Breast Implants

Janaury 2012

I recently submitted the following article to the Western Morning News:-

It is a long standing principle of the NHS that it should treat patients without making value judgements about the lifestyle choices that may have been responsible for their condition. If that were to change as a result of the calls for the NHS not to treat women who have had cosmetic breast implants I think that would be a great shame. After all, where and who would draw the lines? Should we refuse to treat those who take part in high risk sports such as hang gliding or even riding? Would we decline to treat smokers or the person who contracts hepatitis from a dodgy tattoo?

Of course private clinics should be held accountable; they have an ethical duty to treat their former customers free of charge should their use of low cost French breast implants be shown to have an unacceptably high risk of rupture. But if those clinics, along with the manufacturers PIP, have gone into liquidation, then where women are at risk the NHS should not, in my view, leave them stranded if they are unable to afford to have faulty implants removed.

The final advice on the need for removal will depend on an expert review panel convened by the Department of Health but the news that some private clinics are admitting to much higher rupture rates does add to the concern for the thousands of women who have implants. Many have had these fitted following reconstructive surgery for cancer or other serious conditions and several women have contacted me to tell of the worry they face whilst waiting for confirmation of the type of implant they themselves have in place.

At present there is no national register for implants as there is for some other types of prosthesis which makes it more difficult to track which device any individual may have in place. It also makes it more difficult to follow up the true rate of long term complications. The current system involves voluntary reporting to the Medicines and Healthcare Regulatory Agency MHRA, but private clinics may have little interest in long term follow up.

In my view, the private cosmetic surgery industry needs to be held to account for this avoidable scandal. If they have been concealing data of reported harm from former patients and not then sharing this with prospective clients, then both the courts and the GMC should take action. In future perhaps all women opting for cosmetic implants should pay a compulsory insurance premium to cover the costs of replacement should the implants fail or cause problems so that the NHS would not have to pick up the tab on behalf of the multi-million pound cosmetic industry. Such a premium could also cover the cost of maintaining a register.

The two professional bodies representing aesthetic or 'plastic' surgeons should reappraise the ethics of cosmetic implants, particularly where these are promoting a dysmorphic 'plastic' image of women. After all there is a long history of implants failing and anecdotal reports for years from women who claim that they have damaged their health.

There are those who argue that cosmetic surgery is just an extension of the right to make any decision about one's appearance and that it is no one else's business to interfere. That may be the case except that this industry does impact on wider society by encouraging and colluding with an artificial and damaging stereotype of women.

Of course it is ultimately the responsibility of individuals to make decisions about their health and live with the consequences but I can't help feeling that those decisions may have been based on inaccurate follow up data and therefore false reassurance about the safety of implants. I hope the GMC will take action if surgeons and their clinics are shown to have failed to pass on reports of pain or leaking from PIP implants because this should surely have been an ethical responsibility even if not a legal duty in order to fulfill their duty of care to future patients.

For all those women facing the agonising wait for news about whether their surgeon fitted cheap PIP implants filled with industrial grade rather than medical grade silicon, this will be a nerve wracking few weeks.

Ultimately, whatever anyone's views about cosmetic surgery, I feel we should all support the principle of the NHS being there to support us, free at the point of need and regardless of our ability to pay ....and without feeling that its staff will be making judgements about us.

 

 

On the 5th April 2011 I submitted an article to the Telegraph and they published an edited version, below you are able to read the full version.

"I am delighted to say the Government have committed themselves to a listening exercise .

If you would like to get in touch with your thoughts, I am happy to forward them on your behalf.

"The Health and Social Care Bill will need some emergency surgery if it is to regain the support of patient groups and the professions. This could and should have been carried out during its recent committee stage.

The Bill has, however, emerged 'unscathed' except for those amendments tabled by the Government and this begs the question; what purpose was served by whipping through the Bill clause by clause rather than subjecting it to objective professional scrutiny?

The Health and Social Care Bill could pave the way for a shift in the way that legislation is scrutinised in Britain. If Government wants to avoid accusations of U-turns, then a commitment to effective scrutiny involves an open and honest discussion of concerns and an acceptance that some of those concerns might be justified. If members of Bill Committees were expected to leave Party Politics at the door and apply independence of spirit in weighing up the evidence, we could have less confrontation and more of a consensus in our political process, with better legislation as a result.

I hope that the Prime Minister will look carefully at the Health Select Committee report, published today. This Committee has taken a step back from Party Politics to examine some of the complications inherent in the Bill and suggested some changes that might steer the NHS super-tanker into safer waters.

The Select Committee listened to evidence from many experts over the past few months; they do not all agree and it would be naive to think that there is some mythical 'third way' of complete harmony in healthcare policy. Equally, railroading through the current proposals may result in 4 years of dissatisfaction, with the Tories taking the blame for any service failures. It seems unlikely that it would be acceptable in its current form so surely better to amend now with good grace than slug it out with a grudging trickle of amendments that end up satisfying no one.

A key concern is the potential impact of expanding Any Willing Provider, AWP, upon the ability to commission logical high quality integrated care that ensures patients have a seamless journey through the health and social care system. This week's British Medical Journal highlights how integrated health and social care has worked so well in Torbay, improving patient care and saving money by reducing the need for hospital admissions and giving patients a better and safer service at home.

There is a danger in promising patients improved choice and assuming that competition will improve outcomes and save money in the NHS. One senior hospital manager explained it as follows; if half of his patients go elsewhere for care, his own overheads are not reduced but falling patient numbers and a reduced 'tariff' per head mean that the sums just don't add up. If his hospital is a designated rural hospital...in other words, one that is not allowed to fail, then he could get more per patient to support the hospital and this then would then just increase the overall cost to the taxpayer.

There is only a limited pot of money and this has to be effectively reduced by around £15-20 billion in order for the NHS to meet the demands of an aging population and rising costs of treatment.

The only way for the NHS to meet this need is to focus on how to get the best possible results from existing resources. I cannot agree that the proposals in the Bill will achieve this end.

The intentions at the core of the Bill are welcomed by almost everyone; clinical input into commissioning and a change from meaningless targets to rewarding the outcome of care...In other words, does it work and what does it feel like to be a patient. Of course it is a bonus to have choice but this could be between competing pathways of care and not via an uncontrolled expansion of profitable but unconnected pockets of care.

The Government should return to the Bill's core principles and rethink the proposed competitive enforcement role of the economic regulator, Monitor. Rather than turning the NHS into a regulated industry like water or gas with Monitor at the helm, this organisation should help to set the tariffs for treatment and oversee logical pathways of care that deliver the best value for patients and the wider NHS.

I have no ideological objection to involvement by charities, social enterprises or the private sector... there is no reason why they could not be incorporated into pathways of care. But a pick and mix approach to healthcare is expensive, results in poor continuity and ultimately no one taking responsibility if things go wrong. The Secretary of State has made it clear that it will not be deemed anticompetitive for commissioners to design care pathways but it makes no sense for commissioners to be working to control costs when they are consigned to writing the cheques for a smorgasbord of services chosen by patients under AWP.

The fragmentation of the NHS would have far reaching consequences. One surgeon summed it up as follows; he was committed to the ideal of the National Health Service and happy to work far beyond his contracted hours, he would not feel the same about a Commercial Health Service.

We fragment the NHS at our peril."

I submitted an article to the Guardian newspaper which was edited and published on 30th November. The full text of that article reads as follows:-

"I received an email this week asking me to stop the privatisation of the NHS.

The Coalition is not privatising the NHS, but it is in danger of failing to make that clear. It is no surprise that an announcement made in May 2009 by Sir David Nicholson, that the NHS needed to make efficiencies of between £15-20bn over 3 years, should be rebranded a Coalition rather than a Labour cut.

The fact is that despite years of throwing cash at the NHS, productivity was flat or declining between 1997 and 2007. The proposed reforms are a serious attempt to address the problems with commissioning and improve outcomes for patients.

However, it is one thing to attempt such a root and branch reform in a time of plenty, it is another when you are simultaneously trying to deliver efficiencies of over £15bn just to keep pace with demographic changes, new treatments and rising expectations on a near flatline budget. Andrew Lansley argues that you need the whole package of reforms to deliver the efficiencies. He should not be afraid to listen to patients groups and professionals and review further aspects of his proposals. Changing the plan from central to local commissioning of maternity services was welcomed rather than derided as a hand brake turn.

I gave up teaching medical students about the structure of the NHS long before hanging up my stethoscope to become an MP because the chances were that the structure would have changed before they graduated. The lesson from all those reorganisations was that they distracted management from their key task of improving the service for patients and cost far more than expected. PCTs are already in trouble and many are losing their staff in an uncontrolled manner just at the time when they are most needed to advise GP commissioners on their new roles. We must ensure that the best managers are actively retained and feel valued rather than derided. If they all disappeared and GP commissioners had to rely entirely on private sector commissioning support, it really could start to look like privatisation.

The fact is that GP-led commissioning is already happening in many places and delivering service improvements and savings. In places as diverse as Torbay, Cumbria and Hackney, clinical leadership combined with good management is making a difference without the need for a revolution. Most witnesses however, felt that the change to clinical leadership would have been unlikely to happen nationally without a significant shove from above. Geography matters and I hope that Andrew Lansley will ensure that consortia are geographically logical as there is a danger that they could be distorted by fears about inheriting historic debt.

Treating patients with chronic illness closer to home and preventing unnecessary admissions saves lives and money but it will only be achieved alongside improvements to community services. The problem is that whilst commissioning a new community service is popular, the corresponding withdrawal of its hospital based counterpart is not. Change needs careful explanation and consent. New services are expensive to set up and might not even benefit the service that foots the bill. If the Local Authority offers a rapid home assessment service to prevent admissions, it will be the NHS and not the Local Authority that benefits financially. Integrated care works but requires negotiation and less rigid separation between commissioners and providers, especially at a time when Councils are also struggling to make efficiencies.

Choice can be an illusion, too. For most of my former patients in rural Devon, the only practical choices were dictated by geography. In inner cities, choice is often exercised most effectively by those with the least need. Choice is great, but a high quality accessible service is what most patients really want and the chance of a second opinion if things do not go to plan. Choice is also strangely at odds with commissioning. In Hackney, GP commissioners work closely with colleagues at Homerton Hospital on care pathways, only to find that their wealthier patients often choose to be referred to flashier teaching hospitals with no benefit in terms of outcome but huge uncontrolled costs to the PCT. Andrew Lansley is confident that his reforms will remove the perverse incentives for hospitals to over-treat patients. I hope he is right, not least because this is the mechanism for delivering 40% of the 'Nicholson Challenge'. Whilst London might be able to afford to lose a hospital, rural areas cannot and careful oversight will be required to ensure that hospitals are slimming back those services that are better provided in the community and not cutting essential but unprofitable services.

As for the question of whether GPs even want to become commissioners and take on the sharp end of rationing; most do not. They don't have to. But there will need to be a critical mass of clinical leaders. Management cuts are supposed to deliver considerable efficiencies, which does not bode well for enthusiastic participation from the managers concerned.

I know many GPs who are keen to roll up their sleeves to tackle redesign of care pathways and even the issue of failing colleagues, but I do not know any that are remotely interested in EU competition law. If commissioners cannot design pathways of care free from the spectre of law suits from disgruntled private sector providers, they will quickly hand over to commercial commissioners prepared to take the rap. If those private commissioners turn to private providers at the expense of NHS providers then my email correspondent might not have been so wide of the mark after all.

If Andrew Lansley wants to reassure the public that his reforms will not lead to the privatisation of the NHS, he should make it clear that GP commissioners will be liberated to choose NHS providers where they offer the best quality and comprehensive service without fear of legal challenge from private cherry pickers. He should also give patients' representatives a clearer place in his reforms with a seat on the board at every level of the NHS."

It was concern about the NHS that brought me into politics. Despite an unprecedented increase in funding, many who work in the NHS have been disappointed by the wasted opportunities.

The Coalition upholds the values and the principles of the NHS; based on clinical need, not the ability to pay, available to all, free at point of use, and have pledged to increase health spending in real terms in each year of this Parliament.

We all want to see an NHS achieving results. For anyone looking in more details at the proposals outlined in Andrew Lansley's White Paper follow this link to the Department of Health website. It has an executive summary about commissioning.

To summarise, the proposals will radically change the structure of the NHS and also the information and control available to patients. We want patients to have choice of any provider and of consultant led team and more involvment in their treatment. In order to make informed choices patients will need better information (unless patients are able to rate hospitals and clinical departments according to their real experiences, others will not be able to make informed choices about their care.)

We would like to see patients having more control over their care records and a culture of openess so that patients are told when something has gone wrong. In order to achieve these results we believe that it is better for services to be commissioned by those who are closest to their patients, namely General Practitioners. This is the opportunity that GPs have been seeking for many years and I hope they will now get involved with their commissioning groups in order to deliver the care that is right for patients in their own area.

For too long we have seen a health care system that is focused on the need of those who live in cities, rather than recognising that the needs of patients in rural areas are often very different. Patients in rural areas want services that are accessible, so it is all the more important to ensure standards are maintained when there are fewer geographically accessible centres to choose from.

The Coalition believes that the NHS needs to be held to account against clinically credible and evidence based outcomes. We will remove targets with no clinical justification in order to provide an incentive for better quality of care. Those looking after patients should be paid according to the outcome of care, not just the number of patients treated.

Of course, many have expressed concerned that £80 billion is a vast amount of money to hand over to General Practitioner Commissioning Groups, this is why an independent and accountable NHS Commissioning Board will be there to hold Commissioning Groups to account. They will also have to work closely with their local authorities who will be there to promote an NHS that delivers more'joined up' health and social care and local health improvements. Other safeguards will be in place and include monitor for Hospital Trusts and Health Watch both locally and nationally. All of these services will come under the umbrella of the Care Quality Commission.

Travelling around the constituency and talking to doctors from across the region, it is clear that many have concerns about possible creeping privatisation and the potential to de-stabilise the financial security of NHS hospitals. There are issues about the 'historic' debt of some institutions then acting as a barrier to others wanting to join them to form commissioning groups. Doctors also have concerns as to whether this will cost more than initially envisaged and would prefer to have seen the scheme piloted, rather than rolled out nationally. Above all, they look forwatrd to seeing more of the detail.