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Health Insight November 1999
part 1
Health in the news

The dominant health news item in the British media during the second half of October has been yet another scare story - the risks associated with eating meat imported from France, where it has been established that animal (and perhaps human) excrement has been used in livestock feed. The parallels with the BSE story, and France's refusal to import British meat, have of course been highlighted. Health Insight may seem an inappropriate forum to discuss the rapidly developing situation, which is receiving so much attention elsewhere. We have, however, summed up some of the new developments in the other current health scare - genetic modification of food crops.

Another big news story in October has been the continuing trial of a Manchester GP accused of murdering fifteen patients. The Bristol Royal Infirmary Inquiry also continues.

All this should not obscure the real developments in health and healthcare in the UK. The appointment of a new Secretary of Health is unlikely to lead to any change in the government's strategy to reform the health services. The implementation of this strategy proceeds apace. The launch of the Commission for Health Improvement (CHIMP) on 28 October is a key part of the government's plans. Another pillar of the strategy, the National Institute for Clinical Excellence (NICE) has already run into controversy with its decision that the flu drug Relenza should not be available on the NHS.

A theme of the reforms is the need to ensure that the high standards, which many hospitals in the UK do reach, are maintained throughout the whole country. The new national framework on mental healthcare is one attempt to achieve this goal. However, the Audit Commission believes there is still too much variation in quality in intensive care, and the Royal College of Physicians similarly criticises the care provided for stroke patients.

Finally, cancer care is recognised by the government as a priority and further new initiatives have been launched, and a summary of what was said on health at the Labour and the Conservative conferences is also included in this issue.

New man at the helm

The new Secretary of State for Health is Alan Milburn who has returned to the Department of Health after ten months as chief secretary to the Treasury. He was Minister of State for health in the first year of the Labour government, when his responsibilities included primary care and general medical services. Whilst there he launched an NHS efficiency task force to ensure that money was directed at patient care rather than bureaucracy. In his eighteen months as Health Minister he helped to push through changes that were often unpopular with doctors, such as league tables comparing patient mortality for different surgeons. He threatened to 'name and shame' incompetent doctors and end excessively large payoffs to managers.

He returns to the Department of Health as pressure mounts on the government to deliver its pledges on health. NHS Confederation Chief Executive Stephen Thornton believes Mr Milburn's return marks a crucial new phase for the reforms. 'Now is the time for delivery, and in order to deliver there are going to have to be some pretty crunchy decisions taken. All the indications are that Alan Milburn is the man to do it.'

Source: Health Service Journal 21 October, BBC Online

Commission for Health Improvement

The independent watchdog which will monitor standards in the NHS is now open for business. The Commission for Health Improvement (CHIMP) has been given the power to intervene if, in its view, poor quality care is putting patients at risk.

CHIMP's powers will extend to both hospitals and GPs' surgeries. Regular inspections will be conducted, during which the efforts of managers and senior doctors to improve standards will be assessed. Inspections will begin in April 2000; it is planned to visit every NHS facility once every three or four years. Spot-checks may also be conducted.

One function of CHIMP will be to ensure that doctors follow national treatment guidelines and do not prescribe drugs or other treatments which have not met with the approval of the National Institute for Clinical Excellence (NICE).

The development of CHIMP was the responsibility of Alan Milburn as Health Minister. Its launch comes within a few days of his return to the Department of Health as Secretary of State. CHIMP will be headed by Peter Homa, formerly the head of the waiting list task force.

Source: BBC Online

NICE steps straight into controversy

In one of its first judgements on the usefulness of a medical treatment, the new National Institute for Clinical Excellence has decided that the anti-flu drug Relenza (zanamivir) should not be available on the NHS. The conclusion of NICE has been accepted by the Department of Health. It was also welcomed by the Royal College of General Practitioners. The drug, reviewed by NICE's rapid assessment panel, will be reassessed in a year's time, by which time further trials of Relenza will have been completed.

GlaxoWellcome (GW) which manufacturers the drug has, however, contested the decision; Chairman Sir Richard Sykes said it would disrupt the pharmaceutical industry. NICE had asked GW for information on the drug, which would be impossible to provide until it was in regular use. He warned, 'If the government continues to make the environment antagonistic to this industry then obviously it will start to move elsewhere'. The Association of British Pharmaceutical Industry said NICE had 'bungled' its handling of Relenza and this had damaged the credibility of NICE in the UK and overseas. GW has since stated that it wants to see the drug licensed for the prevention as well as the treatment of flu.

Further controversy could be the result of another assignment for NICE. Health Secretary Alan Milburn has asked the institute to advise him before the end of the year as to whether the cancer drug Taxol can be used within the NHS. It costs £5,000 to treat a single patient with the drug, which has been shown to help cancer patients live longer. Some health authorities are willing to pay for it whilst others consider it too expensive. The situation is typical of the kind of problem which NICE was set up to address. Mr Milburn said, 'there is too much of a lottery at present, especially when it comes to getting cancer-fighting drugs. Cancer care should not depend on where you live'.

Another potential controversy has, however, been avoided. Merck, Sharp and Dohme has decided that it will not seek to have its anti-baldness treatment, Propecia, available on the NHS. The drug is available in thirty-eight other countries, but is not provided by the state in any of them.

Guardian 9, 26 October
Times 10 October
British Medical Journal 15 October
BBC Online

National framework launched for mental healthcare

The government's national frameworks for healthcare seek, on the basis of clinical evidence, to set national standards and lay out best practice. Each framework deals with an area considered a priority. Mental health has now come under the spotlight with the launch of the latest framework. Frank Dobson, as Secretary for Health, said, 'In the past people with mental health problems have been let down by unacceptable variations in healthcare. I want services that offer the highest quality to everyone, regardless of their gender, age, race or where they live'.

Seven aims are set out in the framework, covering such issues as; access to care; combating discrimination; assessing needs; effective treatment; the needs of carers; the reduction of suicide rates.

Mr Dobson said, 'We are providing substantial new resources for mental health - £700 million in this and the next two years in our drive to build modern and dependable mental health services'. However, according to the Health Service Journal, many senior NHS managers doubt whether it will be feasible to implement the requirements of the framework without significantly greater resources.

The framework has nevertheless been widely welcomed by such bodies as the Royal College of Psychiatrists, the King's Fund, and the Sainsbury Centre for Mental Health. The latter stressed that 'sustained investment, particularly in people, will be critical to its successful implementation'.

Further details were given of the way in which mental healthcare will be delivered. Health minister John Hutton described the revised 'care programme approach' which will be adopted.

Press releases (Department of Health, Sainsbury Centre for Mental Health)
Health Service Journal 7 October
British Medical Journal 9 October

National Audit Office reports on intensive care standards

The lives of two out of every three patients entering intensive care units are saved thanks to the treatment they receive, but there is an unacceptable degree of variation in the standard of care provided in different hospitals. This is the conclusion of a National Audit Office (NAO) report into the performance of critical care and high-dependency units in England and Wales, which found considerable disparity in mortality rates, even when allowing for the kind of patients admitted.

The NAO said there was little data available on the effectiveness of particular treatments used in intensive care units and called for more research in this area.

The report also noted that different intensive care units with the same case load varied by as much as fifty per cent in the number of nurses they employ, and the cost of consultants varied by a factor of three. NAO Controller Andrew Foster said, 'staff in critical care units should be praised for providing a vital service in a very pressurised and traumatic environment. However, our report raises concerns that some hospitals are not making the best use of current resources'.

The Intensive Care Society has welcomed the report but has called for more resources. In particular the society is concerned about the frequent need to transfer patients from one hospital to another because of a lack of intensive care beds. One per cent of UK health expenditure is devoted to intensive care, compared with ten per cent in the USA.

Source: BBC Online

Stroke care standards come under fire

The Royal College of Physicians (RCP) has suggested that the care of stroke patients is haphazard and disorganised. According to information compiled by the RCP, only eighteen per cent of stroke patients receive the full range of treatment specified in national guidelines. Only forty-four per cent have full visual examinations and only twenty-three per cent are assessed for mental functioning. Of those who return home, only forty-nine per cent are reviewed for their disability six months later.

One problem is that there is an inadequate number of specialist stroke units in the UK, despite evidence that patients who receive care in such units run a much lower risk of serious disability. Dr Tony Rudd, Associate Director of the RCP's Clinical Effectiveness and Evaluation Unit, believes the results of the survey supported the further development of stroke units, which need not be costly to introduce.

The survey, which involved over 16,000 cases in eighty per cent of the UK's acute hospitals, found a similar situation to that which emerged from a Stroke Association study earlier this year. The Association says that stroke care is still 'way down' the agenda of the Department of Health.

Stroke is the most common cause of disability in the UK; approximately 350,000 people are suffering the effects of a stroke at any one time.

Daily Telegraph 12 October
BBC Online

Government steps up war against cancer

World-leading cancer expert Professor Mike Richards has been appointed as National Cancer Director for the NHS. He is to lead the new drive on cancer announced by Health Secretary Alan Milburn. Professor Richards, who currently runs cancer services at Guy's and St Thomas' hospitals in London, is the first senior doctor to be appointed to run a major policy area; he will do the job full-time and answer directly to ministers.

Responsibility for cancer is currently shared between the Department of Health, the NHS, and the various research bodies. Professor Richards will work closely with doctors, nurses, other health professionals, and the voluntary sector to increase the modernisation of NHS cancer services. His aim is to cut death rates from cancer by one-fifth (up to 100,000 fewer deaths in the next ten years) with the help of an £80 million NHS Modernisation Fund over the next two years. He will also work NICE to decide which cancer drugs are most effective, and then to ensure that those drugs are made available throughout the NHS and 'not patchily across the country'.

BBC Online
Press releases (DoH)

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