C-sections and NICE twaddle.

Like all GPs in the UK the team at ND Central own Ferraris and commute along Northernshire’s high moorland roads and through its forests from their baronial mansion houses daily to serve their patients. During this arduous chore a few of us listen to the radio. Several of the team this morning heard an interview on the BBC’s radio Four news which can best be summed up as like watching a couple of pensioners trying to emulate a world championship heavy weight boxing contest.

The link to this is here and it illustrates what our fellow GP blogger said in their piece here.

We don’t know how long the link will last so here is the moron’s take on it. The interview is very long (10.21 minutes) by UK media standards and the twaddle is produced by a Dr Gillian Leng NICE’s deputy chief executive who has loads of obstetric experience if you read here and who says:

“We think that the rate of Caesarean section is likely to decline as a consequence.”

Really? A few choice grunt words came to mind as we heard this pontification for over the years of doing medicine we have heard repeatedly from our colleagues in midwifery over and over again that there has been an increased demand for Caesarian sections that are medically unnecessary.

This is akin to NICE recommended compulsory castration to prevent testicular cancer, the removal of all skin defects to prevent melanoma, and the removal of all subcutaneous fat to prevent obesity. All medically unnecessary, but available, treatments if you so wanted.

Unfortunately we suspect that NICE is doing what it is paid to do to review “alleged” evidence and pander to the politicians to justify their interference in matters medical.

Of course those NICE people do not understand the NHS “meerkat” of NICE cuddly toys held up by politicians to tempt patients, sorry punters their way. Who could resist a NICE cuddly “meerkat” when it is always free when know your NICE rights?

If you were too posh to push and you used to have to pay for it and your local supermarket now gives it away for free where do you think the stampede would be that would crush you?

If the NHS offered euthanasia (or any other medical treatment) for free that is not currently available we bet you that the euthanasia rate (or other treatment) would go up, not down, regardless of need.

Anyone fancy a bet on whether C-section rates will go up or down? After all a NICE lady doctor has told you what will happen and we bet you trust all that is NICE?

Don’t you?

Praise be to the Party and its all wise idiots at NICE who have already increased obstetric costs in a time of increased poverty of resources but for what medical gain? We look forward to next year's drop in the C-section rate and to our trouserring a few pounds from our friends at the local bookies.

Anyone done the maffs?

We have been informed that a Caesarian section will now be a right rather than a medical necessity. A few thoughts occurred to the team. Let us suppose that you work at a hospital that does 12 deliveries a day and that all the women opt for a Caesarian section rather than a natural childbirth.

Let us assume that each Caesarian takes half an hour of operating time then any hospital operating new NHS C-choice™ would have to find a mere 6 hours minimum of theatre time a day above what is provided now. Operating time is not the only thing that would have to be found there would need to be found additional anaesthetic and associated personnel time, surgeon and assistant time, midwife time, paediatrician time as well as porters et al and of course those most essential for true patient care the NHS commissars to prepare the bills that allow the NHS to work independently of all of the aforementioned non essential personnel.

The hospital would also have to find 12 beds a day as well as recovery staff time and ward nursing staff time and that is assuming that these are all done as general anaesthetics rather than epidurals which take longer to work and all were done as day cases.

Indeed our recollection of elective Caesarian sections done under regional anaesthesia which you can bet will be the norm for those too posh to push so they could see their darling little Tarquin or Chantelle-Detritus-Leah (it's exotic!) born and post the event on YouTube was that 2 maybe 3 could be done in a half day session.

So 6 hours of operating time is being optimistic it is more likely to be 2 or possibly 3 theatres operating for a full day plus the increased number of staff. In order to work this would need to be available for 365 days a year as well as facilities for any emergency C-sections.

Obviously as this would be C-choice there would be peaks and troughs for Tarquin’s and Chantelle-Detritus-Leah’s planned arrival into the world. For example I couldn’t deliver at Christmas as I would miss my turkey and heaven forbid any obstetrician says to a woman the only slot we have for an elective C-section is on the night of an X-factor final, FA cup final, or a Big Brother eviction. How would Wayne Trotter the father cope? You can bet that he and Sharon will know their rights then.

The article quotes a figure saying that a one percentage point reduction in C-section rate saves £ 5.6 million. Does that mean that if 100% of births were done by C-section up from the current 25% the NHS would have to find £ 420 million a year for a procedure that some would argue is not being done for a medical reason?

And in order to double check the maffs if one takes the figure of 708, 708 births in 2008 take 75% of these and multiple by the quoted £ 800 extra per birth you get a figure of £ 425 million. Not a small chunk out of £20 billion NHS efficiency savings over five years in the midst of a recession.

Then there is the morbidity and mortality to add in. Yes deaths from anaesthetic complications have decreased in pregnant women over the years but if more women have abdominopelvic surgery then DVTs will increase. We believe that 60 in 100,000 women who are pregnant will have DVTs which is an old figure presumably based on a 25% C-section rate. If that rate increases will DVTs and PEs and their 1% mortality go up as well as general morbidity for example wound infections to match the increase in numbers done? More operations means more chance of misadventure so what would happen to NHS indemnity bills and defense society charges?

Now we are simple GPs here at ND Central and while doing home visits one of the team heard an interesting point being made on a popular TV show as they listened to the normal chest of the infirmed but “too idle to come to surgery”, the ancestor of the "too posh to push" generation. This urgently infirmed geriatric had wanted to be sure they were well enough to go to their granddaughter’s Halloween Party and outdoor barbeque – presumably as the evil looking witch with nicotine stained nails, eau d’cigarette body odour and scary brown hag dentures –  followed by trick or treating with Jemima-Louise.

The point was made on the programme that NICE stood for National Institute of Clinical “Excellence” (not) – got us listening – and that Marshall DC’s poll rating with female voters is low. Could this be the answer to another medical blogger’s posed question?

We await the final publication of any NICE guidance and their reasons for suggesting their policy. We hope that following on from this that all cosmetic procedures will now be available on the NHS for surely if everyone is now too posh to push then no-one is too poor to be ugly?

Praise be to the Party and its NICE organs who evaluate “evidence” rather than science and come to some fairly doubtful “best” political practice ideas.

NICE goes in hard on pubic health?

Following on from the White Paper and the increasing role of NICE in deciding the new targets, sorry comrade, outcomes, a little piece in the GP magazine Pulse caught our caught our eye and after consuming some fermented organic chemical containing beverages led to a few thoughts.

So the Party, after restricting drugs for erectile dysfunction (ED) to only certain worthy groups of ED sufferers, while allowing any spotty Herbert to have anti acne drugs, for we all know that sex is purely for reproductive purposes, is now going to set targets to “incentivise” GPs to prescribe drugs for ED. A slight change there from a policy of proscription to one now of prescription?

Oh misses titter ye not but before you all get excited you ‘orrible little dirty buggers, the article goes on to say a pilot will test 4 new “indicators” to incentivise (its that word again) practices to case find and prescribe treatment for ED in men with diabetes . . .

“Private Nobbings you has diabetes and a touch of the EDs get yourself off to the MO at the double for he ‘as an incentive to get you up ASAP! Left right left right . . .”

Pray tell what will the 4 new indicators be? Will there be new nurse or GP led new ED detection clinics (EDD Cs as opposed to Ed M)? How will success be measured? Will there be a new NICE ED scale similar to the MRC muscle weakness scale and will its units be in degrees or possibly mmHg?

The article goes onto say the aim will be to increase patient awareness and treatment of erectile dysfunction in men with diabetes.

Did we miss something but didn’t the marketing of the drug called Viagra do just that a few years ago? Clearly those up standing members of NICE spend absolutely no time in general practice for if they did they would know that men both with, and without, diabetes frequently come in not having read anything NICE and ask for treatment for ED?

We won’t use words like U-turn but the move from positively discouraging ED treatments to now actually suggesting sending out ED patrols to seek, find and treat with extreme prejudice all diabetic males with ED does raise a few titters here at ND Central.

Will these patrols go out shouting bring out your limp and floppy diabetic ones under cover of darkness or will it be the discrete under the counter brown envelope something for the weakend approach?

Perhaps somewhere in the ConDem coalition there has been a softening somewhere along the line of the members’ attitudes to this topic and someone has had a word with someone NICE to see if they could help them with their little problem?

Nudge nudge wink wink say no more. Where are Kenneth Williams and Frankie Howard when you need them most?

If ever there was a case for NICE being disbanded this is it. Put all ED drugs on FP10s for all patients 30 seconds worth of news on Gormless Moron TV sorry Daybreak and you will pick up more cases of ED in both diabetics and non diabetics than any QOF indicators and for a fraction of the cost.

Praise be to the Party for giving us something NICE to ponder upon after a few stiff drinks. We are sure there will be a lot of hard evidence for this approach and all those at NICE will once again present us with a solid shaft of evidence for these new QOF indicators. We did notice in the article that someone from NICE has had their name withdrawn at their request was this at the last moment as they thought better of their dalliance with matters sexual?

Now we all have to be NICE?

What inspired this piece is an article in the GP magazine Pulse:

http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4121395

where a Party organ has said that doctors must now follow NICE guidelines or face prosecution. An interesting phrase “guidelines” as the Shorter Oxford English Dictionary defines them as “a directing or standardizing principle laid down as a guide to procedure policy etc”. It would appear that if the Pulse article is correct that guidelines have now become a Party diktat.

A lot of doctors ignore NICE as they feel they are politically and economically driven rather than scientifically driven. In Northernshire they are opened, the front cover scanned and then binned by and large and reference made to a variety of other sources journals, books and colleagues opinions before deciding on a particular treatment.

This is called being a doctor. As a doctor, rather than a Party organ, one considers the various options and applying what one thinks is best for a particular patient and their condition. However the Party knows best and if this idea is followed through patients will have any “choice” of treatment as long as it is black and NICE.

An example from the ND’s past experience may illustrate how this ill conceived idea would work in practice.

When ND was in the military, ND was stationed at a hospital that took part in the ISIS2 trial looking at clot busting drugs for heart attack patients. The trial was stopped early because the use of clot busting drugs was so much better than the existing treatments.

The senior medical officers at the base read the results of the trial and decided that it might be a good idea to stop the trial and treat all heart attack patients with the clot busting drugs. They went to see the commanding office at the hospital who was also a doctor, not a manager, and presented their view that the hospital should change treatments and he agreed after a short meeting and a review of all the evidence.

Thus within days of a major scientific trial being published this particular military hospital was one of the first in the State to use clot busting drugs long before many other neighbouring civilian hospitals did. This treatment has been is use now for almost 20 years throughout the world.

This is an example of doctors acting independently, considering the research and coming to a considered opinion before changing treatment for the better.

Now let us look at what would happen if NICE was the only treatment. We know that NICE considers things at a pace slower than a crushed slug can move so it would take months or years for them even to consider new research. Even if it did consider new research it would look at the economics probably have a political slant all of which could mean that something that worked might not be approved because of cost or Party interference.

So the result would be that the Party would approve and ration drugs even more than at present and medical innovation would be stifled by the fear of prosecution.

The Party and its comrade commissar managers rarely learn from history. Someone has not told them that the Berlin Wall has come down, the Cold War has ended and Communism in Europe is virtually non existent. Someone hasn’t told them that once centralized Party driven control was removed from the Eastern Bloc then countries with some of the worst health care systems in the world have risen up the league tables while the increasing centralisation of the NHS is one reason that it has slipped down health care leagues to be almost bottom.

We implore anyone reading this to think carefully about what the effect of Nicentralization would be on the NHS’s ability to offer cutting edge health care. We suspect it would end it and set back NHS care years at a single political stroke.

Let us hope that our faith in democracy and reason will over come the Party’s ill thought out centrally dictated policies that will ultimately harm patients and deny them “choice”.

Praise be to the Party for Gordon’s Little Green Book knows best.