Archive for the ‘healthcare’ Category

If you’ve been awake and living in Northern Ireland this week you’ll have done well to miss this story.

Marie Stopes is to open a private abortion clinic in Belfast this week. The clinic which will also provide advice and treatment for sexually transmitted disease and reproductive health will operate within the current framework of the law in Northern Ireland to provide abortions privately up to 9 weeks of gestation of pregnancy.

Understandably there has been much debate about this in the media and the usual polarised arguments of pro-choicers versus pro-lifers have been debated. I don’t really want to get into the usual debate about abortion but in the discussions I have heard and read since the announcement by Marie Stopes, it seems to me that the right questions have not been asked and important points have not been made. So that is what I hope to do now.

The Law

Our Health Minister Edwin Poots has been quoted as saying “I note that Marie Stopes International state very clearly that they will work within the law.” So what does that actually mean?

First of all lets look at the rest of the UK. Abortion is legal under certain circumstances in England, Scotland and Wales. The Abortion Act 1967 states:

Subject to the provisions of this section, a person shall not be guilty of an offence under

the law relating to abortion when a pregnancy is terminated by a registered medical

practitioner if two registered medical practitioners are of the opinion, formed in good faith –

(a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance

of the pregnancy would involve risk, greater than if the pregnancy were terminated, of

injury to the physical or mental health of the pregnant woman or any existing children of

her family; or

(b) that the termination of the pregnancy is necessary to prevent grave permanent injury to

the physical or mental health of the pregnant woman; or

(c) that the continuance of the pregnancy would involve risk to the life of the pregnant

woman, greater than if the pregnancy were terminated

(d) that there is a substantial risk that if the child were born it would suffer from such

physical or mental abnormalities as to be seriously handicapped.

Now read a summary of the law in Northern Ireland:

The Infant Life (Preservation) Act 1929 allows abortion when necessary to protect the

mother’s physical and mental health. But, performing an abortion in Northern Ireland is an

offence except in specific cases. Abortion in Northern Ireland is only legal in

exceptional circumstances where the life of the pregnant woman is at immediate risk and if

there is a long term or permanent risk to her physical or mental health.

What strikes me about these two quotations is that on the face of it, apart from the clause relating to abortion being allowed for probable severe handicap and the requirement for abortions to be carried out before 24 weeks of gestation, there actually seems to be little difference.

Both laws allow for abortion where there is significant risk to the mother’s physical or mental health. So this being the case let’s look at the statistics for abortions performed.

  • The number of abortions carried out in England and Wales in 2011 was 196,082.
  • The number of abortions carried out in Northern Ireland between 2005 – 2010 was 394.

I think it’s worth pausing here. I find these statistics staggering and deeply upsetting, especially when you look at the birth statistics for England and Wales:

England and Wales 2009-2010 (12 month period)

  • 723,165 babies were born alive
  • 3,714 babies were stillborn
  • Around 35,253 babies were born preterm
  • Around 241,055 women lost a baby during pregnancy or birth

The abortion figures for 2009-2010 were similar to 2011. So basically this seems to suggest that approximately 1 in 6 pregnancies in England and Wales are aborted. So here’s my question:

WTF?

Seriously, what is going on? How can this be? And when only 1% of abortions in England and Wales are performed because of the risk of serious disability of the child, this means the majority have been judged to be necessary to protect the mother’s physical or mental health or that of the other children in the family.

What is happening in England and Wales that is putting pregnant mums-to-be at such risk? Surely these risk factors will be similar in Northern Ireland. And yet I am not aware of any statistics that suggest higher rates of morbidity or mortality for women during or after pregnancy in Northern Ireland compared to England and Wales. Of course some women in Northern Ireland do travel to England and Wales to have abortions but these numbers are relatively low (approximately 1000 in 2011).

Getting to the point….

So here are my concerns about Marie Stopes:

1. Subjectivity of the law

The above statistics suggest to me that abortion can be deemed legal because of the way in which the law can be interpreted. There seems to be a great degree of subjectivity in deciding what constitutes ‘grave permanent injury to the physical or mental health of the woman’. I have been a doctor for 12 years and I don’t remember seeing a single patient who I feel would have met these criteria (according to my interpretation of the law). I have however known patients who have travelled to England for an abortion. The main reasons expressed have usually been because of the inconvenience or disruption that a child (or another child) will bring to their life. These women have been able to make a case of there being significant risk to their mental health. But who am I, you might ask, to make a judgement about these women’s lives and the distress and burden that bringing a child into the world might bring? Well, I could be a doctor in the Marie Stopes clinic. Are the doctors in the Marie Stopes clinic going to apply the same subjectivity to interpreting the law in Northern Ireland as it would appear is done in England and Wales? If 2 doctors (as is required by law) decide that there is permanent risk to a mother’s mental health, how is anyone going to challenge that?

2. Can a private provider be truly objective?

This is my concern about private providers of healthcare and I think one of the great advantages of the NHS. In the NHS there is no incentive for me to perform unnecessary expensive procedures or tests on you unless I feel they are in your best interests. However I believe once you introduce money into the equation, this objectivity at least to a small degree is lost. Can we expect and trust a doctor whose salary is dependent on the way he interprets the law regarding abortion in Northern Ireland to be the same as one who has no financial gain in the matter?

3. Why 9 weeks?

Marie Stopes plan to offer abortions up to 9 weeks of gestation. This might seem a bit arbitrary, and actually I think it is. The reason for this is mainly due to the fact that in pregnancies up to 9 weeks of gestation they can offer ‘medical’ abortions. This avoids the need for a surgical procedure and a whole range of clinical governances and procedures. And to be fair it is therefore safer. But my question is that if Marie Stopes are going to operate under the law as it exists in Northern Ireland (and continue to interpret it in the way that it has been interpreted up to now), how many abortions do they expect to be performing? Which leads me on the my next question:

4. Why offer abortions at all?

Under Northern Irish law how many women at 9 weeks gestation can be judged to be at significant risk of physical or mental harm due to their pregnancy. For the vast majority of women who might be at physical risk due to pregnancy, this is rarely apparent in the early stages of pregnancy. In terms of the risk of harm to mental health, many women only discover they are pregnant between 6-8 weeks of gestation which hardly gives them much time to mentally process the implications of their pregnancy, let alone give time for a doctor (or two) to make a clinical judgement.

Furthermore if only approximately 80 abortions are performed legally on the NHS in Northern Ireland, why does Marie Stopes feel there is a need for this service. And why would any woman pay to go a private clinic when she can get treatment for free on the NHS? My only conclusion is that Marie Stopes expect to be doing more abortions in Northern Ireland than are currently done here and in order for this to happen they will be applying a different interpretation of the law.

And that in my opinion cannot be a good thing!

Final thoughts

I feel it necessary as I finish to point out that I do believe there are circumstances where abortion is acceptable and when it may even be the best available option. I’m not going to specify what those circumstances are because individual cases need to be evaluated according to the specific circumstances.

So I am not completely ‘anti-choice’. But I do worry that the debate around abortion is talked about in terms of being pro or anti choice as if that’s all there is to it. I worry that as a society we seem obsessed with choice generally. We expect and demand the right to make choices about anything that affects us. This to me seems unhealthy. Maybe sometimes in difficult situations having less choice might actually make things easier. And maybe sometimes the more choices you have, the more likely you are to make a wrong one.

I am aware that the majority of my posts are related to being a medic and thus I am guilty of falling into the trap that medics are often accused of – of talking only about medicine. Unfortunately I’m really quite a boring person and have not much else to talk about. However my day is quite often filled with rather interesting people and what follows is the conversation with one such individual.

Background: Middle aged pleasant chronic schizophrenic man (let’s say called George) books an appointment for a pilot’s license medical. Receptionist (whose strength is not spelling) booked it as a ‘pilates medical’ – which is something entirely different. Anyway in walks George:

KBE: So you’re applying for a pilot’s license?

G: Well yes, I’ve been thinking I would like to get a job and I thought something along the lines of being an astronaut would be nice.

KBE: [Pause, keeping straight face -barely] Really?….O..K.

G: Yes, well, I checked on the European Space Agency website and they say I need a pilot’s license medical done before I can apply. But the application has to be in by I think the 6th of June.

KBE: Ok, well let’s see, you have diabetes don’t you?

G: Yes

KBE: Hmm and you’re quite overweight. I’m not sure you would qualify to be an astronaut.

G: Oh

KBE: …..And oh yes, you have schizophrenia -that might cause a problem too! [I think it’s fair to say that people prone to psychotic episodes shouldn’t fly planes (or space ships)!]

G: Oh ok then. Well my schizophrenia is pretty well under control at present [Next breath] I just thought it might be nice to have some solidarity with people who have been to the moon. But that’s ok…. While I’m here, could you look at a rash I have in my crotch…..

apostrophe.png

Perhaps my most intriguing title yet?! (I hope QM doesn’t mind seeing this coming up on his google homepage! 🙂 )

I had an amusing encounter with a patient last week. A middle aged women was suffering with constipation. Nothing was working for her and we were discussing the remaining options.

Then her husband who was sitting beside her piped up, ‘why don’t you try one of those apostrophes?’

I managed to keep a straight face (which isn’t like me!) and said I didn’t have any apostrophes (or suppositories) but I could give her an enema to try in her semi-colon…

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micralax-enema.jpg

Glossary:

apostrophe

suppository

enema

Testicle Teaser

Posted: March 24, 2008 in healthcare
Tags: , ,

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I occasionally check my blog stats (ok, at least twice a day). Sadly the blog traffic has been a bit slow recently, which I can’t really understand given the cutting edge, stimulating and insightful posts I’ve blogged about recently…

Anyway I’ve noticed that a significant number of ‘randomers’ seem to be finding their way to my blog (particularly ‘Unique Questions 2’) by searching using the tag ‘testicle’.

Hmmm…

So testicles are obviously a popular subject which interest people. And being an obliging fellow, I thought I’d give the punters what they want- more stuff about testicles.

I hope no-one will be disappointed – there will be no pictures of testicles… but there are pictures of teasers.

Below is an amusing article from the British Medical Journal called ‘Dissent of the Testis’. By way of introduction/explanation an orchidometer is a string of beads of different sizes which paediatricians use to measure the volume of testicles (and therefore the stage of puberty).

dissent-of-the-testis.jpg
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By the way – you’re not a proper man unless you’re at least a size 20.
And any bigger than a Cadbury’s Cream Egg means you’re an elephant  😉
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om10.jpg

Sardines with room?

Posted: February 26, 2008 in healthcare, random
Tags: ,
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You may well be aware of the benefits of Omega 3 in your diet, high levels of which are found in oily fish such as mackerel, sardines or tuna. Omega 3 fatty acids have been shown to reduce the risk of coronary heart disease. This important health benefit has long been suspected but have only recently been proven through research.

Perhaps the earliest suggestion that oily fish protect the heart comes from the Bible. In Exodus chapter 7, after God turns the Nile to Blood it says ‘The fish in the Nile died ……. and Pharaoh’s heart became hard’

(I have to give credit for that one to Prof Young, RVH)

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It was also well recognized that Eskimos (who pretty much only eat fish) very rarely developed heart disease. But then someone realised that the reason for this was more likely because few of them lived beyond 50! (The nice lady above is only 26!)

Anyway having been made aware of recent research and current guidelines from the National Institute for Clinical Excellence (NICE), which recommends at least 2-3 portions of oily fish per week for the primary prevention of coronary heart disease, I asked my wife purchase me some oily fish – in oil (the stuff in brine doesn’t have nearly the same quantity of omega 3 apparently). She kindly obliged and bought me some tinned sardines and mackerel etc.

Now, what’s the first thing you think of when you think of sardines? I reckon most of us think of a tightly packed tin, full of tiny fish. I mean the word sardine is totally synonymous (had to get my wife to help with the spelling of that one) with being tightly packed.

So I was deeply disappointed to open my tin of sardines tonight to find them swimming freely in a large pool of olive oil, I mean it was like free range sardines. What is the world coming to when sardines of all things are no longer tightly packed? What metaphor are we going to use when in a situation when we are squashed together?

This is an important issue. Write to your MP. Less room for sardines!

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Gordon Brown is really getting on my tits! I’m about to offload one almighty rant so if you’re not in the mood to listen to that sort of thing, click away now!

This is all about GP opening hours and how the government has treated GPs in recent years. I of course need to point out right at the start that I am myself a GP and therefore I am fully aware that my views are completely biased. Nonetheless I would hope that at least some of what I say will make sense and if nothing else that my venting will be in some way therapeutic.

Background
The current contract for GPs (GMS contract) was introduced in 2004 following extensive negotiations against a background of difficulty recruiting and retaining GPs, low morale in the profession and an acknowledgement that GP income had fallen behind other professions. The contract changed from one where funding was related to the number of registered patients, item of service payments and the number of principals and did not reflect the quality of service a practice provided, to one which had far greater emphasis on rewarding the quality of service delivered. Payments are now made through the Quality and Outcomes Framework (QOF) which includes many chronic disease areas amongst other things. For example the higher the percentage of my patients with hypertension whose blood pressure is controlled the more I get paid. At the time the contract was hailed world wide as a groundbreaking way to deliver healthcare. The problem was that the government thought that GPs were all lazy gits and grossly underestimated our ability to reach the set targets. On the one hand this means that patients with heart disease, asthma, copd, diabetes, hypertension, kidney disease, depression, dementia, epilepsy (to name a few) are now receiving better care and more evidence based treatment than ever before in the UK. On the other hand it has cost more money than expected. The other main change in the GMS contract was the out of hours provision. Previously GPs had effectively been providing this service for years for free. In the new contract GPs were given the option of opting out of this out of hours responsibility (which almost everyone did) but not without a reduction in income. Again the government grossly underestimated the cost of providing an out of hours service.

The Problem

The product of all of this has been a government agenda against GPs (with regular smear campaigns in the media). Instead of congratulating GPs on outstanding performance they have continually forced re-negotiation of the (originally non-negotiable) contract using gun-barrel tactics (By effectively saying: ‘You better do this, this and this, otherwise we’ll totally screw you!’)

Now let me say that I have no problem in salaries being reviewed particularly when public money is involved. Let me also say that I realise I am well paid (although not nearly as well paid as what is reported in the media). So I am less concerned about the money issue and I didn’t become a GP for the money anyway. What concerns me is the government pushing its own political agenda without properly considering patient care or how NHS money could be best spent.

They are hell-bent on pushing through their proposals for longer GP opening hours i.e evenings and weekends. They have announced that they have made available £158 million to improve access. (The reality is that this money is being removed from GP’s income and we are being offered the ‘opportunity’ to earn it back by working longer hours -yeah thanks!) Now let me try to make some sense of this longer opening hours malarkey.

I have no problem with the idea of working some evenings or weekends but I’m going to need some time off in lieu and so will every other GP (otherwise we’ll all be breaking European working time directives, not to mention burning out). So who is going to provide these extra hours- there is a shortage of GPs in the UK as it is. Also it is obvious that the longer any business stays open the higher its overheads and staff costs (receptionist, nursing) etc. Who is going to pay for this extra expense?

Needs or Wants?

This begs the question – are longer opening hours really what this country needs? For me the key is understanding the difference between needs and wants. Sure plenty of people say they would like to see their GP on a Saturday but do they need to? Plenty of my patients want sleeping tablets or antibiotics for their runny nose but I have to decide whether they need them. Now I do think there are certain areas (for example some inner city areas) where there is a strong argument for evening or weekend opening but there are many areas where this is not the case.

Whenever I’m driving about at lunchtime doing home visits the roads are always full of cars and people out and about. In the UK working patterns are more flexible than ever before, more people are self employed or working shifts, less people are working within 9-5 than ever before. So I find it hard to believe that the vast majority of people couldn’t take 20 minutes out of their day to see their doctor if they needed to. And what happens when we have evening and weekend surgeries. Are they to be kept for people who work 9-5 or have some other excuse as to why they can’t come during normal working hours. Obviously this would never work which begs the questions: what’s the point of all this extra expense? And would it not be better for local health authorities to decide what the local priorities are and spend the money there? And would it not be cheaper for the government to pass legislation for employers, to make it easier for people to get out of work to see their doctor?

The government have only got themselves to blame for the spiraling costs in the NHS by constantly encouraging patients to think of themselves as consumers. In an ideal world this would be great. We would all like to have choice in healthcare and to get the best and most up to date and most expensive treatments. Unfortunately the NHS is a rationed service with limited resources. I am frustrated by this fact every day. I often feel embarrassed telling patients how long they may have to wait to be seen in some specialties etc. But this is the reality. There are many excellent things about the NHS but it is a rationed, limited health service. The sooner the government are open and honest about this fact the better.

I’ll finish with a quote. Dr Laurence Buckman, Chairman of the General Practitioners Committee wrote recently, ‘The NHS is undergoing some significant and worrying changes which demonstrate a lack of value placed on the quality of General Practice. It appears that the Prime Minister is prepared to ignore the views of the vast majority of patients in order to deliver on a personal commitment, and the enforcement of a consumerist short-term ideology onto a service dedicated to delivering needs-based holistic lifelong continuity of care’

Ahh. I feel much better after that!

Today, I was asked a question I’ve never been asked before by a 20 year old patient at the end of his consultation:

 ‘erm, where do I go to get my testicles checked?’

‘Oh that would be the testicle doctor next door’ I said.

🙂

 

Check your nads!

Lads, check your nads!