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INSIDE HEALTH

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TX:听 12.02.13听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 PAM RUTHERFORD

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Porter

Hello.听 Coming up in today's programme:听 Why changing the brand of someone's medicine to save the NHS money may have hidden costs.听 Contraception and the over 35s - is it really okay to keep taking the Pill until you reach the menopause?听 Parkinson's disease - how the early warning signs are being missed, despite sometimes being present for more than a decade before diagnosis and first aid - would you know what to do if a friend, workmate or member of your family needed your help?

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Clip

I just would have wanted Guy to have a chance, just like anybody would want a relative or somebody that they'd come across, if he was in that position, you'd want to be able to give them the chance to actually be saved and he didn't get basic first aid.

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Porter

I will be finding out why first aid knowledge is so poor in the UK, and asking what can be done about it.

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But first, news that the Department of Health is introducing a new vaccine to the routine immunisation programme. From this autumn, people over 70 will be offered Zostavax, a one off jab to protect against shingles - a late complication of chickenpox that causes a nasty crusting rash, and which can leave those affected in pain for months and sometimes years afterwards.

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But there is another vaccine that protects against chickenpox, and which could be given to children to stop them catching the virus in the first place. So why has the Department of Health opted for a jab that prevents a late complication of chickenpox, rather than the disease itself?

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Adam Finn is Professor of Paediatrics at the University of Bristol.

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Finn

Chickenpox is caused by a virus which once you've got it you keep it in your nerves for the rest of your life but you keep it under control with your immune system. As you get older your immunity gets a bit weaker and so it can reactivate, so that infection that you got many years before can travel down your nerve on to area of skin and cause the same kind of rash and make you ill and that's called shingles or Zosta.

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Porter

Adam, are you an advocate of chickenpox vaccine?

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Finn

Yes I am, I believe that prevention is better than cure and in fact in this case there isn't a cure, so I think that we should be using this vaccine.听 Clearly that needs to be done at a sensible price and clearly we need to know that we can do it in a way that will really control the disease.听 And if you're from the slightly biased perspective that I have as a paediatrician working in hospital you see a lot of trouble and illness and suffering caused by the disease.听 I think it's a good analogy to draw with measles, which also was a common disease that we all got and people of my generation and most of us were fine afterwards but a minority of the children that got measles died of it and that's often cited as a reason for measles immunisation.听 Chickenpox is really no different from that, it's also a disease that's normally fairly mild, can leave you with a bit of scarring but a minority of children who get it and certainly adults who get it can get very sick indeed.听 It would also be of benefit to pregnant mothers, who had not had chickenpox, who wouldn't have to worry about being exposed.听 There is a risk if you get chickenpox as a pregnant woman who's never had chickenpox before of course that that virus can affect the foetus and cause abnormalities and illness in the unborn child.听 And actually in practical terms the real trouble that this causes is that not infrequently mothers who are pregnant have children who have chickenpox and there's a big panic around that and they have to be given injections of antibodies to try and minimise the risks of transmission to the baby.听 So although it doesn't cause trouble in terms of damage to children very often it causes a lot of anxiety and medical expense.

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Porter

Well the man behind the introduction of the shingles vaccine is Professor David Salisbury, Director of Immunisation at the Department of Health.

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Salisbury

Well our plan is to introduce a vaccine against shingles starting this autumn and this will be a programme that we will roll out with increasing numbers of groups of individuals being advised to be vaccinated, so we will start the programme with 70 year olds and indeed the 79 year olds in the first year, then the second year we'll do 70 plus 78 plus 79 and then each year we'll successively bring in more individuals, so that we have vaccinated the group that's at highest risk of getting shingles.

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Porter

And that's the over 70s effectively?

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Salisbury

Yes because as immunity wanes with increasing age so the risk of shingles goes up and as the risk of shingles goes up so the complications from it get bigger.

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Porter

Did you look at the possibility of introducing a vaccine much earlier and perhaps protecting against chickenpox in children?

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Salisbury

Yes we looked very carefully at the balance between vaccinating against chickenpox in children to stop people getting the virus at all and vaccinating against shingles to stop them getting the complications from the virus.听 In terms of the burden on people and the burden on the health service shingles is a far greater issue.听 People can be really unwell with shingles and it can go on for a really long time, so preventing that was the first priority.听 There are also theoretical concerns about vaccinating children and not really getting rid of the virus completely from our community and then there's a risk that you catch chickenpox at an older age when the complications are worse.

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Porter

So if a chickenpox immunisation programme was to be introduced and some people, perhaps 20% of the population, didn't have the vaccine they could be at much higher risk?

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Salisbury

Yes that's the issue and so what we need to do is get the shingles programme in successfully first and then we'll come back and look again at the issue of chickenpox in children.

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Porter

Could you ever envisage a day where we might look at perhaps using both, so protecting against chickenpox in children and perhaps using the shingles vaccine in older people?

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Salisbury

I think that's a very rational approach and certainly if you look at the very long term it would be great to think that nobody is at risk of chickenpox but in the sort of middle term then a programme of vaccinating older age groups against shingles and children against chickenpox does have attraction.听 We need to look very carefully at the cost and the effectiveness of such an approach.

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Porter

How effective is the vaccine, what sort of level of protection does it offer and how safe is it?

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Salisbury

Well, let me deal with the second first.听 It's a very safe vaccine, there really are very, very few complications from the vaccine, it's very attenuated, that means it's very weakened in terms of the disease it causes, but it does give good protection.听 So the complications are very rare and by and large mild.听 In terms of the duration of protection then the evidence, which is only as long as the vaccine's being used, is that you get good protection for probably eight to 10 years and that's why we've chosen the age that we've chosen.

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Porter

Looking forward can you see a day when we'll be introducing chickenpox vaccination into the UK?

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Salisbury

I think that it's quite likely but we need to get this programme in place first, we will continue to review all of the evidence about the benefits that would come from childhood vaccination against chickenpox and look at all of the economics and then make our decisions.

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Porter

Professor David Salisbury. And you will find some useful links about chickenpox, shingles and the vaccines on our website - go to bbc.co.uk/radio4 and click on I for Inside Health.

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Now if you are on regular medication from your GP you are probably all too familiar with moves to cut the NHS bill by switching to cheaper alternatives of the same drug. The new version will contain exactly the same active ingredient, but it is unlikely to look the same - and new research suggests that the appearance of a medicine may affect the way you take it. Inside Health's Margaret McCartney joins me now from our Glasgow studio?

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Margaret, tell us about this new research.

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McCartney

So this study is from America and it looked at people who were taking drug tablet treatments for epilepsy.听 And they looked at a large amount of people who had stopped taking their medication and compared them to people who continued taking their medication.听 And when they looked back to try and find out why that was what the difference was between these two groups they found that the people who had stopped the medication were more likely to have had a change in their tablet shape, size or colour beforehand.

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Porter

So the implication is that if we doctors do that, and we do it quite a lot in general practice, it might have an impact on the way that our patients are taking the drugs?

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McCartney

Absolutely, now it's important to point out that there was a small difference only between this group, it wasn't enormous but there is such a big problem with people not taking medication that they're prescribed to begin with.听 So the World Health Organisation estimate that only about 50% of people will take medication as they have been prescribed.听 We know that statin tablets are stopped at five years in between 6 and 30% of people who are meant to be taking them and some drug treatments for mental illness about 50% of people in some studies have been found not to take them after a period of time.听 So if this is one of the reasons why people are not taking them and perhaps they're better on them than not this might be something quite important.

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Porter

So I mean there are two things we can do.听 One is we as doctors, I suppose, can explain every time we change a patient to a different type of medicine, often, it must be said, for cost purposes we should sit down and explain what we're doing with them.听 But the other thing is it would be helpful, wouldn't it, if most of the pills looked the same?

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McCartney

Absolutely.听 Now what was fascinating in this study that just one tablet, a drug called carpamazepine, which is used for epilepsy and some other conditions as well, they found that during the course of the study the tablets could be either pink, black, blue green, brown grey, yellow or blue yellow, so it's incredibly difficult to keep track of which tablet is which, especially if you've got more than one to take at the same time.听 So I think it makes it very difficult for patients.听 And there's been a lot of studies done in the UK when they ask people what bothers about you about your tablets, do you feel okay about taking them, people say well actually it confuses me, I feel myself getting quite stressed about them because I don't really know what I'm taking or what I'm meant to be taking and the tablets keep looking different month to month.

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Porter

And presumably there's no reason why simvastatin, a commonly used cholesterol lowering drug, from one manufacturer should look anything like one from another?

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McCartney

Well, the European laws on drug manufacture are very, very stringent about the quality of the active drug that's inside the tablets, what they're not at all stringent about is how the tablet should look or what size it should be or what colour it should be.听 We've even had things recently - and it's for all the right reasons, we want to save the NHS money, we want to put money where it can be best spent - even changing things over, for example, one tablet, a 40 milligram capsule, is much more expensive than two 20 milligram capsules but you can see how confusing it can get if you're on several medications at once and we keep making cost saving changes which are constantly changing, so you're never really in a situation where things are steady, it's always in a situation of flux, and actually becomes very confusing for people.

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Porter

Drug companies take note! Margaret McCartney - thank you very much. And there is a link to the study Margaret mentioned on the Inside Health website at bbc.co.uk/radio4

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Now, how good is your first aid knowledge? Would you know how to put someone in the recovery position or start resuscitating them if their heart stopped?

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Probably not according to a new campaign by the British Red Cross which suggests that the UK sits at the bottom of the European league table when it comes to first aid knowledge. The charity believes tens of thousands of lives could be saved every year if more of us knew how to help in an emergency - and 17 year old Guy Chesney-Evans might have been one of them, according to his mother Beth.

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Beth

Guy was riding along a country road in Oxford with three friends, he was on his motorbike and they were driving in convoy along the road.听 Guy just came off the motorbike, he keeled over and scooted along the grass verge and he ended up in the ditch.听 His friends obviously stopped, shocked, they didn't know what had happened.听 They dialled 999.听 Sadly they weren't given any first aid instructions at all, so Guy didn't receive any first aid.听 What happened was his heart had stopped and he wasn't breathing.听 The only thing that might have made a difference was if someone had known how to give CPR.听 They were all 17, they had never had first aid lessons either in school or anywhere else, all that they could think of doing was to put their jackets over him to keep him warm.

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Porter

The British Red Cross is campaigning to have basic first aid training made part of the school curriculum. Joe Mulligan heads the education arm of the charity.

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Mulligan - actuality

Okay thank you very much for coming back from the break, it's always good to see the same number as we had before the break.听 So as we were discussing before we had the break for coffee we were looking at somebody in Henry's case here who was unconscious but he is breathing.听 And I know some of you may have learned how to - how to respond in this scenario previously.听 Some of you have learned the recovery position previously - what do you recall from having learned that before?

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Pupil

I have to say there was so much to it that I have forgotten quite a lot of it.

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Mulligan

Right, so is there anything that comes to mind at all from what you learned previously?

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Pupil

You should lift their leg up and turn them on their side, with that leg - kind of thing.

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Mulligan

Okay, so lots of things about moving legs, yeah.

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Pupil

And hands.

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Mulligan

And hands, okay.

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Pupil

And also if they're wearing glasses you might want to take them off.

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Mulligan

Okay, so they're, in a way, almost the incidentals.听 The really important thing to do if you discover somebody who is unconscious and breathing is to get them on to their side and tilt their head back to ensure they continue to breathe because one of the things we're most concerned about for an unconscious person if they're on their back is that they either swallow their tongue and that therefore would compromise their breathing or that they choke on their vomit.

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Beth

They were told not to touch him by the ambulance service.听 However, the pathologist said to me if someone's not breathing they will die, so the first basic rule of first aid is is that person breathing, if not you have to do something about it.

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Mulligan

One of the recurring themes we see where first aid is formally part of the curriculum not only do we have a greater level of first aid skills and knowledge and a greater willingness to act in the context of an emergency but we also see that the perception of the subject is very different because one of the challenges that we face here in the UK is that it's perceived as slightly geeky and freaky as a subject, as it were, so therefore if you speak to most people that we do in relation to first aid they will talk about it in the context of learning it in the church hall on a Tuesday night, people using slings and all of those kind of almost dated analogies of the subject, rather than the initial intervention at the scene of an emergency.

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Porter

It's also perceived as something that you're likely to do to a stranger as well isn't it?

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Mulligan

Absolutely, one of the most common perceptions of the subject when we talk to the public is they believe that it's something actually that you're going to do on to somebody you don't know and of course all of the detail tells us that the beneficiary of your skill, your first aid skill, in an emergency is going to be somebody you know and potentially love, primarily because it'll be somebody you work with, it'll be a member of your family or it'll be somebody you socialise with.

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Porter

And how willing are people to use their first aid skills if they are one of the minority who's been trained?

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Mulligan

One of the challenges that we are facing from the educational side is this whole thing of the bystander effect, whereby something happens, predominantly in a public place, and a group of people stand around and nobody is prepared to step forward and to intervene to provide any immediate care.听 And of course one of the reasons that actually happens is because there's a perception that actually if you do something and you get it wrong you may be sued.

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Porter

But actually probably the most dangerous thing they can do is nothing.

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Mulligan

Absolutely right.听 All of the clinical and educational data bears out one stat and that is that the action of the first person on the scene is absolutely critical in terms of having a positive outcome.

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Porter

Why is it not included in the curriculum in the UK do you think?

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Mulligan

Well it has never been on the curriculum, I mean we are now working with government in terms of getting it on the secondary curriculum and the primary curriculum and I think part of the issue is that while you and I may acknowledge it as a life skill it is not seen by many people, including key decision makers in government, as that.听 So there's this perception issue that it's a nice thing to have and again coming back to the European perspective in Europe it's actually seen as the ultimate humanitarian act.

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Porter

Do you think people see it as complex?

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Mulligan

Yes, I think that one of the biggest misconceptions there is about first aid is complexity and there's a belief that, for example, in relation to putting somebody on their side in the recovery position is one of the most common first aid skills that we've taught earlier today, there's a perception there that there are 11 or 12 discrete steps, in medicine you just flick the person on their side, we're not going to be quite that rudimentary in the first aid world but the principle is important, so if you teach it as 12 discrete steps there are certain members of the public who will then believe that there are potentially 11 ways that they will get it wrong as it were.听 We're not preoccupied any longer with this whole textbook approach to it, so keep it simple...

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Porter

And do something.

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Mulligan

Absolutely right, the worst thing you can do is to do nothing because you are the most important link in that chain of survival and the actions of the first person on the scene is critical in terms of a positive outcome.

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Porter

Joe Mulligan from the British Red Cross.听 And it is not the only organisation offering first aid training - you will find a link on how to find out what is available in your area on our page of bbc.co.uk/radio4.

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Elizabeth e-mailed insidehealth@bbc.co.uk to find out more about contraception options in older women:

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Elizabeth

Well it's concerning the risks relating to taking the contraceptive pill for slightly older women.听 I'm 44 years old and have two boys, I'm generally healthy, have low blood pressure, I've never smoked but my mum did have breast cancer while she was on hormone replacement therapy.听 And I've been on the contraceptive pill for years and years with no problems but when I recently went to the doctor I was discouraged from continuing with it because of my age.听 And I was just wondering if I could have clarification on what are the risks to consider when using the contraceptive pill as you get older.听 Presumably my fertility is now dropping and I wondered if because of that something simple like using condoms would give sufficient protection for me now?

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Porter

Well to answer that I'm joined by Dr Paula Briggs who's Contraceptive Lead for Southport and Ormskirk Hospital NHS Trust.

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Paula, let's break this up.听 Elizabeth's mother had breast cancer, I'm presuming it's in her 50s or 60s because she was on HRT at the time, lots of women on the pill will have had a relative with breast cancer, is that anything to worry about?

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Briggs

No, having a relative who's had breast cancer would not prevent Elizabeth or any other woman from taking combined hormonal contraception and in fact the only contraindication would be if Elizabeth herself actually had breast cancer and even for women who've had breast cancer once they've been free of disease for five years the combined pill wouldn't be completely contraindicated although obviously it would be used with great caution and it would fall into a risk category.

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Porter

Okay, well that's reassuring.听 Let's move on to her next point that - I'm suspect this is something she's picked up from her own doctor that at 44 she's too old for the combined contraceptive pill - the pill - she's been offered other choices but she wants to stay on the pill, what's your view on that?

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Briggs

Age alone is not a contraindication to any method of contraception and in fact for women in their 40s being on the combined pill can have lots of added benefits, such as reducing heavy bleeding and helping manage premenstrual symptoms which get worse in the peri-menopause.听 So it certainly wouldn't restrict her from that method and an assessment of the individual woman would be looking for other risk factors such as being overweight and I think it's fair to say that as we get older we tend to get heavier, so that might be the restriction but certainly not age alone.

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Porter

But if you're a fit non-smoker you can take the pill right up until the menopause?

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Briggs

You can take the pill right up until the age of 50.听 And there are lots of benefits to being on the combined pill which women aren't aware of, such as a reduction in the risk of cancer of the ovary and of the uterus, the womb, and even bowel cancer and also a reduction in things like rheumatoid arthritis and the benefits of the reduction in heavy menstrual bleeding and of the symptoms of premenstrual syndrome and endometriosis.听 So I think often when we talk about these benefits to women they're very surprised.

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Porter

What about her last point that at 44 her fertility is waning naturally, can she get away with using something simple like condoms?

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Briggs

Well, I would say absolutely not, I mean condoms are not a particularly reliable method of contraception and I think when women are in their 40s that's when they probably need good reliable contraception with added benefits and so I think it's not a time in one's life when one wants to take risks about becoming pregnant unless that's what the woman actually wants.

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Porter

Dr Paula Briggs. And please do get in touch if there's a health issue that's confusing you that you think we can help with.听 E-mail insidehealth@bbc.co.uk or send a tweet to @bbcradio4 containing the hashtag insidehealth.

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There are around 130,000 people in the UK with Parkinson's disease, the classic symptoms of which include tremor and difficulty moving - those affected often get the shakes at rest and have a shuffling gait. But there are other non-movement related symptoms too - like a poor sense of smell - and new research by a team from Newcastle University suggests that these other symptoms are often missed and that they can precede more recognised movement related problems by many years.

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Lucy Norman was told she had Parkinson's disease in 2010, but in hindsight clues had been there for much longer.

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Norman

Probably a couple of years before my diagnosis I was having sort of problems sleeping, I've always enjoyed a good quality sleep and go to bed about half tenish but found I was waking up about two, half two, but absolutely wide awake and put it down to actually probably stress because we were house hunting and getting new jobs and stuff like that, so kind of put it down to stress.听 But the strange thing was was not feeling groggy throughout the day.听 I noticed my sense of smell had gone probably about three to four years prior to diagnosis.听 It's funny actually because when I lived in Kent I actually found out that I had a leak in my boiler, a gas leak, and I didn't smell it.听 So that was kind of a bit of an indicator, looking back now, that actually my sense of smell had gone.听 But now very limited sense of smell.听 And another one was actually my eyesight got a little bit worse.听 I went to the opticians regularly and always had the same prescription but in the last few years my prescriptions have gradually got worse but again pre-diagnosis well you know I'm skidding towards 40 that these things happen.

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Porter

Ray Chaudhuri is Professor of Neurology and Movement disorders at King's College Hospital in London.听 Ray, Lucy there talked about visual problems, not being able to smell properly and poor sleep in the lead up to her diagnosis - is that typical of very early Parkinson's disease?

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Chaudhuri

It is indeed, yeah, it's becoming increasingly obvious that the symptoms which we call non-movement or non-motor symptoms occur probably a fair few years even before we see people in the clinic when they typically present with the tremors and the stiffness and the slowness.

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Porter

How long before?

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Chaudhuri

Estimates would suggest that loss of sense of smell, for instance, or a reduced sensibility to the sense of smell could occur anything up to 15 to 20 years even before the actual diagnosis of Parkinson's is made.听 Probably a more conservative estimate would be about 10 years at least.

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Porter

Now the Newcastle study suggests that doctors aren't very aware of these non-motor related symptoms - is that your experience too?

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Chaudhuri

Absolutely, I mean we published our own observations which was in a European study the year before and that mirrored the results very, very closely.听 We found, for instance, in up to 60% of people with Parkinson's questions on sense of smell, on bowel habits, on mood, pain, were not asked about when these things are so clearly associated with Parkinson's.

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Porter

Can we run through the most common ones that you'd see then?听 We talked about loss of sense of smell, what else might raise a suspicion that something funny's going on?

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Chaudhuri

The common things that occur, these non-movement problems, in the early phase of Parkinson's are apart from the loss of sense of smell is sleep problems, which are alluded to in this interview, and they're typically insomnia, which is lack of sleep essentially but also a condition called REM Behaviour Disorder - RBD - where people act out violent dreams and often end up either falling out of bed or talking in their sleep and so on.听 So sleep problems are common and also is common daytime sleepiness, people feeling very tired, very drowsy during the day.听 Along with that constipation is now recognised as one of these problems that can precede the development of Parkinson's, as can depression.听 And finally pain as well and these are pains - slightly different in that they're pain usually on one side of the body, often in the limb that is later on going to show the signs of Parkinson's.

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Porter

Of course there are lots of other reasons why people might have those sorts of symptoms.听 Why's it important to attribute them correctly to Parkinson's?听 First of all is there any advantage to diagnosing Parkinson's or picking up the disease very early in its progress?

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Chaudhuri

I think this remains a real challenge.听 I think the advantage at the moment would be planning but in the next few years I'm hopeful that we will be coming up on neuro-protective or rather neuro-modulatory treatment.听 When that is available earlier diagnosis is the key because this is the stage where you have the maximum nerve cells to protect.

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Porter

So you're giving a treatment that actually slows the progression of the disease, so obviously the earlier you start it the better?

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Chaudhuri

Absolutely.

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Porter

What about the implications for the individual themselves?听 I mean they come to your clinic, they've been diagnosed with Parkinson's already and they've got these other symptoms - are we looking after them properly at the moment do you think?

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Chaudhuri

I think treatment strategies or management strategies for Parkinson's, particularly in relation to non-movement problems, are still not very robust...

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Porter

Because we concentrate on the stiffness and the tremor and all those things don't we.

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Chaudhuri

Sure, absolutely.听 And I think this is something where research needs to go on, pharmaceutical companies need to invest more in clinical trials addressing these symptoms because there are many of these which are probably the biggest determinant of the quality of life not just of the people with Parkinson's but also their carers yet we, at the moment, do not have very successful treatment strategies for some of these symptoms.

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Porter

Do we know what's going on - why should changes in the part of the brain responsible for movement that we know are associated with Parkinson's have all these other effects?

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Chaudhuri

Well I think that's partly because the signs of Parkinson's so far is purely focused on the dopamine neurones in the brain.听 It's abundantly clear now that in the very early stage of Parkinson's other areas of the brain degenerate and transmitters such as serotonin, asetilkolin, noradrenaline are affected right at the beginning.

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Porter

So the conventional story that I was taught at medical school is a bit of an oversimplification?

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Chaudhuri

Possibly yes.

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Porter

And do patients often raise these complaints with you?

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Chaudhuri

Yes they do, I mean many people are also aware of the other issues now through work through the Parkinson patient groups and dribbling of saliva is an example, can be extremely socially disabling but often they're not discussed in the clinic adequately and can be managed properly if it is discussed.听 So it's very, very important particularly the medical doctors and the nurses address these questions in the clinic.

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Porter

But the conventional approach to treating Parkinson's Disease wouldn't help a problem like that, so you have to look at it and treat it in a different way?

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Chaudhuri

Absolutely.

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Porter

But it's easy to do, comparatively easy?

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Chaudhuri

Definitely, yes.

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Porter

Professor Ray Chaudhuri, thank you very much. Just time to tell you about next week's programme when hospital food gets the Inside Health treatment as we examine new proposals to move nutrition higher up the NHS agenda and not before time.听

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ENDS