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INSIDE HEALTH

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Programme 5.

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TX:Ìý 21.10.14Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Hello.Ìý Coming up in today’s programme:Ìý Warfarin – NICE has recently approved self-monitoring devices as an alternative to conventional blood tests to ensure patients are taking the right dose of this blood thinning drug. So why are so few people using the new technology?

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A Scottish initiative to reduce kidney damage – if you are on medication to lower your blood pressure, help heart problems or ease your arthritic jointsÌý then don’t miss Margaret McCartney’s advice coming up later.

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But first private hospitals, no longer the preserve of the wealthy or the insured. These days they are full of NHS patients too. Last year around 1.6 million operations were carried out in the UK private sector, around a quarter of which were paid for by the taxpayer. A trend that is likely to accelerate as more independent providers compete for NHS business.

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The attractions may seem obvious, not least likely perks such as your own room and en-suite facilities, but what about the downside? Will you get treated at least as well as you would do in a NHS hospital? And how safe are you if something goes wrong?

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Professor Colin Leys co-authored a report into patient safety in private hospitals so does he think the average patient knows enough about them?

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Leys

I don’t, in my experience, talking to people, they either haven’t really thought about it or if they have they imagine private hospitals must be better if you’re paying for it.Ìý What they don’t know is that they’re very small, being small means that they don’t run to – in most cases they don’t have intensive care units with intensive care staff, which means that if even after a very simple operation and even in a healthy person if something goes wrong they have to be moved to an NHS hospital and in being moved there’s a risk.Ìý And we know of cases where the delay or mishandling of the transfer has sometimes unfortunately cost people’s lives and that’s a risk that’s built into being treated in a small private hospital.

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Porter

Looking at current trends in the NHS Colin it’s likely that more patients are going to be treated in the private sector than are being done currently and there’s already quite a few.Ìý Do you think we know enough about standards in those hospitals to compare them directly with an NHS facility?

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Leys

No we don’t, we know remarkable little, either in terms of the general performance of individual private hospitals or in terms of their serious incident and death rates.Ìý I mean we discovered, for example, that in the last four years there have been 800 unexpected deaths in private hospitals and 900 serious incidents, such as falling over and breaking your leg because you weren’t being looked after and that can happen in all sorts of hospitals.Ìý Or something I discovered just the other day, looking at one Care Quality Commission report, a hospital which had had three misplaced joint replacement implants in the course of 12 months, I mean that’s a pretty drastic kind of serious incident.

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Porter

They were put in wrongly?

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Leys

Put in the wrong place.Ìý So I mean maybe the wrong knee.Ìý Then you think okay how did that happen, what kinds of patients were these, were all the incidents – they clearly weren’t all that, that’s dreadful but we don’t know.Ìý For private hospitals, unlike NHS hospitals, we don’t have that information.

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Porter

Well Margaret McCartney’s in our Glasgow studio, of course the key point here for us as GPs Margaret is that we’re referring patients on the NHS and they’re often these days getting their treatments in private hospitals.

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McCartney

Yes, in Scotland I think it’s fair to say that the private interest in NHS contracts is limited and it is still there but it is much smaller than it is in England.Ìý The great ability of a general practitioner I think is if you live and work in an area and you have done for many, many years you get to know the services.Ìý We’ve had patients who have been through a cataract service, a hernia service, so you kind of know what to expect and what the surgeons are like.Ìý But with these contracts they are by nature temporary, they are a firm that come in, do a quota of operations and in most cases move on, so as GPs I don’t feel as though we’ve got the same expertise of watching a company perform over a period of time and that makes me feel quite uncertain about it.

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Porter

But listeners may be surprised because surely if they’re doing NHS work they must be subjected to the same sort of scrutiny?

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Leys

They do have to report serious incidents to the Commissioner, in the case of NHS patients and also to monitor but they don’t have to report more than the fact that it occurred and what the incident was.Ìý Whereas for NHS hospitals it’s all reported to the National Reporting and Learning System and that does a very careful inventory of exactly what went wrong and then for all the hospitals in the country then they can see the patterns that are developing and if a particular hospital has a pattern like the one I just mentioned then action is taken but we don’t in the case of private hospitals, we don’t have that.

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Porter

So we don’t know whether they’re doing well, we don’t know whether they’re doing badly, we just don’t know.

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Leys

Not in the way we know for NHS hospitals, no.

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Porter

So Margaret, what do you think GPs should be saying when they’re referring someone, for instance, with a knee replacement and the patient can understandably get a choice of hospitals they go to, they go well I’ll have it done in the private hospital, it’s much nicer?

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McCartney

Certainly, the political imperative is to offer choice to patients.Ìý What I want to know is though what is the evidence base for making that choice, where is the safest place to go and yes we all love to have lovely high thread count sheets, freshly cut flowers just adjacent to our bed but what really matters is who’s doing your operation, what experience they have, what your follow up is, who will deal with the complications.

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Leys

I think you put your finger on it to my mind, as far as England is concerned, when you said we don’t know what kind of follow up there can be.Ìý And the big difference to my mind that came out of looking at this is the sort of jolt, the patient has chosen a consultant that they’ve been recommended, fantastic, they get treated by that consultant, when the consultant has finished they’re being looked after by a single relatively junior generalist doctor, the resident medical officer, who’s looking after up to 40 or 50 patients being treated by different consultants for different conditions without the presence of a specialist team, which if they were in an NHS hospital that same consultant would have a specialist team for the resident medical officer to turn to if he’s worried.

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Porter

Do we know what happens to people when things do go wrong in terms of transfers from the private sector to the NHS hospitals when there’s a complication after an operation for instance?

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Leys

What we do know is that there are about 6,000 transfers from private hospitals in England to NHS trust hospitals and of those slightly less than half are emergency transfers.Ìý So what you’re looking at is let’s say two and a half thousand emergency transfers of patients who have been treated in a private hospital and for one reason or another there’s a crisis or their condition deteriorates afterwards, they get transferred.Ìý And then the NHS hospital takes care of them, if they do well that’s great and if they don’t it’s a death in an NHS hospital.

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Porter

And not in the private hospital?

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Leys

I think that’s fair to say.Ìý Again my concern is not to knock private hospitals, my interest is in what happens to patients especially when we’re paying for them.

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McCartney

This is not a new problem, I remember being a very junior doctor working in various places in the UK and finding a patient being transferred over from the private sector, that patient did need intensive care but there was no intensive care facility within the private hospital and of course if something goes wrong, something goes badly wrong, the patient dies in the NHS hospital it is the NHS hospital that takes the hit – their figures look bad – whereas the private sector’s figures don’t.Ìý So I think it’s a bit of a tragedy that we haven’t managed to sort this out well before now and especially before so many contracts are going to the private sector from the NHS.

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Porter

Inside Health was contacted last week by a listener who feels she has suffered as a direct result of differing standards between NHS and private hospitals. Kate had a hip replacement in 2010 after being referred to a specialist by her doctor.

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Kate

Well my GP thought it was likely that I needed a hip replacement and so I got on to the chosen book system, spotted this surgeon and it was within a few weeks and I thought oh that looks good.Ìý So I booked that appointment.Ìý And it was only after I’d done the booking that I realised it was going to be in our local private hospital.Ìý I had two consultations with him and I blurted out, as I do, I just said straightaway what happens if anything goes wrong and the surgeon said we will take you up to the local NHS hospital, rather through gritted teach, I have to say.

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Porter

And how did that make you feel?

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Kate

At that point I didn’t have any reason to feel that anything would go wrong.Ìý Like a lot of people I assumed that the NHS operations done in the private sector would be done to absolutely the same standards as in the NHS.Ìý So I didn’t feel particularly disquieted then.

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Porter

What happened after the operation?

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Kate

I came home fairly promptly.Ìý I’d already begun to experience discomfort in the back of my lungs.Ìý I wondered if this was to do with having to lie on your back as you do after a hip replacement and then a few days after coming home I went upstairs and I began to feel breathless.Ìý It feels as if a portion of my lungs have simply cease to function.Ìý And I went downstairs and told my husband, who is much more clued up and scientific, and he just phoned the GP’s surgery and that day I was admitted to our local NHS hospital with suspected PEs, which was confirmed by CT scan.

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Porter

So you had a blood clot in the leg which had spread to the lung – a pulmonary embolism – now that’s a recognised complication of having hip replacement surgery, but – and therefore it’s standard procedure to take steps to prevent that, were they followed in your private hospital?

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Kate

No, I wasn’t given the anticoagulant, heparin, which I know, having checked it out, I would have been given in the NHS hospital.

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Porter

Now what’s happened to you since then – have you been particularly poorly with this?

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Kate

Unfortunately I’ve ended up extremely breathless, it’s getting worse all the time.Ìý I’ve now got a lot of chest pain, I can’t walk across a room without becoming breathless.

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Porter

Listener Kate with a cautionary tale.

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You can download a copy of Professor Colin Leys report at the Inside Health page of the Radio 4 website.

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We put some of the concerns he raised to the Association of Independent Healthcare Organisations who sent us this statement:

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Association of Independent Healthcare Organisation Statement

The reality is that these institutions offer very high levels of care to NHS, patients – a fact that has been, and continues to be, independently verified by the Care Quality Commission.

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But the independent sector acknowledges that we need to publish more data, and we have been working with interested parties to make direct and meaningful comparisons.

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Now here’s something you don’t hear very often in a hospital setting.

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Hyperbaric Chamber Actuality

At depth 14 metres.Ìý Okay Sarah, we’ve landed, are we all well?

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Porter

The hyperbaric chamber at St Richard’s Hospital in Chichester - used to deliver high doses of oxygen to patients in the hope that it will accelerate healing. It’s an unusual approach, but how well does it work? I joined the team to find out.

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Hassan

My name is Sarah Hassan, I’m a hyperbaric nurse working at St Richard’s Hospital in the Hyperbaric Medicine Unit.Ìý And we’re just about to start a treatment this morning.

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Porter

Can we have a look inside?

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Hassan

Yes of course.ÌýÌý Well we’re now standing inside the chamber, as you can see it’s fairly large, we can take up to five patients seated.Ìý At the moment we’re plumbed up for air and oxygen.

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Porter

So all of this pipework on the wall here, it means you can alter the gases that are coming here, to what you want really?

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Hassan

Yes absolutely.

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Porter

It reminds me bit like the size of an underground tube carriage, isn’t it, it’s about what so eight, nine feet tall, nearly 20 feet long, I suppose 15-20 feet long.

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Hassan

The oxygen is stored in banks and the patients this morning will be breathing 100% oxygen at 2.4 atmospheres pressure.

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Porter

And how does the patient get that 100%?

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Hassan

A bit like a space helmet, if you like.

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Porter

Goldfish bowl over the head effectively?

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Hassan

Yes, yeah, that’s a very good description of it, yes, yes.Ìý Or for the younger audience perhaps – a Buzz Light Year helmet is often how it’s described.

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Porter

So what actually happens inside, what do people notice when they’re inside here?

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Hassan

Very little, during compression the only thing that people really feel, as we’re forcing air into the chamber to increase the pressure inside, is an increase in temperature because it does get a bit warm but also your ears, like on an aircraft where your ears pop.

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Porter

As you’re coming into land, that sort of feeling, as the pressure rises, yeah.

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Hassan

Yes that sort of thing and it’s exactly the same process yes.Ìý So we compress fairly slowly and now we’re going to close the door and start the compression.

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Actuality Hyperbaric Chamber

Okay Sarah, if you’re sitting comfortably we’ll begin in about 15 seconds.Ìý Leaving now.

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Glover

My name is Mark Glover, I’m the Medical Director of the Hyperbaric Medicine Unit in St Richard’s Hospital in Chichester.Ìý The best way of explaining it I suppose is if I had a box of oxygen and I was to squash it and squeeze it then actually I would be increasing the concentration of oxygen and that’s all we’re doing, we’re simply compressing the gas that we’re giving to the patients to breathe and then when it’s actually breathed into their lungs it’s delivering a much higher dose of oxygen to the blood.

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Porter

So that’s a much higher dose than you could deliver even given them a 100% sitting on the ward?

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Glover

Yes.Ìý The basis is that if you have an organ or a tissue in the body that is not receiving enough oxygen because its blood supply has been compromised in some way if you can increase the amount of oxygen that’s delivered to that part of the body then you can restore the normal oxygen levels within that tissue and within that organ.

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Actuality Hyperbaric Chamber

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Glover

We use the chamber every weekday, treating conditions caused by radiation damage to healthy tissue after radiotherapy for cancers.Ìý The typical changes that you see in the tissue that is not able to repair itself after radiotherapy is a gradual reduction in the number of very small blood vessels, the capillaries, within the tissue and as a result the tissue becomes gradually less and less able to help itself because the oxygen levels are declining.

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Actuality

Okay Sarah we’ve landed, are we all well?

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Yeah all well.

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Thank you very much indeed.

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Firth

My name is Oliver Firth and I am a hyperbaric physician at London Diving Chamber in St John’s Wood.

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Porter

What sort of work do you do at your unit?

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Firth

Well we are predominantly set up to treat diving related injuries, so we treat classic cases of the bends, very rarely we treat gas embolisms as well but increasingly we’re looking more at the other uses of hyperbaric oxygen, particularly diabetic wounds in the extremities, so the feet and hands and in the feet they can often get ulcers that are very difficult to heal because the blood supply is so poor.Ìý So if we can bypass the normal oxygen delivery mechanism by dissolving lots of oxygen in the plasma we can then get it to the centre of the wound that’s lacking oxygen, if we can get oxygen to it we can kick start the healing process and hopefully get that wound to heal.

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Porter

So it works on exactly the same theory – delivering more oxygen to tissues that are struggling to heal themselves?

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Firth

It does have other effects too – it can actually enhance the activity of the immune system to fight infections.Ìý So a lot of diabetic wounds get infected and won’t heal because of that and the oxygen’s been shown to have useful effects on certain white cells that will kill off infection.

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Porter

Using the diabetic example what sort of duration of therapy would you have to offer somebody?

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Firth

By and large it’s not a quick treatment, you’re looking at sort of a wound that’s been there perhaps indolently for a year, more than that, so sometimes you start off with usually a batch of 40 sessions, they’re done a daily basis, so we’re talking about eight weeks of treatment but we don’t have enough chambers around at the moment to actually supply the demand.

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Porter

And is there good evidence that these interventions help?

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Firth

There is good evidence in certain conditions such as the diabetic foot, we have some good trial evidence that it is successful, in admittedly small numbers but that evidence is increasing all the time.Ìý In other areas the evidence is less clear.

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Porter

What about sports people, someone like Usain Bolt gets an injury, is there any evidence to suggest that it can heal ligament tears and things in people like that?

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Firth

Evidence I would probably say no, unless you’re talking about anecdotal experience, in which case yes a lot of the physiotherapists who look after these people are surprised when they’ve had treatment at how quickly they return to full function.Ìý Now whether that’s due to just being confined in a small space and not allowing themselves to train for a short time…

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Porter

Locked up for hours on end.

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Firth

Exactly.

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Porter

Dr Oliver Firth. And you will find more background information on hyperbaric medicine on the Inside Health page of the Radio 4 website.

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Now on to a new Scottish initiative to reduce kidney damage. NHS Highland has produced patient advice cards outlining what to do if you fall ill while you are taking a number of common medicines that could damage your kidneys if you get dehydrated. Inside Health’s Margaret McCartney is here to explain more.

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McCartney

So at the moment we prescribe lots of medications which the aim is to try and keep people healthy.Ìý So, for example, we prescribe medications to treat people’s high blood pressure or to keep people’s diabetes in control.Ìý And that tends to be a good idea but the problem is when people become otherwise unwell, by which I mean vomiting or diarrhoea as a bug, fevers, sweaty illness, if I’ve got a high temperature, unwell with pneumonia or something like that.Ìý And the problem is that these drugs that we’re prescribing for preventative purposes can end up having side effects when that person becomes unwell.

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Porter

And those side effects are what – what are we concerned about?

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McCartney

Well the big problem is kidney failure or kidney injury.Ìý So most of the time these drugs will be trying to protect the kidney but when people become dehydrated the drugs can end up actually becoming toxic or we get side effects because the drugs are not being passed through the urine as rapidly as they usually would be.Ìý So the problem is that people end up taking medications that aren’t when they’re otherwise unwell helping them, they’re actually causing harm.

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Porter

And which drugs are the major culprits?

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McCartney

Well the big concern is a group of drugs called the ACE inhibitors and these are the ones that end with pril – so perindopril, lisinopril, ramipril, captopril – these are the ones that really there’s been most concern about.Ìý But there’s also concerns about the other group of drugs for high blood pressure that end in sartan, so Losartan, Candesartan.Ìý There’s also worries about anti-inflammatories like ibuprofen or diclofenac, water pills like frusamide or metformin, which is a tablet taken for diabetes.Ìý The big problem has been that over the last few years there’s been awareness that we’re seeing more patients ending up in hospital with acute kidney injuries and we think this is related to the increase in prescribing of these ACE inhibitor drugs in particular.Ìý

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Porter

And the advice to patients taking these drugs should be what then?

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McCartney

Well we’re not talking about just a one off, being sick once or having one single episode of diarrhoea, we’re talking about people who are actually unwell and who are having really continuous symptoms over the course of a day.Ìý And the advice is to stop taking these medications while you’re unwell but to restart them 24 or 48 hours after you’re feeling better.

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Porter

And do we know if that has any impact on the number of people who are being seen with kidney damage?

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McCartney

So there’s a great scheme happening in my neck of the woods, really coming out of work that’s been done through the Patients’ Safety Agencies and what it is to try and do is alert patients, carers, pharmacists and doctors to the fact that when people are on these drugs routinely there are some times that they shouldn’t take them when they’re otherwise unwell, when they have a sickness and diarrhoea.Ìý So the scheme was that pharmacists would give out special little cards, credit sized cards, for people to keep in their wallet just to remind them that if they’re having sickness and diarrhoea bugs, not just one episode but being continually over a day, then to stop the medicines and the list if there of all the tablets that you shouldn’t take while you’re unwell and to stay off them until you’re feeling better and restart them 24 or 48 hours after all is well again.

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Porter

And is that something that’s likely to be adopted across the UK – I mean it’s the first I’ve heard of it to be honest?

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McCartney

Well I think for a while we have been warning people when we start off on the ACE inhibitor drugs, routinely when we’re prescribing them I think we are saying to people now if you become unwell do remember to stop them.Ìý But it’s quite a lot of information to remember and it’s always better to have something written down that you can refer to as you need to.Ìý So I think it’s a really good idea.Ìý And NHS Highland are in the process, just now, of analysing the effect of giving out these cards and they’re hoping to see a difference being made in preventing renal problems caused by taking these drugs when people become otherwise unwell.

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Porter

Thank you very much Margaret.Ìý And there’s more information on the Sick Day Rule cards – and to which medicines the rules apply to – on our website. Where you will also find details of how to contact us. This listener got in touch about a new way to monitor people taking the blood thinning anticoagulant warfarin.

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Walker

My name’s David Walker, I’m a community pharmacist on Merseyside.Ìý I’ve been reading about self-monitoring kits for patients taking warfarin and to my surprise, having read about them, I don’t actually see it being done in this area, though I understand that throughout the country there are huge variations in uptake.

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Porter

And David have you ever been asked by any of the people coming into your pharmacy if you can get hold of these self-monitoring kits?

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Walker

Occasionally from time to time, recently I have because there was some national publicity around it but the trouble is there are no arrangements in place locally to support those patients so I just wondered if Inside Health would look into that.

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Porter

It’s thought that around a million people in the UK take warfarin because of underlying problems like an irregular heartbeat that increase the risk from clots in the circulation. But it needs close monitoring.

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The National Institute for Health and Care Excellence has just supported the introduction of the kits David is asking about. Consultant haematologist Peter MacCallum from Barts Hospital advised NICE.

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MacCallum

Now warfarin works by reducing the levels of certain clotting factors in the blood.Ìý It’s a very effective drug but it does need to be regularly monitored.Ìý First of all patients vary considerably in the dose that they require, this is variation between patients.Ìý And then for a given patient the requirements can vary over time.Ìý There are lots of interactions of warfarin with other medication, as well as with other factors such as diet, alcohol, general health.

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Porter

And presumably the problem being that if you haven’t got enough warfarin on board your blood’s too think and if you’ve got too much it’s too thin and there’s a risk of bleeding?

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MacCallum

Yes that’s absolutely right.Ìý If the warfarin level is too low then the consequences are of blood clotting and that can lead to things like stroke and if the level of warfarin is too great then that can cause a problem such as bleeding.Ìý So this means a regular blood test, the frequency of which varies from person to person, depending on just how stable their individual control happens to be.Ìý And this means having blood tests either in very large, very busy clinics…

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Porter

This is in a blood thinning clinic effectively in a hospital?

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MacCallum

In an anticoagulant clinic.Ìý But care can also be delivered closer to home in GPs’ surgeries or other healthcare settings, including community pharmacists.

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Porter

Certainly in our surgery someone who’s well controlled might have a blood test every couple of months or so but I’ve – and people frequently are coming in every week when their control’s a bit erratic.

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MacCallum

That’s absolutely right.Ìý There are some people who can go literally months on end with very stable readings and very infrequent tests and others have to literally come every week.Ìý So the self-testing kit works by literally a finger prick test with a drop of blood being put on to a little strip that goes into the testing device and stimulates the blood to clot and measures the speed with which that happens.Ìý In about a minute or so after applying the drop of blood you’ve got an indication as to the reading, the result, but then somebody else has to then interpret the clinical significance of that result in terms of dosing.

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Porter

Okay, so a patient’s doing that themselves or is it that being done by a doctor or nurse in general?

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MacCallum
Mostly that is done by a healthcare professional.

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Porter

But patients can do it themselves?

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MacCallum

Indeed patients can do it themselves and there are a number of patients, certainly in my practice and throughout the UK, who currently do that.Ìý Uptake of this approach has been greater in other countries where there are several hundred thousand patients both self-testing, where the patient does their own test and self-managing where they actually adjust the dose of warfarin themselves.

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Porter

And what sort of level of control do you get when patients self-test and self-monitor, is it as good as they get from having it done with a healthcare professional or dare I say could it possibly be better sometimes?

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MacCallum

The studies suggest that overall the control of anticoagulation is every bit as good as with a standard practice and in some studies care has actually been improved by patients self-testing and self-managing.

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Porter

Peter MacCallum. So it works, but why isn’t it more popular? Well cost is bound to be one stumbling block – a few hundred pounds for the machine, and around £3 a time for each test strip. And in many parts of the UK it is still unclear as to what the NHS is prepared to pay, and when.

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Dr Margaret McCartney’s practice is in Glasgow, has there been much uptake there?

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McCartney

It’s uncommon, so we definitely do have patients who are self-monitoring and self-managing their own INR level for their warfarin but it’s not very common, we think probably about 1% of patients who are on warfarin are using a home kit to do their testing.

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Porter

Do more want to use it, is it something that’s difficult to get hold of?

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McCartney

It’s really interesting, if you go online you’ll find lots and lots of people very upset that they’re not able to access home testing as they would like to.Ìý But I think there’s a bit of a problem because there are lots of people who are on warfarin that I’m sure don’t want to or are not able to manage self-testing but there probably are quite a lot of people who could be doing it for themselves and who are not getting the opportunity to.

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Porter

So Margaret, given that this technology would seem to be a lot more convenient for the patient and actually may actually be easier for the doctor or practice nurse as well, and NICE has supported it, why do you think it’s not being taken up more quickly?

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McCartney

I suspect it’s all about the money.Ìý To outlay the cost of these machines it’s going to be a fair bit and then the test strips as well.Ìý And initially that’s going to come out of prescribing budgets.Ìý Now the problem is that that prescribing budget is not going to instantly increase because we’re not going to instantly see a decrease in the lab tests that have been done, with the GP time, with the nurse time, with the warfarin clinic time.Ìý So it’s not going to be a rapid exchange of money going from one bit of the hospital system to the other bit to fund it.Ìý And I suspect that that’s why there’s been a hesitation and in fact there’s a lot of clinical commissioning groups are not offering to pay for the equipment for this, some are putting quite strict restrictions upon it, in Scotland we can’t prescribe the initial equipment – the gadget that gives you your INR test – but we can prescribe the strips that you need, that you put the little bit of blood on to get the result from.Ìý So there’s various ways that it is and isn’t being funded at the moment and I think that’s probably the reason why the uptake has not been as big as it might have been.

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Porter

Well it will be interesting to see how this pans out, thank you very much Margaret.

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And you’ll find details on the latest NICE guidance and the kits on our website.

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Next week - another increasingly popular option for people fed up with needing regular monitoring for warfarin, forget having your own testing machine, why not ditch the drug altogether and switch to blood thinners that don’t need monitoring? I will be looking at the pros and cons of the newest generation of anticoagulants.

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And, as it’s the last programme in the series, time to hear some of your feedback - brickbats and bouquets.

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ENDS