Breast Screening – Is it worth it?

Choosing whether to have breast screening is a complex decision for any woman, balancing the risks of benefit and harm. The program was introduced 30 years ago for those aged 50-70, using 3 yearly mammograms, which use X-ray imaging to find breast cancer before a lump can be felt. However, it wasn’t until a review in 2012 that women were given proper information about the downside instead of the patronising ‘have screening, it’s good’ government line. The Marmot review found that for every 1,000 women screened over 20 years, about 5 breast cancer deaths are prevented at the expense of around 17 women being diagnosed and treated for a cancer that would never have caused them any problem. Furthermore, more than 200 women will experience significant psychological distress, anxiety and uncertainty because of false positive findings. And to make matters more confusing, the overall death rate from ‘all causes’ does not improve with screening. The lives saved from screening are balanced by the lives lost through overtreatment from X-ray exposure, surgery, chemotherapy and radiotherapy. In addition, screening doesn’t pick up all cancers and some women die at the same age of unrelated causes whether they had screening or not.

In 2017, the Nordic Cochrane Centre published a cohort study that found that screening did not reduce the number of late stage tumours (those bigger than 2 cm) and that screening is unlikely to reduce breast cancer mortality or lead to less invasive treatment. It found 1 in 3 breast cancers detected in women by screening are likely to be over-diagnosed and over-treated, which costs the NHS a significant sum but makes private practice very lucrative. Independent expert groups in Switzerland and France have recommended that breast screening be stopped or reduced substantially. And the American Cancer Society recommends less frequent screening of a narrower age group. In England, the NHS was planning to extend the screening age range from 47-83 but has inadvertently cut it by failing to send out 50,000 final mammogram invites a year for 9 years. Could this have done more good than harm? And should women queue for their missed screen or let it be?

Health Secretary Hunt rightly apologised but then claimed that 135-270 lives may have been shortened by the screening recall failure. Medical negligence lawyers such as Leigh Day are licking their lips but – when the evidence is forensically dissected – it will be near impossible for any woman to prove that her life may have been shortened by the error. For a start, there is no current evidence that missing a single screen at age 68-70, at the end of a 20 year screening programme, will harm you. Hunt’s guess comes from the most optimistic estimate that 1 in 1400 women has an early death from breast cancer prevented per screen. Hunt and Public Health England (PHE) appear to have divided 450?000 by 1400 to get 321, then factored in the fact that 30% of women decide not to be screened so 225 lives may have been shortened, but make it a range (135-270) to make it clear it’s a guess and individual harm is hard to prove. However, given that the government has spent 30 years simplistically telling women that ‘screening saves lives’, it would be hard to perform a volte farce and argue that not screening doesn’t shorten lives, even if the evidence – particularly for older women – is lacking.

The initial error may have been in computer programming, setting the wrong age parameter, but the fact that it wasn’t acted on for 9 years, despite some hospitals raising concerns, has led PHE and Hitachi to blame each other. 50,000 missing mammograms a year sounds a lot, but given there are 79 screening units in England, only a dozen women a week in the older age group were not being screened. The NHS has gone into full panic mode. The emergency phone line (0800 169 2692) had more than 8000 calls on its first day and PHE has promised to contact the 309?000 women they think are still alive by the end of May, with the aim of providing mammography to all who want it by the end of October. Breast screening units across the country may have to arrange thousands of additional appointments and many are already stretched to the safe limit due to staff shortages. This could be a recipe for more errors and more litigation. As the Nordic Cochrane website observes, the tremendous advances in breast cancer treatment make early diagnosis through screening less important to survival; ‘It no longer seems beneficial to attend for breast cancer screening.’ By opting out of screening, a woman will lower her risk of being labelled and treated for early breast cancer with no benefit to her quality of life, or life expectancy. Many women will still choose to be screened but for the 800 or so who would have been over-diagnosed, the NHS error may have been a blessing in disguise.

More Privates on Parade

The NHS has always had an awkward relationship with doctors who also practice privately. Unlike schools, where teachers choose state or private, consultants can serve two masters simultaneously thanks to the ‘stuff their mouths with gold’ compromise agreed by health secretary Nye Bevan in 1948, to try to win around the 85% of doctors who had voted against joining the NHS in a BMA plebiscite just 5 months before the new service was due to launch. Bevan – and the consultants – preferred option was to have NHS pay beds which allowed doctors to stay ‘on site’ and not bugger off to Harley Street leaving their junior staff to fly by the seat of their pants. And it also gave private patients the benefits of NHS facilities and emergency care if their treatment went badly awry.

In the event, the creation of the NHS and the provision of universal healthcare made private practice much less popular, with fewer than 100,000 people having private medical insurance in 1950. In the sixties, it made a comeback as a company perk for rewarding workers who couldn’t be paid in cash and by 1974, 2.3 million people were covered (4% of the population). Half of them were treated in NHS hospitals, a much safer option that being stranded in the upgraded nursing homes that masqueraded as private hospitals but had no emergency cover. Only consultants benefited financially from private practice, which led to resentment from junior doctors and other NHS staff who were often roped in to look after precious patients. There was also evidence of consultants using NHS equipment for private patients without reimbursing the NHS and manipulating waiting lists – keeping them artificially long to tempt patients to go private, or to allow private patients to jump NHS queues when they had run out of money (see John Yates book ‘Private Eye, Heart and Hip’ – Eyes passim).

In 1974, ancillary workers “blacked” private patients at Charing Cross Hospital, and Labour health secretary Barbara Castle legislated to phase pay beds out of the NHS completely but ‘only when alternative private provision was available locally.’ This lead to a massive increase in private hospital building – an 80% increase in beds up to 1979 alongside widespread industrial action and lengthy NHS waiting lists. By 1980, 26% of the population had private health insurance and Barbara Castle was dubbed ‘the patron saint of private medicine.’ The danger for patients of this new arrangement was that although many private hospitals had plush rooms and nutritious food, they still didn’t have cardiac arrest teams or intensive care. MD’s only foray into private practice was to be the only on call doctor covering an entire hospital over a weekend in 1988. There was no hand over, I didn’t know anything about any of the patients and the cardiac arrest trolley consisted of a bottle of port and the death certificate book. The only hope of survival if something went wrong was for someone to spot you were ill in your private, secluded room and call 999 to transfer you back to the NHS safety net.

How safe are private hospitals today? Last week, the Health Service Journal reported that assistant coroner for Manchester West Simon Nelson has written to Jeremy Hunt warning about poor processes for emergency transfers, the lack of responsibility private companies have for consultants they use, and junior doctors working alone for 24 hour shifts with a lack of training and monitoring. He has given Hunt until next month to respond, following his investigation into the care of 77 year old Peter O’Donnell. Mr O’Donnell, who was an NHS patient, died in January 2017 after hip replacement surgery at BMI Healthcare’s Beaumont Hospital in Bolton. His hospital-acquired pneumonia was not promptly recognised by staff, who dialled 999 to rush him to the Royal Bolton Hospital four days after his surgery, where he died from a cardiac arrest, organ failure and sepsis. The coroner cited an excellent report by the Centre for Health and the Public Interest, which is also investigating the rogue breast surgeon Ian Paterson (Eyes passim). CHPI points out private hospitals are likely to have profited handsomely from his malfeasance. ‘The 750 patients who underwent breast surgery and numerous other unnecessary procedures will have generated a very large amount of revenue stream for Spire Healthcare, which employed him as freelance surgeon. This large income stream could have meant that there was no strong incentive for the hospital management to look closely at the nature of Paterson’s work’. CHPI recommends consultants be directly employed by private companies who should have responsibility for monitoring performance, and the coroner agrees. Whether Hunt will agree remains to be seen, but with a substantial number of NHS operations now outsourced to the private sector, the safety holes in private hospitals could trap anyone. FFI www.chpi.org.uk

Whistleblowers Seldom Win

Do NHS whistleblowers have any meaningful legal protection if they take safety concerns to the media? In 2012, Edwin Jesudason –a highly regarded consultant paediatric surgeon and researcher – went to the media because he believed Alder Hey Children’s Hospital (AHCH) failed to address serious concerns about harm and risk to children, and the smearing of the mental health of a fellow surgeon-whistleblower, Mr Ahmed (Eyes passim). Jesudason hoped he would be protected by the Public Interest Disclosure Act (1998), which was introduced to protect whistleblowers after the appalling treatment of anaesthetist Steve Bolsin, who became unemployable in the NHS after exposing the Bristol heart scandal, and saving dozens of babies from brain damage and death (Eyes passim).

In July 2012, Jesudason won a temporary high court injunction with costs against AHCH, which was seeking his “no fault” dismissal after certain surgical colleagues refused to work with him. However, in trying to make the injunction permanent and to improve whistleblowing protection for other NHS staff, Jesudason lost at a second high court hearing after his union, the BMA, withdrew their legal support for him. The BMA often represents doctors on both sides in whistleblowing disputes, hardly an ideal situation. AHCH have since claimed that all Jesudason’s concerns were unfounded and had been dealt with, but it heavily redacted an investigative report into safety by the Royal College of Surgeons, and Jesudason believed it was misrepresenting the report to defend its reputation and hide failures of care. Jesudason was particularly concerned that avoidable deaths were not learnt from openly, a view supported by the mother of Caitlyn Parry, who died after surgery at AHCH in March 2010. Sian Parry had to take legal action against AHCH to get to the truth – seven and a half years after Caitlyn died because major arteries had been cut in error by a surgeon who had just returned from sick leave and was supposed to be overseen by another surgeon.

In the same year as Caitlyn’s death, on learning Jesudason (now on secondment in America) had reported safety concerns, AHCH surgeon Colin Baillie wrote ‘It is imperative that our legal position is solid should trust wish to terminate the employment of Jesudason… The allegations of patient harm go beyond the cases mentioned in this document, so we can expect more damaging revelations. There are only two possible outcomes; major departmental restructuring (on the quiet) with Jesudason returning… or a very dirty fight, fully in the public eye, with the organisation’s chief weapon being to bring Jesudason (who remains a talented surgeon and researcher) before the GMC for sanction.’

‘Weaponising the GMC’ is a standard procedure for punishing whistleblowing doctors. Raj Mattu, a brilliant cardiologist lost to the NHS after raising patient safety concerns at University Hospitals of Coventry and Warwickshire (UHCW) had to endure absurd and invented allegations of sexual misconduct, fraud and over 200 spurious referrals to the GMC (Eyes passim). Mattu eventually won a record payout but not before the trust, under the ‘leadership’ of CEO David Laughton has squandered over £6 million of public money in trying to shut him up or discredit him. Loughton is now CEO at the Royal Wolverhampton and the proud owner of a CBE for services to the NHS. Meanwhile, Jesudason and I submitted a poster about his concerns to a paediatric meeting. AHCH’s Medical Director and former BMA Place of Work Representative, Mr Rick Turnock responded: ‘I think the first priority is the poster. Then we turn our attention to Dr Hammond GMC number 3257087.’

Jesudason wanted his concerns to be investigated fully, but the BMA wanted him to accept a pay-off and compromise agreement, their standard mo when making awkward situations disappear. When Jesudason went public, they not only withdrew legal support, causing his case to collapse, but pursued him – and are still pursuing him 6 years later – for costs in the case – estimated at £250,000. The BMA knows Jesudason lost his house and surgical career and has no chance of making any such payment. Jesudason had to represent himself against the BMA in October 2016, and judgment is still awaited 18 months later. Why the doctors’ ‘union’ would want to inflict such a punishment beating is unclear, but its later discrediting of junior doctor whistle-blower Chris Day continues this pattern (Eyes passim). Jesudason lost an initial Employment Tribunal in Liverpool after it refused to grant him whistleblowing protection and excluded important evidence against AHCH. He now has an Employment Appeal Tribunal in London on April 17-19. It’s an important test of whether workers, in good faith, are legally protected when they take legitimate concerns outside their organisation when they are not being addressed internally. You can support his case at: https://www.crowdjustice.com/case/whistleblower-seeks-protection/

Fat Kids, Fat Profits

In 1946, poor children in the UK were on average 2kg lighter than rich children at the age of 11. Today, they are 2 kg heavier, according to an analysis in The Lancet Public Health. Then and now, poorer people struggle to eat sufficient nutritious food. But now they eat an excess of cheap, sugary, salty highly-processed crap, triggering an obesity epidemic that has become the commonest cause of preventable disease and premature death, and is bringing every health service to its knees. Nearly a third of UK children aged two to 15 are overweight or obese and younger generations are becoming obese at earlier ages and staying obese for longer. So who’s to blame?

The strategy for the last 40 years has been ‘to encourage individuals to make healthy choices’ whilst giving them the wrong information and allowing the food industry to run riot. But simply blaming the food industry is too simplistic. Egged on by the pharmaceutical industry, doctors have for decades focused on the aggressive lowering of low-density lipoprotein cholesterol to reduce heart disease risk by cutting out saturated fats in the diet and prescribing statins. This in turn encouraged the food industry to aggressively market zero or low fat foods that claimed to be ‘heart healthy’ but were anything but, being crammed with sugar. This slavish mantra of low fat, low cholesterol and ‘statins for all’ has made billions for food and pharma firms but has helped trigger the massive rise in obesity and type 2 diabetes, where the main culprit is the sugar spikes from processed foods causing insulin resistance. And the solution is not new and better drugs, but better food.

The trouble is, it’s hard living the Mediterranean dream in, say, Gateshead. A wide variety of seasonal fruit, vegetables, legumes, nuts, seeds, extra-virgin olive oil, sustainable fish and organic meat may not always be easy to source. Preparing the meals from these raw ingredients takes time and skill. Wastage is higher because fresh food spoils more quickly. And the ingredients cost far more than, say, multi-buy frozen nuggets, burgers, chips and pizza. Even if you could persuade your children to fill in a rainbow chart on the fridge to ensure they’ve eaten their daily seven different coloured fruits and vegetables, rich in antioxidant polyphenols, the chances are they’d be social outcasts at school.

According to an excellent report on the social determinants of health by the Health Foundation, it is three times more expensive to get the energy we need from healthy food than unhealthy food. It is not only harder to buy healthy foods in deprived areas, but there is also a higher density of fast food outlets. Just 1.2% of advertising spend each year goes on vegetables, compared with the 22% spent on confectionary, cakes, biscuits and ice cream. While ministers ‘consider’ curbs on advertising, pack sizes, ingredients and two-for-one deals on unhealthy food, poorer children are eating themselves to ill health and premature death. A baby girl born in Richmond upon Thames is expected to live 17.8 more years in good health than a baby girl born in Manchester, and to live almost a decade longer. And much of that is down to diet.

Gateshead Council is at least doing its bit. It has used local planning policy to ensure that any application for a hot food takeaway will be declined if it is in an area where more than 10% of children in year 6 are obese; if it is within 400m of secondary schools and other community amenities, or if the number of hot food takeaways in the area is equal to?or greater than the UK national average. Schools and hospitals should also ban highly processed food and sugar drinks from their sites. Too many hospitals are tarts to the processed food industry, and some have even had fast food outlets on site. It is still not uncommon in the NHS for someone to have a lifesaving stent inserted into a blocked coronary artery only to be served a burger and chips afterwards.

But the overriding message of the global obesity epidemic is that ‘encouraging healthier choices’ hasn’t worked. Politicians have to get their shit together and legislate for healthier food, particularly in areas where it may not be top priority. If you have no job, no house, no self-esteem and no future, you’re unlikely to pop down to Waitrose for some oily fish and a punnet of seasonal berries. The government’s childhood obesity plan has at least committed to the reformulation of nine categories of popular, mass market foods, to reduce their sugar content. If you can’t change the people, you have to change the food. Time for the Nanny state to act, and the food industry to pay. Enjoy those Easter eggs, while you still can. (PS 100% dark chocolate is best, being rich in anti-oxidant polyphenols).

Safety First?

The 2018 World Patient Safety, Science and Technology Summit at the ‘stunning’ 8 Northumberland Avenue in London ‘was organized with the support of the Secretary of State for Health and Social Care, the Rt. Hon. Jeremy Hunt MP’. Prices were $1000 for hospitals, healthcare organizations and committed partners that have made a formal pledge of allegiance to the Patient Safety Movement Foundation (PSMF). For ‘first time’ attendees who were ready to commit it was also $1000. For medical technology, medical product and pharmaceutical companies that have not formally affiliated with the PSMF, the price rose to $5000. The highlight of the conference is the PSMF Humanitarian Award which each year goes to the ‘patient safety leader who has made significant progress in eliminating preventable patient deaths so that we can reach our shared goal of zero by 2020.’ Step forward Jeremy Hunt, without whose support the conference would not have been possible.

Given the large number of preventable patient deaths and widespread avoidable suffering in the NHS due to insufficient capacity, unsafe staffing levels and widespread cancellations of routine care, this would seem a bold choice. True, MD would far rather have a health secretary who is interested in patient safety than one that isn’t, and Hunt has certainly listened selectively to the stories of some people whose relatives have been seriously harmed by healthcare, whilst ignoring the tales of others, particularly NHS whistle-blowers, whose stories are politically inconvenient. His latest campaigns are to try to reduce medication related fatalities (a good thing) and to encourage staff to call consultants by their first name to try to make it easier for anyone to speak up if they spot and error. Hunt cited, as he often does, the preventable death of Elaine Bromiley as an example of a nurse knowing what to do (an emergency tracheotomy after a failed anaesthetic intubation) but not being able to override the consultants. Whether calling them by their first names would have made a difference is debatable.

Elaine Bromiley died in 2005, and MD wrote about it long before Hunt became health secretary (Eye May 2008). She was operated on privately by a very experienced team – her consultant anaesthetist had sixteen years of experience, the ENT surgeon had 30 years under his belt and three of the four nurses in the theatre were also very experienced. There was no short staffing or competing interests of emergency cover and the theatre was fully equipped. It was a ‘dream scenario’ for patient safety, rarely found in the NHS. And yet they made a catastrophic error when the intubation turned out to be unexpectedly difficult. No-one was found guilty of gross negligence manslaughter or struck off.

Contrast this to the preventable death of Jack Adcock in 2011, in NHS circumstances so unsafe that no amount of consultant first-name calling would have made a jot of difference (Eye recent). Indeed, Dr Hadiza Gawa-Barba had no consultant cover on site when she made errors in Jack’s care in an otherwise unblemished career. She missed a diagnosis of sepsis, as thousands have before and since, and yet was singled out for gross negligence manslaughter and aggressively pursued and struck off by the GMC. In 2005, Professor Graeme Catto admitted to missing a diagnosis of septicaemia in a man in his twenties admitted as an emergency, who subsequently died. Catto was not found guilty of manslaughter or struck off, but he had been president of the GMC for 4 years when he made his public admission.

The GMC has variously been described as racist and vindictive in pursuing a BME junior doctor when so many senior white men who make similar human errors face no sanctions. Hunt has at least spoken up about the folly of permanently erasing an otherwise competent doctor who openly admitted to her errors and should never have been put in such an unsafe situation, but he has overseen the 100,000 vacancies and widespread bed shortages in the NHS workforce that make it such an unsafe place to work and be sick in. As he was collecting his award, Dr Chris Day tweeted ‘Had a man with bowel obstruction with lactate of 4 (seriously ill). Patient had to have fluids in corridor and his wife had to act as a drip stand as one could not be found. Whilst all the patient safety champions are off at conferences congratulating themselves, NHS staff deal with reality.’ Dr Day is a true patient safety champion who blew the whistle on unsafe staffing levels in intensive care in Woolwich, was removed from his training program and discovered that 55,000 junior doctors have no whistleblowing protection. (Eye). The NHS has spent £100,000 trying to block his case getting to court and Jeremy Hunt, global humanitarian patient safety leader, refuses to meet him. Perhaps Dr Day should organise a global patient safety conference and give Mr Hunt another gong.