On Friday March 31st, British airwaves were full of news about a significant change in Britain’s National Health Service.
After its 8 AM news headlines, Radio 4’s flagship news program, Today, featured the boss of the National Health Service, Simon Stevens, explaining how the new system would be better even though long-established targets for waiting list times (18 weeks) would likely be missed.
Before the 8 AM headlines in a warm up feature Zoe Duncan entered the Nottingham home of Maureen Snelling who was getting an Intravenous infusion of an osteoporosis drug from community nurse Donna Roe. This was probably the bisphosphonate related Zolendronic Acid. (Check it and other biphosphonates out on RxISK).
Maureen explained how uncomfortable it was living with osteoporosis – feeling all your internal organs press up against you when you stooped down. Now, she would no longer have to take two buses across town to the hospital to get the injection there. While she could manage this, others, she explained, couldn’t. But even for her it was just luxury to be able to get the treatment at home.
Duncan put it to Roe that getting treatment like this organized at home was bleeding obvious. Sounding slightly taken aback at the choice of phrase, Roe agreed.
Duncan chased the Family Doctor, Annemarie Stewart, who explained it took 4 years to get the osteoporosis drug reclassified from a “Red Drug” to one that could be given at home.
Duncan then talked to the hospital who explained they were losing money in the process but were sucking up the loss as the new approach was clearly in the interests of the patient. Besides they might save on reduced use of Emergency Department resources owing to the reduced number of fractures everyone expected from getting anti-osteoporosis drugs delivered efficiently to older women.
Cut to 84 year old May Cumberbatch whose back had crumbled after she came off a stepladder. May would now get her treatment at home. Prompted by Duncan, between this and staying away from stepladders May figured she’d now be okay.
Seen from Space
Next up was Niall Dickson, CEO of something called the NHS Confederation, ex-CEO of the GMC. Dickson explained that these changes were a twenty-first century change to healthcare. Duncan and the listeners needed to realise, this was very different to the twentieth century privatization of the health system typically termed the Lansley reforms that in 2012 had been portrayed as so big they could be seen from space.
Natch, Dixon said. The Lansley reforms just involved a reorganization of the administrative deck-chairs. Once he said deck-chairs, no one had to mention the Titanic. Every listener will have known there is a desperation to keep the NHS afloat.
These changes Dixon said would deliver real and meaningful improvement in care.
Weren’t they really just about saving money, Duncan challenged. No Dixon said. They might not save any money but they were clearly the right thing to be doing as the Nottingham example made very clear. This was about repairing the breakages in our system – restoring links between general practice and hospitals and patients.
This Nottingham example has been trailed widely in all sorts of academic and lay media for over a year as an instance of the kind of innovative thinking that will transform current services and save the NHS. It is close to the only example being offered.
This is staggeringly beyond belief, a psychosis in spades, a triumph of the Sheriff of Nottingham over the good guys.
Making sure that more older women get osteoporosis drugs by delivering care at home is a recipe for more fractures not less, for a significant impairment in the quality of these women’s lives and for vast increases in expenditure beyond anything that healthcare functionaries or politicians appear capable of comprehending.
Here’s how it happens.
Twenty months ago, on a Friday I fell and broke my shoulder. The Xray above, taken an hour later, makes radiologists wince. The orthopedic team on call said it needed a plate. The operation was done that afternoon. I was in work on Monday.
This is the kind of health care that can be delivered free. It gets people out of sick beds, or saves their lives or otherwise leaves British citizens in the best shape possible to compete with the Americans and Germans and Chinese.
A few weeks later I opened my post and my jaw dropped. It was a letter from the local Health Board inviting me to a bone screening session. This was a pro-forma letter. Everyone – male and female to avoid gender bias – over a certain age – probably 50 maybe less – gets one.
Had I gone along, there is every chance the scan would have shown some bone thinning and I might have had an osteoporosis drug recommended. I could now be having infusions once every 3 months in my office here in the hospital.
This is lunacy. These drugs increase the risk of clinically significant fractures. Before we began using them widely in the 1990s, it was very rate to see spiral fractures of the femur – where the bone might shatter into twelve different bits. Before 1990, dentists never knew what it was like to try and drill into marble and rarely had to warn patients about osteonecrosis of the jaw.
Follow the Money
But its not just the cost of the drugs that’s the problem. The price we pay for the drugs doesn’t improve anything. People are more likely to end up in beds or off work or if at work to be impaired so that Britain is less likely to be able to compete with the Koreans or Mexicans or the soon to be independent republic of Gibraltar.
Beyond their price, the drugs lead to the employment of staff to run the screening program and an increasing number of auditors and managers to monitor why we seem to be having more fractures rather than less. And all this will lead to a climate of bullying and harassment of nursing and medical staff who exercise any kind of discretion. The exercise of discretion is blamed for things going wrong.
What is mad about all this is it is happening against a background of no-one having access to the data from biphosphonate trials or the trials of other drugs creeping in for osteoporosis. The literature that underpins the guidelines recommending these drugs is ghost-written and no-one – not the regulator (FDA – MHRA – EMA) or the guideline writers or the notional authors of any papers has access to the data.
When access has been extracted, it turns out there has been a representation of the data that could be regarded as fraudulent.
And yet – as Fragile Doctors and Stevie’s Story shows – doctors will get incredibly nasty if you show a reluctance to take the medication. That’s partly because the system is gamed so they get paid more – or get paid at all if you take the meds. And its partly because most doctors still believe in the Evidence.
This crazy situation doesn’t just apply to bone medicine. It applies right across the medical board. Its part of what is leading to the opioid epidemic in North America – managers and patients want patients to be treated according to guidelines that are gamed.
In all these cases, pharma can plead innocence and point to the fact that they are getting comparatively little for the drugs. Enough to make them the most profitable companies on the planet, but still comparatively little compared to what is being spent on osteoporosis – which close to didn’t exist forty years ago.
Perplexed the managers and politicians go back to re-organizing the deck-chairs. Perhaps if people get their treatment at home everything will be just fine.
This has nothing to do with privatization. Its the same in public health and private health systems and is everywhere leading to a growing psychosis.
It would be great if anyone having problems on an osteoporosis drug or with the osteoporosis octopus could report to RxISK or send us your story.