Thoughts on our Healthcare

“It is forecast that by 2030, the global consumption of antibiotics will rise by more than 30% (200% if it continues at current growth levels). By 2050, the annual death rate will have risen from 700,000 to 10 million with no action.”

 

It is a humbling situation when one realises how fragile we are in the face of nature and how little we really know in the battle to protect ourselves.

My generation have the unique honour of having grown up at a zenith of medical know-how. As a child, I often reassured myself that, if I or anyone I knew ever became unwell, everything would be fine. I always comforted myself that, should it be needed, there would be the medical expertise somewhere to cure anything. I was confident that the medical care and consensus behind every treatment was solid and complete; its efficiency spotless. Now I realise that this was simply a form of therapeutic self-delusion.

The truth is that, although our capabilities far exceed the wildest dreams of Hippocrates and Aristotle, we are far from perfect. What we don’t know far outweighs what we do. Treatments remain speculative, their quality reliant upon where we fall at any one time on the curves of demand and supply. Despite officious regulation, treatment remains highly subjective according to who treats you (bearing in mind this may be an exhausted doctor or nurse running on empty), and could still be based on faulty or unreliable evidence. We can’t guarantee a cure for your cancer and we can’t always tell for sure why you’re feeling so tired and achy, so sometimes we have to guess a bit.

Our exaggerated opinion of our own ability as a species extends beyond just medicine of course. While that can be catastrophic in other fields, it does at least provide some benefit in a healthcare setting. Confidence in physicians can be a therapy in itself. Despite what I have said, this trust is important and well placed. Though not perfect, we are better than nothing! And yet, when something like the Covid-19 pandemic hits – something so undeniably out of our control – it highlights those cracks that we’ve otherwise consciously chosen to ignore. 

What has struck me most about the Covid-19 pandemic is our reaction to it. While in some places it has highlighted tremendous courageous and community spirit, in others it has merely brought out human attributes that are the polar opposites of the aforementioned. For me, it has emphasised the prospect (and quite possibly the need) for fundamental change in how we utilise the medical expertise and the knowledge we have accumulated.

The meaning of ‘our NHS’ has become a bit warped in recent times. When someone has been treated with kindness and care, it is the NHS that gets the thanks. In reality, it is the people that work for the NHS who should be thanked as well as the organisation as a whole; a distinction that I feel too often gets overlooked. Obviously this is semantics and very often that is what people will mean when they praise the NHS. But in merging the two, a powerful message is being lost.

The people that work in healthcare, whether it be within or without an NHS, deserve all the praise they are getting. Likewise, the idea of a National Health Service that provides universal, comprehensive and free healthcare should also be praised. The problem is, at its inception in 1948, the idea of comprehensive healthcare is very different from what it is now.

In 1948, paracetamol was yet to become readily available, open heart surgery was 4 years old, statins had not yet been invented and antibiotics were in their infancy. Fast forward to the present day and we are seeing around 200 heart transplants a year in the UK, an entire pharmacy of medications available to us at our beck and call, lifesaving emergency services 24/7 and access to state of the art intensive monitoring equipment. Around half of the UK population takes at least one regular prescription medication. If your hips or knees go, you are entitled to have metal replacements inserted for no extra charge. If you have a rash, you can have it seen to or if you want your ingrowing toenail sorted, you can have it clipped or lopped off. If your ears are blocked, someone will clear that for you too.

With our population increasing and growing older, it is little wonder that the whole thing is beginning to creak. The outcome…? You have to wait a long time for your hip replacement, you might be denied the chance to have your bunions sorted out because it is a low funding priority. Your GP is running late by 20 minutes or even a bit longer. That may seem a bit insensitive or flippant (or both) but believe me, I’m not happy about it, certainly if it means people are waiting for treatments in agony. While some have a rational grip on such situations, others will not. Those are the ones that abuse the staff who are only trying their best in impossible circumstances.

Demand has far outstripped supply already. At current levels of funding, the promise of delivering a comprehensive service is no longer accurate. But that is only if we all agree on what counts as comprehensive.

We have been rather spoilt with the NHS, rather like a child who is given one sweet and then pleads for several more, never content with what they are given. The level at which our baselines have shifted (there is an actual concept know as shifting baselines syndrome that one could probably apply to much that is wrong with the world) is significant. Consider 100 years ago, antibiotics were non-existent, surgery was more dangerous than beneficial and not long before that there wasn’t even the luxury of an anaesthetic. Just read the 1810 diary account of Fanny Burney, the English novelist, who developed Breast cancer and underwent a mastectomy without anaesthetic to see what I mean.

Antibiotics and our use of them serve as a perfect microcosm to demonstrate my point. For all they have given us, they have also contributed to levels of antibiotic resistant infections that kill 700,000 people a year globally. Don’t get me wrong, antibiotics are great; a lifesaver in fact. Prior to their widespread utilisation, a cut or scratch could become infected to life threatening degrees and as such they have arguably become the single most important tool in our therapeutic arsenal (vaccination is arguably more important). And yet they have suffered a severe case of mission creep. They lend a hand in all sorts of unexpected ways. Caesarean-sections and routine hip replacements would be rather more hit and miss in terms of survival without them. Not content with saving lives, in fact they have become somewhat of a luxury, whether it be to shorten a cough or a bout of diarrhoea or to fatten up our animals so their meat is better.

In the UK, at least 20% of antibiotics prescribed in primary care are inappropriate (I would probably argue that figure is higher depending on your definition of inappropriate). At any one time, a third of patients in hospital are on an antibiotic. 

Resistant organisms transfer at will from one person to another, or to food and animals. As they do, we edge ever closer to a circumstance in which we are unable to treat them at all. There are already strains of TB and gonorrhoea that cannot be treated even by the antibiotics reserved as last resort.

The WHO cites antibiotic resistance as the biggest threat from global pandemic. Considering what is going on at the moment that should prick some ears.  Just as there are warnings about antibiotics, so there were for coronavirus. A pandemic such as the one we find ourselves in isn’t exactly a surprise and yet to a large extent, we have all been caught napping.  I liken it to sitting on a beach with a bag of popcorn, admiring the spectacle of a tsunami rolling in. Suffice to say, a tsunami of antibiotic resistance is far less palatable than the comparative swell of coronavirus we are seeing now.

It may therefore be time for some realism and some hard choices. This includes both those at the very highest levels but also, I’m afraid, for us all. Who knows in what shape we’ll emerge from the current saga.

In an ideal world, the government would pledge a suitable amount of money for the NHS to cater perfectly for everything from the largest and most severe of our medical needs down to the smallest and most trivial. Failing that, management of the entire system must get realistic and we must allow it to do so. No one wants to see a privatised NHS, (including the government if what they say is to be believed). Clarity of mission alongside acknowledgement of the problems– not spin – is what we need. Without this, whispers and rumours of privatisation will continue. If measures are to be painful, in my opinion telling people that is far better than trying to sneak it under their noses. Better still, a cross party approach in order to depoliticise proceedings is preferable so election success no longer rides on it. What we don’t want to see are more layers of management. Time and time again, we experience instructions from those at the top, far removed from the realities and often the progress we make is in spite of these targets instead of because of them. In any situation, the more layers you add, the more complex it becomes and the easier it is to trip over yourself. A bit like the game Tetris – a certain amount of blocks at the right speed will build something solid but as soon as the rate and number of bricks increases, it all runs away from you.

Just as importantly, perhaps even more so, is our individual role in all of this. As we clap our health workers every Thursday evening while in lockdown, perhaps take a moment to consider what we ask of them under normal circumstances. A large proportion of GP consultations are unnecessary and could be dealt with either by a pharmacist, or by the patient themselves. The NHS website has the information available if people were only to access it.

Between February and March, there has been a 22% fall in A&E attendances, many of would have been unnecessary anyway and would have taken up valuable resources and time.  General practice and outpatient secondary care has also seen a sharp drop in demand for routine enquiries. Many issues will have gone away on their own, or have been dealt with using online advice. Still more infections will have settled without antibiotics. We must harness this new way of using the health service.

This current situation may therefore serve as a not so gentle reminder of what are reasonable expectations in terms of our healthcare. That said, between early and late March, there has been a fall of 150 patients per day presenting with symptoms of heart attack. Now, it is unlikely that the Covid-19 pandemic has somehow cured heart disease altogether and though many people with chest pain turn out to be fine, there will be some within that cohort of 150 who have had real heart attacks; heart attacks that are currently going untreated.

Lack of presentation for this sort of thing, or indeed other worrying symptoms of things like cancer (loss of weight and appetite or a change in bowel habit to name just three), means the health impact of this pandemic will not be just related to Covid-19. For anyone with worrying symptoms like this, you absolutely must not ignore them just because of the outbreak.

We need to use the NHS sensibly. Not too much, but not too little. We have swung from one extreme to the other in the last few months. Once we emerge from this, we must all consider how best to use it going forwards, and focus on the bigger issues at hand, no doubt at a time of great change. Self-care is a big part of that, not just in how we deal with an acute medical situation but also in how we look after ourselves in general. Smoking alcohol, diet and exercise are the key areas that cost nothing to improve.

As a nation, our perspective in terms of the scope of our healthcare has run away from us. Some expect miracles – you don’t need to go to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash. Meanwhile, the threshold for others is far too high and there is a proportion of people that will hold off in coming to a doctor when they actually need to be seen.

As doctors we want to ensure that everyone who needs to be seen, and who we can help, presents to us appropriately. At the same time, we would request that others, who might reasonably be able to manage their own minor issues, do so. It is a fine balance and even writing this makes me uneasy that some may stay away for fear of overusing the service. The level of disparity in comprehension of how best to use the NHS is, in my experience, remarkable.

Nevertheless, I think we all could perhaps do with shifting our baselines back a hundred years or so. As doctors, we need to look at how we are using our resources and considering whether far more significant changes are necessary. Antibiotics use is just one example. Fundamental change at the top is needed to streamline the provision of healthcare and cut out the obfuscating bureaucracy. Difficult lines must be drawn. Leaders must consider taking more than half a glance at the deeper issues facing us – after-all from our current position, an antimicrobial resistant pandemic suddenly doesn’t sound as far-fetched as it did a few months ago. If that change is severe then so be it. Sometimes you have to go backwards to go forwards. In that case, we all have a responsibility to understand it and adapt, though politicians must realise that we cannot be expected to do that if left in the dark.

Urgent care must remain a priority for the service as a whole, but how we look after an ageing population effectively is just as vital. Prevention of health problems is key. One of the best ways to help therefore is to look after yourselves properly (we can only do so much in that respect) but also to seek help when appropriate in order to avert bigger health issues down the line. Staying away isn’t always the answer (particularly at the moment) although granted, there is a fine balance. That balance has always been upset one way or another and we all need to contribute in order to redress it. Now might be the time to set it straight.

 

 

 

 

 

 

The Problem with Antibiotics

Our honeymoon period with antibiotics and their undeniable benefits ended long ago, but since their inception we have created a deep seated culture of dependence.

Many thanks for your responses to my article last time around – keep those suggestions for topics coming. Shortly after I had finished the article about the common cold, I developed a cold of my own, so I have decided to postpone indefinitely my planned article on smallpox.

Our topic this week is antibiotics – a subject which is garnering more and more attention in the media. Since 2015, there has even been an annual ‘world antibiotic awareness week’ which, appropriately, was last week.

Why the fuss? Well I am sure most people by now have heard all sorts of stories in the news about antibiotic resistance and the emergence of ominously entitled ‘superbugs’. This is all for good reason as I will expand upon.

To begin with, let’s focus on antibiotics and what they actually are. Prior to their discovery and development in the early half of the twentieth century, we had no really effective ways of treating bacterial infections. Historically, all manner of approaches were used, from the rather dramatic process of blood-letting (thought to stabilise the balance of the perceived four humours: blood, phlegm, yellow bile and black bile), to the use of things like willow bark by the ancient Greeks for curing fevers and pains. (Willow bark actually contains salicin, which is chemically related to modern day aspirin).

Things all changed when the Scottish botanist Alexander Fleming returned to his laboratory in 1928 after a family holiday and noticed that mould had grown in his petri dishes of staphylococci bacteria. The mould in question (penicillium) had killed off the surrounding areas of the bacteria prompting Fleming’s famous response – ‘That’s funny’.

The rest, as they say, is history and since then many different families of antibiotics have been developed to fight off bacterial infections that had once been, at best, troublesome and, at worst, fatal. As we approach a century of antibiotic use, we can look back upon a vast improvement in our ability to treat infections such as pneumonia, syphilis, tuberculosis, meningitis and many more. This has no doubt had a vast social and economic impact. However, now we come to the problem.

Antibiotic resistance is a process that has been developing from the very beginning. In broad terms, let us consider a group of bacteria exposed to an antibiotic. In any reproducing population, there will always be random mutations that occur in the genes of certain individual bacterial cells. Sometimes these mutations happen to protect the bacteria from the effects of an antibiotic. Bacteria without that protection die, leaving the resistant bacteria free to multiply without competition. Over time, these populations spread from person to person, meaning that, when the same antibiotic is used repeatedly, it becomes less and less effective in controlling these bacteria. That’s it in a nutshell.

We are now at a stage in which no new class of antibiotic has been found since 1987 and there are thought to be around 12,000 deaths each year in the UK as a result of bacteria resistant to antibacterial treatment. If this trend continues without further action, the World Health Organisation (WHO) state that the global mortality from such infections could be as much as 10 million people a year by 2050. Advancements and achievements in modern medicine such as chemotherapy, organ transplants and routine operations like caesarean sections and hip replacements – all of which rely heavily on the availability of effective antibiotics – are now potentially at risk.

Development of resistance is and always was a natural and unavoidable process but our use of them has unequivocally made things worse than they could have been. In 2015, it is thought that around 25% of antibiotics were taken unnecessarily in the UK. When you factor in un-regulated use of antibiotics in farming and the availability of antibiotics over the counter in some countries, one begins to see how much of a global issue this is.

On a personal note, I have certainly seen strikingly inappropriate use of strong antibiotics prescribed in other countries for even the most trivial of ailments. There is most definitely a responsibility amongst us as healthcare professionals to monitor what we are prescribing. Having said that, there have been surveys suggesting that up to 90% of GPs have experienced pressure from patients to prescribe antibiotics even when this was not appropriate and would serve no purpose. While this obviously differs from area to area (and to be fair you’re a pretty good bunch), we all share a certain responsibility in tackling this issue.

I don’t want to sound too gloomy, and thankfully there has been some international recognition of the issue. The WHO endorsed a global action plan in 2015 (though lamentably it will certainly now have to make do without the help of Robert Mugabe) and since then 193 countries have given further political endorsements via the UN to install tighter regulation and encourage further research into new antibiotic classes.

As often is the case with such gradual phenomena, the effects of such crises are not always immediately apparent. However, in this case, the signs have been there for a long time and Fleming himself warned about the potential for resistance. Now those signs are becoming ever more obvious and we must face up to the inconvenient truth. We stand to lose a lot if we refuse to do so.

Hygiene both in the community and in hospitals is vital to prevent the spread of bacteria. Responsible and restrained prescribing from doctors both here and all over the world is also required. Research into new antimicrobial agents is ongoing but slow, and techniques to bolster our existing agents is important for our short term management of the more serious infections. Crucially, educating people as to why it is often inappropriate to prescribe an antibiotic is just as important – after all we’re all in this together.

Our honeymoon period with antibiotics and their undeniable benefits ended long ago, but since their inception we have created a deep seated culture of dependence. This will be difficult to withdraw from, especially considering the advances we have built around it. Over the coming years, we must now consider whether or not an even more dramatic shift in our utilisation of such medicines is required before nature takes the matter out of our hands.