The Francis report on the dreadful doings at the Mid Staffordshire hospital can only be welcomed. The events were horrific, something went terribly wrong and heads should roll. But could what happened be a symptom of a wider problem? Does it tell us anything about the way medicine is practised in general?
The most common explanation for the tragedy seems to be that management, fixated on achieving foundation status, were preoccupied with ticking boxes. The result was that actual patients vanished off the radar. Instead of monitoring their overall well-being, the focus was on numbers admitted, diagnostic procedures, throughput, costs, length of stay and so on.
It seems to me that this fragmentation of patients into independent elements has an echo of the problem identified in the book I co-authored with Patrick Holford “10 Secrets of Healthy Ageing” where we described how easy it is to be on five or more drugs by the time you’re over 65.
It happens because GPs are expected to follow a set of guidelines – if your cholesterol, your blood pressure, or even just your age is above a certain level, there is drug you should be getting. Similarly there are drugs for depression, drugs for insomnia and drugs for weight loss (actually currently only one). Nearly all of these conditions are frequently inter-related and tackling the underlying issue could resolve a number of them, but in practise this approach is not taken very seriously. Instead we are sliced up into symptoms and each is treated separately.
In fact all these conditions respond well to various life-style changes delivered by properly trained professionals. Cholesterol, blood pressure, insomnia all improve when you lose weight, change the way you eat and exercise. We describe what’s involved in detail in “10 Secrets”.
At this point most medical professionals will yell in exasperation: “Of course we know all that. We tell patients to do it endlessly. Trouble is most people can’t or won’t follow that sort of advice and all too often given up fairly soon. So we do what we can with the drugs.”
The implication is that the problem lies with the patient’s lack of moral fibre. If only they weren’t so greedy, lazy, self-indulgent they wouldn’t be in an unhealthy state in the first place or be unable to lose weight if they did occasionally pile on the pounds.
But what if the root of the problem wasn’t personal but the way modern medicine is set up? The touchy feely stuff that’s needed to comfort and look after disturbed patients is not that different to what’s required to help seriously obese people to keep the weight off. There is no doubt that it works the but the current system doesn’t really value such skills and pushes them to the edges.
This is a disaster for both patients and costs. The lifestyle disorders – obesity, diabetes, heart disease – that eat up an increasing chunk of the health budget and GPs time respond well to such skills. However providing them or improving their techniques has a far lower priority than a possible drug breakthrough
So how might it work differently? Let’s go back to the weight loss scenario and imagine you’ve been piling on the pounds and your markers for diabetes are rising. Or even that that you have had diabetes for a few years, the pills are becoming less effective and and your doctor is warning that you may soon have to start injecting insulin.
You may be surprised to learn that for at least 20 years, thanks to the results from bariatric surgery, doctors have known that a dramatic weight loss of about 15% of your body weight can reverse diabetes in a week. All those markers fall back to a healthy normal level and drug intake plummets, sometimes to zero. Problem is that surgery is risky and very expensive – we’d be bankrupt if that was all we relied on.
But maybe equally surprising is that it has also been known for years that you don’t need surgery to shift that much weight – you can do it with a low energy diet, getting 800 calories a day from a nutritionally balanced formula. At which point the “regain” objection springs up. But two recent studies make it far less plausible.
Less than eighteen months ago a small study at Newcastle University showed that putting severely obese patients on a low energy diet reduced the markers of diabetes back to a healthy level for a significant proportion of them. Then earlier this month a study involving 91 severely obese patients and run by the Scottish government showed that the diet enabled those who followed the programme – about a third – to lose over 12 kg - the amount needed to reverse diabetes. What’s more, and this is the important part, with proper support and help from nutritionists, exercise trainers, and psychologists if necessary, the weight could be kept off for at least a year.
The last objection is cost. For everyone in the trial the cost of the program was 800 pound and for each one who hit the target weight and kept it off, the cost was just over 2000. Looks pretty good compared with the hundreds of thousands a diabetic can rack up.
It’s a heartening story about an important breakthrough but one element is depressingly familiar. An approach with the potential to tackle a major and costly disorder is largely ignored for years because it’s not a biochemical breakthrough. It just involves professionals who have good interpersonal and physical skills to help patients in need. Precisely what those those unfortunate patients on the ward were so cruelly lacking.