and at a quite rapid rate in sociological terms?
Duncan Petty: I think many pharmacy professionals are scared of the changes that are going to be imposed upon them, and it’s partly because they have huge amounts of money invested in premises and businesses, etc. I expect it is too late for them to change their way of delivering health care. But younger pharmacists are enthusiastic about the opportunity to work as clinical pharmacists in primary care—to put into practice what they learnt in college. I see the supply side of the pharmacist’s role diminishing, because this can be done by technicians and others.
Jillian Riley: From the nursing perspective, we saw a slide this morning that demonstrated that nurses were running with the changes that the NHS Plan proposed—they accepted them and wanted to get involved. From my own review of nurses, I would agree with that. The vast majority of nurses are fully aware that we need to make some major changes to the NHS and are fully aware of the need for multiprofessional working; they know what skills they have and want to be able to use those skills.
Question: I would like to ask Evan Harris whether he thinks there is any prospect of the three main political parties working together constructively to rescue the NHS before it crashes without trace?
Evan Harris: To a certain extent this comes down to political culture and electoral systems. It is happening in Scotland. Certainly there needs to be accountability through opposition, but not “opposition-itis.” My party [Liberal Democrats] has an approach of constructive opposition. There are critical political areas where debate is essential but we should not be having political debate about some of the implementation aspects, because politicians should not be involved. On the issue of smoking cessation, when nicotine replacement therapy and bupropion became available the government said that treatment would not be freely available on the health service. One of the most cost effective interventions you can make and they rationed it. I was highly critical of that, and said I would rather see delay on NICE looking at complex chemotherapies that are much less cost effective per QALY. That led to a deluge of complaints from CancerBACUP and other groups. So while politicians make these decisions they will be swayed by their post bag and Daily Mail column inches. The tabloids will tend to back those diseases where celebrities are involved, which is more likely to be breast cancer than obesity.
Miles Fisher: As a Labour party member in Scotland I had thought that we could have the kind of debate that Evan Harris described, as sometimes the level of political debate is more mature. But I have become disillusioned because basically no-one in the party will agree that we are rationing—it is couched in many other terms. I agree that as a mature democracy we can decide how much we want to spend on our taxes and with the money we have got we can then allocate, prioritise, argue, and decide where we spend in different areas. But I’m afraid that most politicians do not want to accept that we are rationing and a veil is drawn over what we are doing.
Question: There has been little mention today about the scope within the work place for health promotion. There are some 27 million people in work, and there’s a huge increase in the number of women now working, particularly in part time jobs. This should be included as part of the primary care drive to look at ways in which the community can be involved in reducing cardiovascular risk. The work place is changing dramatically and it is impacting on the health and the lifestyle of not just the employees but also their partners and their families. Issues that may underlie the development of cardiovascular disease include the sedentary nature of jobs, shift work, long working hours, fatigue, and other things that influence behaviour. Is there an opportunity to develop this rather neglected area?
Martin Cowie: I would back you on that. Employers have a responsibility to look after their best resource, which is the human resource. They have to take their human resources seriously and as a health care community we need to get the health promotion message across to employers very strongly.
Jillian Riley: On the issue of worksite based approaches to managing cardiovascular risk, from a literature review that I did the only study that I could find was in the 1980s, and was physician led, but it clearly demonstrated improved outcome both in health perception and in medical data outcome for people who had interventions by occupational health staff in the work place. I was unable to find any reports of nursing interventions contributing in this way, which is a pity given the number of nurses employed in the work site. There is a clear need to promote this element of “health” over “illness”.
Ian Campbell: A recent study in the BMJ looked at occupational stress levels. It reported that job strain (a combination of high demand and low reward) was associated with raised cholesterol levels. The work situation is crucial when trying to help people lose weight. I am currently working with an airline company and this involves office workers, manual engineers, and airline pilots, each with a different working environment. A weight loss programme has to be constructed around that environment. The most important thing about work as far as health is concerned is how you get there: are you walking, are you getting off the bus early, or are you driving in your comfortable car. Not only does obesity make you less likely to be employed, but people in the lower socioeconomic groups are more likely to be unemployed and more likely to be obese, and they have less facility to change things. So it is inescapable: we have to look at environmental, occupational, and socioeconomic issues.
Comment: On the occupational health issue, considering the acute workforce problems we have within primary care we have to take advantage of all the health professions. We should all work more closely together.
Question: The primary care collaborative has shown nationally that you can make changes in primary care without investing large sums of money. Many practices have already achieved much of what we have been talking about today, and the changes will get rolled out. The issue is going to be what do we do about the “rump”—those doctors and nurses who say “no I don’t want to integrate, I don’t want to work in a team, I don’t think any of it makes any sense”. What should we do about this?
Jillian Riley: It is all to do with managing change, and about good leadership. Certainly within the NHS at the moment, there is a lack of real leadership. This is one of the key issues that we need to address.
Miles Fisher: For me the interesting thing is how the question acknowledges the changes that have occurred. Until relatively recently, primary care involved many individuals competing with each other, and now the new structure enables them to work together. There will be an issue in trying to drag along the people from the back, as the questioner said. But it is interesting how far the political debate has gone already.
Comment: In managing change you do of course need leadership, but sometimes you need penalties too and perhaps there is an opportunity to link the “rump” to revalidation.
Lewis Ritchie: Absolutely. At the end of the day, if there is a small, and hopefully vanishingly small, number who don’t want to be team players there has to be some form of constraint.
Question: By and large all the speakers have been optimistic, but there is one area where there is growing pessimism and that is drug compliance in the elderly. As a geriatrician, I believe things have got better in recent years, but this is only because we know to simplify drug regimens and limit the amount of drugs actually dispensed. To do this you have to set treatment priorities. But with the introduction of protocols for treating vascular disease, bowel disease, brain disease, etc, and with these being audited and hence more or less mandatory, we now have to prescribe regimens which we know in our heart no intensive care unit in the world would ever be able to dispense accurately. Does Joyce Cramer have any views on how we balance appropriate prescribing for the diseases versus appropriate prescribing in the clinical context?
Joyce Cramer: With the advances in diagnosis and pharmaceuticals, we are now treating people for diseases that they would not have been treated for years ago, and that makes for polypharmacy. Many elderly people, perhaps particularly those over 75, know in their hearts they don’t really need certain treatments. I think a lot of poor compliance in that group relates to the view “I am going to die anyway, do I really have to take all these pills to prolong it all”. People set their priorities as to which disorders are a problem for them and which they really want to be treated for. We impose our priorities on them and it becomes the typical seven prescriptions each of which is taken several times a day. So I think that there is a large element of so-called intelligent non-compliance within this group.
Lewis Ritchie: To reinforce that point, the dignity of the patient is something that we don’t talk about much. We concentrate on disease management instead of patient centred care much of the time. We need to refocus on a true patient centred approach and this is a difficult paradigm shift for those of us who have been used to looking at diseases in isolation.
Question: If we want to work effectively as teams in primary care, is there something more we should be doing in the realms of multi-professional education?
Jillian Riley: Interprofessional education is certainly something that is being promoted within nursing education and we have examples of where this has been successful—for example, in advanced life support. I think we would all agree that the more we understand about the uniqueness of everybody else’s profession, the more we can work together as a united team.