I have recently had a short, unexpected holiday in the Royal Bournemouth hospital. Many thanks to all those patients who have wished me a speedy recovery. I am, thankfully, well on course to achieving that goal.
It is a sobering thought that one day I felt on top of the world and was plotting how I could improve my times for the Parkrun and may be set a personal best and yet less than 24 hours later I would be undergoing lifesaving surgery. The old adage that you never know what’s around the corner is so true. This makes me appreciate the here and now even more and to try to live every day to the full.
I have reflected on lots during my week in hospital – lying in a bed, hooked up to an intravenous line and not being able to eat for 3-4 days, feeling pretty immobile due to various tubes coming out of me and utterly wiped out by having to have an emergency operation – does give you the enforced opportunity to simply contemplate life.
Here are some of those thoughts – firstly when it comes to VFM (Value For Money) for interventions on the NHS, life-saving surgery is right up there at the top of the list. The decision-making process is quite straightforward. If you don’t have the operation you die, if you do you’re back to normal in a couple of months or so.
When it comes to funding the NHS these essential interventions are top of our list of priorities.
We use a tool called NNT (numbers needed to treat) to gauge how we should spend our scant resources in the NHS. NNT is the number of people needed to be treated for one person to benefit from that treatment. Now I imagine most people reading this are shaking their heads in disbelief – because why would anyone want an intervention that didn’t have a value of one?
Alas, medicine is complex. An emergency operation for a strangulated hernia which has the potential to burst has an NNT of just a little above one. The reason why it is not quite perfect is that not everybody would survive the operation, in this case there are complications during surgery such as anaesthetic risks and bleeding and infection which means that, may be, one in a thousand don’t do so well (ie die) – these risks are known as NNH (numbers needed to harm) in this case I’m guessing that the NNH would be 1000 (for death) but if you added in all the other complications such a chronic infection and long-term pain that number comes down to 10 – in view of the fact that you’re still alive, these are simply acceptable risks.
However there are other interventions where the NNT seem to be ridiculously high but in actual fact, because the NNH is even lower the treatment is still worthwhile. For example taking a paracetamol has a NNT of 4 – so only 1 in 4 people taking paracetamol actually benefit, the strange thing is that almost everyone who takes paracetamol actually feels in less pain. The reason is that NNT use a comparison of taking paracetamol against taking a placebo and placebos are actually very effective painkillers (especially if they’re coloured red!).
The government is keen that people who have a 10% risk of a heart attack (most men over 60 and women over 65) should be taking statins. If you take statins for 10 years instead on 10 people out of 100 suffering a heart attack or stroke (ie 10% risk) only 8 people will. In other words, you have to treat 100 people for 10 years for 2 people to benefit or put another way 500 people for 1 year – ie a NNT of 500.
Now, this may seem like economic madness how can it possibly be financially prudent to treat all those people just for one person to benefit. The answer lies in the fact that statins are cheap, they roughly cost 3p a day, so to treat 500 people for a year costs £5,475 – ie. it costs £5,475 to prevent one heart attack or stroke.
The health industry measures the cost of health interventions in QALYs (Quality Adjusted Life Years). It considers that a QALY of £20,000 per year (ie it spend £20,000 to extend one person life for a year and that year is of good quality) or less is cost-effective, a QALY of over £30,000 per year is probably not.
To consider our patient on his statins the average person whose life has been saved by taking a statin has, say, another 15 years extra life so the QALY cost for each year is £365. From a health economist’s point of view even though we need to treat 500 people for a year for one person to benefit it is actually fantastically cost-effective. Indeed it is possibly more cost effective than my own recent operation!!
Now I hear all those Daily Mail readers shouting out ‘what about the NNH for statins’, which they know in a NNH of 1. Alas, as usual, the Daily Mail follows pseudoscience and not a rigorous scientific method. To find out the true NNH you have to compare it against a placebo and the real answer is about 200. In other words, 1 in 200 will suffer true side effects and should stop their statins. Only 1 in 30,000 suffer severe side effects causing a risk to health.
The bottom line is that the boffins are absolutely right when they say that lots more of us should be taking statins.
Not a good patient
Back to my imposed thoughts of being a patient. Try as hard as I could I was not a good patient. I was an impatient inpatient. Rest is not a word I really understand. Lying in bed feeling utterly exhausted and sleeping 14 hours a day, feels like such a waste. I say sleep but it isn’t – you have prolonged periods of simply lying as still as possible, trying not to move (for fear of tearing something) and trying to sleep. But the constant blood pressures and observations along with injections and so on, means that sleep is nigh on impossible.
But whilst you’re lying awake trying to get some shut-eye, you’re also thinking ‘ok the best way for me to get better quickly is to sleep, turn off my conscious brain and let my subconscious do its stuff and get me out of here ASAP’. I was lucky in that I was in a side ward and could shut out the external world, but most patients were in bays of 6 patients and inevitably there would be constant distractions with alarms going off and so on.
The bottom line is that even though the staff were wonderful and treated me very professionally and with great dignity and respect, a hospital is a stressful and difficult environment in which to recover.
The sooner I was discharged the better. I think my impatience is now serving me well on my journey to recovering speedily. It is interesting that those patients who recover best are usually the bloody-minded ones who ignore doctor’s advice and just crack on with living. I’ve also found that having a positive attitude about pain is really useful – I see pain (in the context of recovering from an operation) as a positive sign that my body is busily going about repairing itself. If I’ve had a day which has been relatively pain-free then I need to push myself a little harder the next day. I’m sure most runners would understand the strategy – you get fitter by causing microscopic damage to your muscles – muscle aches are often a sign of increasing fitness.
Improve patient care
I also had lots of thoughts about how the ward could be changed to improve patient care. I think there is a lot to be learned from asking patients their views but it is interesting that when I left I was asked to complete a questionnaire and I could only offer my sincere thanks and praise for a group of people who had saved my life. The thought of offering any suggestions about how the ward could possibly improve their care almost felt like a betrayal to the staff. It doesn’t take a significant shift to realise that when we ask for feedback many patients will be reluctant to be brutally honest for fear of upsetting a team that you know is doing their very best to help you under very difficult circumstances.
I think you actually have to sit down with someone and discuss your experiences to get real meaningful feedback.
The attitude of staff when you are feeling very vulnerable and weak has the greatest impact on how you feel. I’ve known and practiced this for years, a confident reassuring manner makes a massive difference. From a patient perspective knowing that the team around you exude confidence dispels any doubts and helps you get better quicker.
Finally a little word of caution about the 111 service. I know this has a place in the NHS and it is here to stay but unfortunately, my few interactions with them have not been positive. These range from me ranting down the line about their heavy-handed approach to safeguarding issues – such as reporting a nursing home to the CQC for omitting a dose of medication accidentally, to my phoning up for an ambulance when out walking the dogs and bumping into an ex-patient having a heart attack in the street.
That conversation went something like this;
‘Hello sir which service would you like?’
‘What is the problem’
‘I’m Dr Cowley a local GP and Mr X is having a heart attack, he is presently conscious but in significant pain is cold and sweaty and his pain is not eased by his GTN spray. We are at xxx. Please send an ambulance now.’
‘Ok, who are you?’
‘I thought I just told you – please send the ambulance’
‘OK what’s wrong with the patient – is he bleeding?
There followed a series of questions to which the answers were;
‘What? I don’t think you’re listening. I’ve already told you …’
After 5 minutes the operator finally agreed to send an ambulance!
Alas my latest encounter was little better;
‘How can we help?’
‘Hello I’m Dr Cowley a local GP, I got a painful swelling in my groin and I’m pretty sure its an incarcerated hernia and I’m going to need an operation.’
There followed a series of questions about who I am and where I live – fair enough.
‘Now have you got any chest pain?’
I thought, ok been here before, just go with the flow;
‘Are you bleeding?’
‘Are you short of breath?’
And so on for another dozen questions until;
‘Do you have a swelling in your groin?’
‘Bingo… oops sorry yes’
‘Is it painful?’
‘House….oops sorry yes’
And then there followed another dozen questions all with negative answers and I was thinking ok they’re either going to tell me to go to the Out of Hours centre (at the Royal Bournemouth Hospital) or they’ll try and send an ambulance. I was mentally working out how I could avoid the embarrassment of blue lights at 6am when the operator said;
‘Ok you should contact your GP when they open and ask for an appointment today.’
I was about to give the 111 service both barrels when I thought what’s the point;
‘Ok’ … and I took myself off to A&E instead.
No doubt I will be another statistic of someone who abused the health service by going to A&E rather than waiting to see my GP.