More on the White Paper

A particularly interesting part of the White Paper is paragraph 3.8, which we mentioned in the February newsletter:

3.8  The Welsh Office will build on the work of its clinical effectiveness initiative which has a stated objective that all who provide health care will work together and in partnership with patients to increase the proportion of clinical care which has been shown by evidence to be effective. The Government wishes to ensure that ineffective practices are discontinued and that inappropriate variations are targeted. In order to demonstrate use of evidence, health authorities will be required to monitor and explain statistical trends for ten surgical interventions which fall into either a high cost or high volume category and for which evidence exists to support changes in practice. (my emphases)

 At the present time it is up to each Health Authority to decide on which ten surgical interventions it will choose to monitor. The first problem will be to decide on what is meant by a surgical intervention. Many procedures, which might be thought of as surgical interventions, are diagnostic, such as biopsies. Are bronchoscopy or cardiac catheterisation surgical interventions?

It may be thought that such questions are prevarication. My own preference would be to concentrate upon treatment interventions. We have mentioned the classical one of D&Cs in women with menorrhagia under the age of 40, which most of the evidence bases suggest should not be performed. The problem with choosing it as one of our ten interventions is that it is now a rare operation. We have not yet looked in detail at grommet insertion, the other classic in the evidence based medicine field, but the same problem is likely to apply. We will look at it shortly just to check.

It seems important to me that we should start a debate on the issue.

To start the ball rolling here are 15 where I think there is some evidence for a change in practice, or at least a need for clarity on what is being carried out. Please write, e-mail or throw note with brick attached. I will print any (printable) comments received. One that strikes me is - what has surgery done to deserve all this attention?

• D&Cs - low volume
• Grommets - do we do many?
• Tonsillectomy -
• Varicose veins - evidence for best practice?.
• Hernias - keyhole vs non. Patient preference.
• Types of hip prosthesis -
• Fractured femur - early vs late treatment?
• Prostatectomy -TURP vs TUIP - controversial in UK
• Follow up breast cancer surgery question - 30 or more breast operations a year.
• Other cancers - the specialist (Calman-Hine) questions
• CABG vs endarterectomy - not clear but good to examine
• Any GP procedures ?(ops) with good info.
• Does dentistry come into this?
• Investigative ops which are not useful or overused?

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Outpatient old:new ratios in Obstetric and Gynaecology

The Audit Commission, some years ago, produced an excellent report on the problems of outpatients. This newsletter entered the fray with data on did-not- attend rates in mental illness, but there are a number of interesting specialties which can be looked a within the area, especially old:new rates. The difficulty with making comparisons between trusts in this area is that some trusts in some specialties may have more complex cases than others.

This is less likely to be the case for obstetrics and gynaecology where trusts generally see their local people. Figure 1 therefore compares the old:new ratios for outpatients between the trust for ante-natal obstetric care and gynaecology. The figure shows that the old:new ratio for gynaecology is greatest in East Glamorgan, greatest for ante-natal care in North Glamorgan

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Anti biotic resistance is in the news again with the House of Lords’ Select Committee on Science and Technology report. An excellent BMJ leading article has looked at this:

Firstly, is there a problem of antibiotic resistance? The answer is yes and no. Some bacteria still remain sensitive to long established treatments. Against this, however, is the increasing array of resistance problems.

Secondly how does resistance arise? Resistance genes and mechanisms existed long before antibiotics were used. Antibiotic resistant bacteria have been isolated from deep within glaciers, estimated at 2000 years old. The adult human has 10¹⁴ cells, but only 10% of these are human. The remainder are bacteria, fungi, protozoa, worms and even insects that make up our normal flora. Each time an antibiotic is administered the normal flora are exposed. Many antibiotics are excreted in an active form exposing environmental bacteria. In the presence of antibiotics, resistant mutants have a selective advantage. Resistance can be passed vertically from generation to generation and horizontally by gene transfer. Resistance can be passed to other species and genera.

The next question is, who’s fault is it? Antibiotics are overused and misused in human and veterinary medicine, farming, aquaculture, and plant culture. All must recognise the problem and agree strategies to slow down the loss of important drugs.

The final and most important question is, what can we do? We must educate the public, increase the emphasis on infection in undergraduate teaching. develop surveillance systems for resistance and apply evidence based guidelines.

In veterinary medicine the use of growth promoters, which are likely to be used in human medicine, should be phased out. The veterinary use of anti-microbials such as fluoroquinolones, which are so important in treating human infection, should be used only in strictly defined circumstances.

The control of infection by proper hospital hygiene and vaccines play a part in decreasing the use of antibiotics. The government should develop an overall strategy for safeguarding the effectiveness of anti-microbials.

Finally, we must not neglect international aspects. It is no use the United Kingdom or the European Union acting alone. Bacteria do not recognise international boundaries, and intercontinental spread of resistant bacteria is well described.

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