The Bewilderness

National Hell Service (for some)

When the Labour conference worshipped the National Health Service, their acts of exaltation and their accusations of sacrilege by the Tories (for daring to allow the wicked heresy of price to prevail), left them blind to its failings. And failings there are. Over a hundred and fifty people died of starvation or thirst in NHS wards last year. These are the most extreme cases. Underlying this is a cast of hundreds dying of malnutrition and thousands dying of infected wounds.

So, we have an elderly or incapacited person in the care of a profession, whose name defines their purpose as giving aid and comfort. Neither are achieved. Yet, we never hear of individual nurses or managers brought to account or struck off for this rollcall of daily neglect. How can teh sick, supposedly supervised and cared for on a daily basis, die of neglect? We know the root cause: a lack of accountability at a professional and at an institutional level. The Grauniad does not appear to cover the story.

The health bill gathers pace

The most contentious bill currently on the Coalition's agenda is the watered down health and social services bill. This anodyne, diluted echo of Blairite reform is now opposed by both Labour and left-wing Liberal Democrats ("we should be in Labour but ended up in the wrong party).

The bill has faced a series of motions set down by the Labour party ("Official Opposition") and Liberal Democrat party ("In power but opposing"), both in the Commons and, soon, in the Lords. All of the current motions against the bill have been defeated, quite comfortably. Liberal Democratic outrage at the activist edges is not derailing the government plans on health. 

Innovate to cure

An article, interviewing the IEEE emerging technology committee chair: Professor Atam Dhawan at the New Jersey Institute of Technology. Dhawan highlights five categories: IT software, optical imaging technologies, bioelectronics, regenerative medicine and medical robotics. The overlap between the categories is quite clear; their effect, if state systems and debt dysfunction do not kill off all innovation, will prove revolutionary. 

A genome sequencer coming soon to a hospital near YOU!

This may be more than a month old: a strikingly pure example of the convergence play: nano, bio and info. Genome sequencing is decreasing in price, but the next generation prototypes depend upon complex instrumentation and suffer from the constraints embedded in their processes. A simpler and more effective process is nanopore genome sequencing:

For over a decade, researchers have been working on nanopore sequencing, which could eliminate these problems by directly reading off the sequence of long, unprocessed strands of DNA. The principle is to identify each base in the sequence as the molecule is threaded through a nanoscale hole (or nanopore) outfitted with a sensor.

Nanopore sequencing has been developing for a decade: a useful reminder of how long the road from pure research to commercial viability. The goal is to transfer genome sequencing into hospital labs, the next step towards making this capability a viable and permanent expectation of the patient.

 

Free at the point of death

Hear hear for the Liberal Democrats. Through their principled stand on behalf of producer rights, they allowed the National Health Service to live up to its greatest principle: free at the point of death! The Telegraph has highlighted a new report studying the actions used by health service trusts to eke out their resources. Lengthen the time patients stay on the waiting list and they may lose patience and turn to the private sector. If not, then hopefully they will die if sick enough.

Some managers insisted that longer waiting times would lead to overall savings as “experience suggests that if patients wait longer then some will remove themselves from the list”. Interpreting this statement, the panel noted: “We understand that patients will 'remove themselves from the waiting list’ either by dying or by paying for their own treatment at private sector providers.”

Such results are achieved when you are a burden on the budget, rather than a customer who deserves service. Such professional practices have probably been embedded in this institution since 1948. Sixty years of the death panels and counting....

Another top-down revolution in the NHS falters....

Smoke and mirrors have attended the latest differences in opinion over the NHS. Andrew Lansley, Health Secretary, has taken some flak for being too radical in public sector reform. Wasn't that the distinct flavour of the coalition? Yet, after a torrid spring conference for the Liberal Democrats with howls of "save the NHS" from the remnants of producer interest still within their ranks, Cameron and Clegg have bowed to concerns and the bill is stayed at committee stage.

The raft of reforms appear quite radical on the surface: a regulated market in healthcare, an independent commissioning board and concentrating procurement power in the hands of the GPs. Yet, the right of centre think-tank, Policy Exchange, have cast doubt on the efficacy of the reforms:

The statement by Lansley follows the Policy Exchange warning that the health and social care bill's proposals to abolish every primary care trust (PCT) by 2013 "could lead to the new structure simply replicating the existing system in all but name".

Without support from GP consortia and ensuring the necessary skills to exploit the new structure, an NHS 'big bang' could result in much heat and eventual status quo. So, the 'Lansley problem' is one of two left feet: annoying the GPs without Bevan's pot of gold, whilst the set of reforms suffers from a skills gap. Surely the answer is to seek out those who have the skills and allow them to partner with GP consortia to allow the reforms to move forward (perhaps they could, whisper it, make a profit too!).

Lansley's reforms, a rehash of earlier organisations, are failing because they do not allow enough diversity in provider or provision. Typical top-down revolution without considering that local structures must mutate to meet local needs. Wasn't devolution a principle once upon a time?

Coming this side of 2020: the $1,000 scanner

Scanning technology holds a particular interest for me: as the intersection of medicine, computing power and innovation. The improvements in scanning technology have boosted surgical accuracy, preventative medicine and saved lives: all at a cost that is going down rather than up.

The latest crossover is the technology underpinning 3D imagery. This is now being applied to diagnostic imagery.

From CT to MRI and PET, new medical imaging devices are using three-dimensional technology, robotics, and color imagery to quickly and painlessly diagnose possible life-threatening conditions. 

With the continuous improvement in radiation exposure, we can expect scannersto become more portable, accessible, perhaps even ubiquitous in the coming decade. Can someone offer a prize for a $1,000 scanner, suitable for Africa or South Asia.

Good stem cells require innovative tools

Stem cells are one hypefest that peaked before the curve. Years after they were trumpeted as a cure-all, and encouraged surgical butchery in unscrupulous countries, research programmes are beginning to bear some fruit. Even with the recent setback in the United States over embryonic stem cells, results have begun to be published.

A recent paper on the introduction of adult stem cells to damaged heart tissue has begun to answer some of the deep problems:

• How do you inject stem cells into damaged tissues?
• How do you ensure that the stem cells survive and begin to replace the damaged tissue?
• Can any clinical programme resulting from this research satisfy the FDA or other medical regulators?

The answer lies in technique and tools, rather then the content, with some nifty engineering and biomechanical materials:

But now, WPI researchers have developed a biopolymer microthread technology that could deliver these hMSCs directly to damaged heart tissue. The microthreads are made of fibrin, which is a protein that assists in blood clotting, and can be engineered to acquire different tensile strengths and to dissolve at various rates once implanted. This makes it easier to adjust the threads for several different uses. 

[Glenn] Gaudette and [George] Pins used small bundles of the fibrin microthreads to seed hMSCs, where the stem cells would attach to the threads. Once attached, the hMSCs were cultured for five days. According to the study, the stem cells started multiplying and eventually covered the two-centimeter-long threads completely. There were approximately 10,000 hMSCs on each one. 

Once the seeding and growing process was complete, the microthreads were attached to a surgical needle and drawn through a collagen gel. This gel stimulated the human tissue, keeping the stem cells both alive and attached to the threads. This result suggests that the cells could be sutured into human tissue.

These researchers at Worcester Polytechnic Institute illustrate the lesson over stem cells: that they are only as good as the tools that propel them to the damaged tissues. Innovation in medical tools may prove even more important than stem cells themselves if medical researchers wish to explore their full potential.

The new enemy is salt

The new enemy is salt. Here is an interesting example at an early stage of how calls for legislation leap from study to implementation. A survey has looked at salt.

In the paper, Kirsten Bibbins-Domingo and colleagues, from the University of California, San Francisco, USA, undertook a computer simulation showing the effects of population wide reductions of dietary salt intakes in all adults aged 35 to 85 years in the USA. Reducing dietary salt intake by 3 g per day (1200mg less sodium per day) could result in 60,000 to 120,000 fewer cases of heart disease , 32,000 to 66,000 fewer strokes and 54,000 to 100,000 fewer heart attacks.

Just one study and even then, dietary recommendations are notorious for lack of reliability. But the recommendation follows like day after night:

A reduction in dietary salt of 3g per day, the authors went on to say, would have approximately the same effect on reducing cardiac events as a 50 % reduction in tobacco use, a 5% reduction in body mass index among obese adults or the use of statins to treat people at low or intermediate risk for CHD events. Furthermore, reducing dietary salt intakes by 3g per day would save $10 billion to $ 24 billion in annual health care costs.

Precise, costed benefits that bear little resemblance to reality, but a comparison with the other devils of public health is utilised to define a 'collective benefit'. Thus the call for legislation by the European Society of Cardiology:

While individuals may use salt sparingly at home, around 75 % of the salt we eat is already in the food we buy. This, says the ESC, underlines the need for legislation to lay down guidelines. "The reality of international food production in Europe means that such public health initiatives need to be tackled on a European wide basis, rather than an individual country basis," said [Professor Frank] Ruschitzka.

Throw in a publicity week and the NGO for good measure:

Salt will again be on the agenda with World Salt Awareness Week 2010 , which runs from February 1- 7 (3). The week is being run by World Action on Salt and Health (WASH), a global group that works with governments to highlight the need for widespread introduction of population based salt reduction strategies.

Add salt!

Living across the 21st century

If life expectancy continues to rise as it has done, then children born between the cusp of the century and now can expect to become centenarians. The average age of death in advanced industrial countries will shift to 100. That is a nice round number, and that is based on current trajectories. That could go down, as it builds upon the thirty year rise in life expectancy during the twentieth century. Or it could go up, assisted by the progress of medical knowledge and technologies.

The linked article explores some of the potential alterations to life and work that will result from this change. Bring it on. For life has already undergone one of the greatest social shifts over the last fifty years: the emergence of equality between men and women. If we can deal with that, then the changes required to work and live for a full century should be just as invisible and just as dramatic.