A blog by Dr. Jeff Schryer, Chair of NHS Bury CCG.

In the late 19th century one of the commonest operations performed by urologists was a form of fixation of the kidney. There was a belief where kidneys that move out of their normal position cause all kinds of problems ranging from backache to depression and irritability. This was fuelled by x-ray findings where kidneys were seen to move, only later to realise that it is normal for kidneys move when the diaphragm contracts as a person breaths! Many people seemed to have been ‘cured’ by the surgery given its popularity amongst patients and surgeons; but how many people were harmed or even killed?

Thankfully these operations are no longer offered, however many operations are still performed or medications taken despite a lack of evidence. Yes, some people may feel better after a procedure or taking medication but there is a massive placebo affect; and then there is the cost. Costs are not only calculated as the direct cost to the NHS, but also the time that could be allocated to other areas by diverting surgeons from doing other operations, or prescribers focusing on other priorities.

With every procedure there will always be risks and side effects. Recently I was reviewing reports of patients who had undergone varicose vein surgery and became aware of the number of patients who had to re-attend hospital or visit their GP with complications such as allergies to medication and skin ulcers. The latest findings show that there is a lack of evidence for the benefits of this surgery, so I started questioning why this procedure is taking place. The cost of varicose vein surgery does not only impact the NHS, it affects the patient and their carer too – the time taken off from work, organising transport, attending clinics and then the procedure and recovery time… the list is extensive.

Similarly, the benefit of taking medication must outweigh its side effects. If we look ‘across the pond’ and take note of what is taking place with in America, there is an outcry about the damage opiates (a drug group which includes morphine, tramadol and oxycodone) have on an individual’s wellbeing. There is a growing legal challenge where patients are filing claims for the impact the drugs have had on their health. Although opiates have a fantastic evidence base for effective short term pain relief, there is limited evidence for their long term use with some research show that they can make chronic pain much worse!

The BMJ, one of the most prestigious medical journals, recently looked at the preventable harm for patients across medical care settings. They drew on evidence from 70 different studies and found that six percent of patients were harmed by medical interventions, of which 12% were either permanently disabled, had prolonged disability or even died. The most ‘at risk areas’ were intensive care and surgical units, but the study was hampered by a lack of evidence in general practice and psychiatry. Most prescribing in the NHS happens in general practice!

No decision is also a decision. A person, who decides not to take a medication such as statins or stay in hospital for a further period of time whilst awaiting social care or tests, should know that this is also a decision with consequences.

So what should the NHS be doing?

NHS Bury CCG needs to improve the way we approve procedures. Greater Manchester, in common with many other areas, has a comprehensive process for ensuring that only procedures that have an evidence base are carried out. These guidelines are agreed by a wide group of people after extensive consultation. Some procedures with a limited evidence base are restricted to specific indications and need a clear record of why the procedure has taken place. There is a process for specialists to apply for approval when they think exceptions apply. However having done audit work in this area, the CCG knows that the evidence behind why some procedures or decisions to prescribe is not clear.

The CCG must work with all clinicians and managers to make it transparent for why decisions to operate or prescribe medications have been reached. There needs to be a clear line of accountability and decisions should be open to scrutiny and review. Where patients have commenced treatment in areas there is a lack of evidence the NHS should support people to change medications. Equally, the NHS must support clinicians to help patients reduce prescribing where current guidance would not support the drug’s use.

The NHS needs to have a much more proactive conversation with patients!

The CCG should be helping patients to understand the risks and benefits of procedures and medications, and there are helpful NHS websites that we should be using routinely.

No action is also a choice, and patients need to consider what might be the benefits or risks, for example a patient who chooses to stay in hospital should be able to understand not only what the benefits are, but also the continued risks such as a secondary infection, confusion and falls. The NHS must help patients to ask the right questions when they see professionals and help them to evaluate the evidence. Patients should be able to listen to the evidence, weigh up the choices and feel they have control over what they are being offered.

References

https://doctorskeptic.blogspot.com/2013/10/the-magical-floating-kidney.html

Preventable Harm; getting the measure right. BMJ 2019;366:l4185