I’ve written a couple of articles in the last couple of months on the general theme of the abject state of science/health journalism in the mainstream press - see Why is the Indy Shilling for Big Pharma? and Dumbing Down Dementia- the second of which includes this observation:

“…if one wishes to find good quality source material for a good debunking, then I can heartily recommend that you open any newspaper and scour the news sections for the words ‘health correspondent’.”

Today’s proof of that statement comes from the Guardian, and specifically from the current health correspondent, Polly Curtis, who, so far as one can tell from information in the public domain, appears to possess solid credentials as a generic journalist - runner-up in the feature writer of the year category in the 2000 Guardian Student Media Awards, followed by a steady progression through the ranks at the Guardian from ‘contributor’ and journalist to, first, education correspondent and, now, health correspondent, but exhibits precious little to suggest that she is adequately qualified to correctly evaluate and report accurately on the content of specialist research/journal papers in anything other than a superficial manner.

Now I may, conceivably, be being a little harsh in my evaluation of young Polly’s apparent background where, in truth, she is actually packing a raft of GCSEs, A Levels and a degree in the natural and/or social sciences, some of all of which are relevant to the subject at hand (health) but when set against a benchmark of what science/health journalism looks like when written by a real scientist, of the likes of Ben Goldacre, then it would be fair to say that on the evidence of her efforts today, I have my doubts…

Cannabis use linked to 40% rise in risk of schizophrenia

You knew that was coming, didn’t you? Even if you didn’t see this being trailed on Breakfast TV this morning, you just knew that with cannabis/mental health scare stories being the current flavour of the month, there was going to be a very good chance that this would be the subject of Polly’s article.

Smoking cannabis increases the risk of schizophrenia by at least 40% according to research which indicates that there are at least 800 people suffering serious psychosis in the UK after smoking the drug.

Increases the risk of schizophrenia by 40% from what?

What is the risk of developing schizophrenia if you don’t smoke cannabis, and does that risk apply evenly across the whole population or is contingent on other causal or contributory factors that modify the level of base risk according to individual circumstances? Is this 40% figure a measure of the increase in annual risk or lifetime risk?

Without any of that additional information, the assertion that smoking cannabis increases the risk of developing schizophrenia by 40% is entirely meaningless, even if the quoted figure is true. You simply cannot make an informed evaluation of personal risk from such a statement unless you can assess the percentage increase in risk against a known baseline figure.

Mental health groups called on the government last night to issue fresh health warnings and launch an education campaign to advise teenagers that even light consumption of the drug could trigger long-term mental health problems.

Without wishing to sound cynical - well they would, wouldn’t they?

The fact of the matter is that however one views the motives the of the voluntary sector in general, such an education campaign amounts to, at the very least, as sizeable raft of free publicity for these groups to piggyback on - and that’s if the government decides to develop and operate such a campaign in-house. If, on the other hand, its decides to commission in resource materials or outsource delivery then there’s also the prospect of a few nice fat government grants as well.

The findings came after a rush of ministers declared their cannabis-smoking pasts and an order from the prime minister for officials to consider whether the drug should be reclassified amid fears about its more potent “skunk” form. Last night the Home Office said the research would be considered in that review.

And? I suppose that’s a useful bit of filler that describes the political context behind the current moral panic about cannabis use, but it still tells us nothing of real substance.

The study, an analysis published in the Lancet medical journal of previous research into the effects of the drug on tens of thousands of people, provides the most persuasive evidence to date that smoking cannabis can cause mental illness years after people have stopped using it.

Does it?

Let’s see what the Lancet actually has to say, at least in summary (to get the full article requires a subscription or payment of a day rate of $30).

Background

Whether cannabis can cause psychotic or affective symptoms that persist beyond transient intoxication is unclear. We systematically reviewed the evidence pertaining to cannabis use and occurrence of psychotic or affective mental health outcomes.

Fair enough.

The starting point for this research is ‘we’re not sure if there is evidence to support a causal link between cannabis and long-term mental health problems, so lets review the current evidence that’s available’.

It’s a meta-analysis study, which a perfectly valid research technique but one not without its potential problems and pitfalls, which is something I, unfortunately, cannot explore in detail without access to the full article, so for the purposes of this article we’ll take it as read that the study has been competently conducted and provides a valid set of outcomes and conclusions.

Methods

We searched Medline, Embase, CINAHL, PsycINFO, ISI Web of Knowledge, ISI Proceedings, ZETOC, BIOSIS, LILACS, and MEDCARIB from their inception to September, 2006, searched reference lists of studies selected for inclusion, and contacted experts. Studies were included if longitudinal and population based. 35 studies from 4804 references were included. Data extraction and quality assessment were done independently and in duplicate.

Okay, that’s also very useful is as much as it tells use two very important things.

First, given the scope of the publication databases listed as having been searched for suitable studies, it seems highly likely that the data used in the study in not UK specific. Nothing wrong with that, but it does mean that we may find some statistical discrepancies when comparing the output data in this study with actual data from the UK.

Second, this is research is based on data drawn only from longitudinal population studies. Again, there is nothing wrong with that, but what it does tell us is that it’s highly unlikely that the research will be able to provide anything more substantial than indications of any observed correlations between cannabis use and mental health problems - which means that any claims of causation deriving from or attributed to this research need to be regarded sceptically.

Findings

There was an increased risk of any psychotic outcome in individuals who had ever used cannabis (pooled adjusted odds ratio=1·41, 95% CI 1·20–1·65). Findings were consistent with a dose-response effect, with greater risk in people who used cannabis most frequently (2·09, 1·54–2·84). Results of analyses restricted to studies of more clinically relevant psychotic disorders were similar. Depression, suicidal thoughts, and anxiety outcomes were examined separately. Findings for these outcomes were less consistent, and fewer attempts were made to address non-causal explanations, than for psychosis. A substantial confounding effect was present for both psychotic and affective outcomes.

Now that is very interesting, because what the study is reporting - if we assume that baseline for no increased risk is a pool adjusted odd ratio of 1 - is that the 40% increase in risk cited by Curtis applies to ‘any psychotic outcome’ and not just schizophrenia.

There are actually a wide of conditions, diseases and even situations that can give rise to psychotic episodes and outcomes, ranging from the psychological (schizophrenia, bi-polar disorders, severe clinical depression and/or stress) to the organic (brain tumours, multiple sclerosis, Alzheimer’s disease and other dementias, syphilis - in rare cases even influenza and mumps can induce psychotic episodes) to the broadly self-inflicted, which includes cannabis but also covers a wide range of other drugs that can, and do, have psychoactive effects ranging from dear old alcohol through a range of prescription drugs (barbiturates, benzodiazepines, some anti-depressants and anti-epileptics) to the classic range of ’street drugs’ which encompassed pretty much anything that’s cocaine or amphetamine-based plus all the usual hallucinogenics.

It also cites a doubling of the risk of psychosis (a 100% increase) in data relating to long-term use of cannabis and indicates some of the potential shortcomings of the research that the study reviewed. There’s both consistency in outcomes and in efforts to eliminate external factors in studies looks specifically at the incidence of psychosis, much less consistency and effort to account for external factors is studies focussing on depression/anxiety and a substantial confounding effect across all studies that needs to allowed for, statistically, before reaching any valid conclusions.

On the whole, that looks pretty good as research methodologies go, certainly good enough to suggest that this is, indeed, a competent and exacting piece of research and give the study’s conclusions some serious consideration.

Interpretation

The evidence is consistent with the view that cannabis increases risk of psychotic outcomes independently of confounding and transient intoxication effects, although evidence for affective outcomes is less strong. The uncertainty about whether cannabis causes psychosis is unlikely to be resolved by further longitudinal studies such as those reviewed here. However, we conclude that there is now sufficient evidence to warn young people that using cannabis could increase their risk of developing a psychotic illness later in life.

So, what the study actually concludes is that there is sufficient statistical evidence to take the issue of risk seriously although not enough to prove a clear causative relationship or accurately define the parameters of that relationship. Indeed the study goes on to indicate that, so far as statistical population studies go, we’ve pretty much hit the wall in terms of what they can actually tell us about the possible relationship between cannabis and mental health, which means that any further answers are going to have to come from those strands of research currently examining this relationship in terms of genetics and biochemistry.

In short, it doesn’t really tell us anything new and it certainly doesn’t establish a clear causal relationship between cannabis use and long term mental health problems, but it does suggest that there’s enough statistical evidence of risk to justify warning young people of the existence of such risks.

All very reasonable and nothing that’s really the stuff of scare stories and moral panics if understood (and presented) properly.

Getting back to Curtis’ article, the good news is that she’s at least taken the time and trouble to actually include some of the research outcomes in a form that can be evaluated.

The overall additional risk to cannabis smokers is small, but measurable. One in 100 of the general population have a chance of developing severe schizophrenia; that rises to 1.4 in 100 for people who have smoked cannabis.

The bad news is that she’s made a complete hash of presenting this information.

Notice the shift in tone - ‘the overall additional risk is small, but measurable’ - which is certainly true, but not what was implied at the start of the article when she was banging on about a 40% increased risk.

She also claims that this increased risk relates specifically to the possibility of developing ’severe schizophrenia’, which is certainly not what the summary given by the Lancet suggests - remember that refers to the increase risk of ‘any psychotic outcome’, not just schizophrenia and certainly not just ’severe schizophrenia’ - unless there is such a specific reference in the full article then it looks very much as if Curtis is over-egging the pudding and misrepresenting the conclusions of the study in terms that suggest that the qualitative elements of risk (i.e. the severity of the condition linked to cannabis use) are significant greater than those indicated by the actual study.

But the risk of developing other psychotic symptoms among people who smoke large quantities or are already prone to mental illness is significant, the researchers say.

People who smoke cannabis daily have a 200% increased risk of psychosis.

Well, yes, the study does indicate an increased risk with regular use and higher dosage, but that risk is a little over double the baseline risk (actually 109% greater) not the 200% that Curtis cites - a basic mathematical error, one would presume, but one that still gives a distorted picture of the actual outcomes of the research.

Moreover, while we’re talking about baseline risks, the 1 in 100 figure cited is the generally quoted figure for schizophrenia in the general population of the US, the actual figure given by the National Statistical Office for the UK is around 1 in 200 for all psychotic disorders, not just schizophrenia. In terms of assessing risk, this is actually rather important as what it does suggest is that even allowing for the degree of increased risk noted in the research study, the actual risk of a regular cannabis user developing a psychotic disorder in UK is only about the same as base risk of schizophrenia in the US.

In fact, if one narrows the scope down just to schizophrenia, then the generally cited rate of prevalence in the UK is only 3 cases per 1000 population with an annual incidence rate of between 0.1 and 0.2 cases per thousand, which makes accounting for the differences between US and UK rates even more important.

What this may well indicate, more than anything else, is marked differences in diagnostic practices between the UK and US that need to be considered and factored into our calculations, and which certainly needs to be accounted or allowed for in assessing the value of this research in terms of public policy.

They estimate that 14% of 15- to 34-year-olds currently suffering schizophrenia are ill because they smoked cannabis, a figure previously thought to be between 8% and 10%.

Because?

How the hell do you get ‘because’ from a study that concludes:-

The uncertainty about whether cannabis causes psychosis is unlikely to be resolved by further longitudinal studies such as those reviewed here.

The answer is, ‘you don’t', because, as yet, there is no definitive proof of causation and the most promising line of inquiry at the present time suggests that the risks of developing psychosis as a consequence of cannabis use are likely to be confined to a segment of population that has a genetic predisposition towards mental health problems to begin with.

Where, exactly have those figures come from?

According to the current diagnosis rates about 800 people would have been spared schizophrenia if they had not smoked cannabis.

Ah, now I see - they come from mixing and matching incidence rates (i.e. numbers diagnosed each year) with estimates of risk derived from prevalence rates.

Having done a bit of scouting around to see if I could find any reported studies where a comparison of outcomes between them and this new study might give the figures cited by Curtis, arriving eventually at this report, which appears to fit the bill.

If cannabis causes schizophrenia - and that remains in question - then by 2010 up to 25 per cent of new cases of schizophrenia in the UK may be due to cannabis, according to a new study by Dr Matthew Hickman of the University of Bristol and colleagues, published in Addiction journal.

Note, once again, the big ‘if’.

Not only that, but if we look at this study’s reported methodology, we find:

The research study matches historic trends in cannabis use and exposure from a national population survey against estimates of new occurrences of schizophrenia in three English cities (Nottingham, Bristol and the London Borough of Southwark). The researchers assess what might happen to schizophrenia cases if we assume a causal link between cannabis use and onset of psychotic symptoms, an association widely recognised by some psychiatrists and researchers and considered recently by the Advisory Council on the Misuse of Drugs.

Now there is a potential problem with that methodology and that is:-

Ethnic minority groups are at increased risk for all psychotic illnesses but African-Caribbeans and Black Africans appear to be at especially high risk for both schizophrenia and mania. These findings suggest that (a) either additional risk factors are operating in African-Caribbeans and Black Africans or that these factors are particularly prevalent in these groups, and that (b) such factors increase risk for schizophrenia and mania in these groups. (source)

In terms of demographics, the Black population of Southwark amounts to 25.9% of the total population of the borough; for Nottingham its 4.34% and for Bristol its 2.32%.

For the UK as a whole, the Black population amounts to 1% of the total population, so the Bristol study is taking its data from areas in which a ethnic minority population that is known to be at increased risk of developing psychotic disorders is over-represented in comparison to the national population by anything from 2 to 25 times.

Not to mention that the study, itself, works from a premise that assumes that a causal relationship between long-term mental health problems and cannabis use will be established.

And is all that were not enough…

The researchers said the evidence was the strongest yet to show that cannabis caused psychotic mental illnesses, and not just that people who were ill smoked more. Dr Stanley Zammit, of Cardiff University, said: “We think the evidence is such that we need a new official warning about the risk.”

At the risk of repetition, the summary in the Lancet explicitly states:

The uncertainty about whether cannabis causes psychosis is unlikely to be resolved by further longitudinal studies such as those reviewed here.

And you’ll notice that the apparent claim of causality attributed to the researchers is not an actual quotation, in fact the only direct quotation given calls for the a warning about the apparent risks, which is supported by the conclusions of the research study but only the context of statistical correlations and not proof of causation.

Paul Corry, director of public affairs at the mental health charity Rethink, echoed calls for more warnings but said it was not evidence in itself that cannabis should be reclassified. “Rather than focusing its attention on the reclassification debate, the government would do well to crack on with the more important job of informing the public about the health implications,” he said.

Well yes, quite…

But then before doing that, should we not be just a little more exacting in how those are expressed, in terms of giving an accurate assessment of the evidence of risk provided by these studies and by not claiming causation when there is still no definitive evidence to support such claims?

There is rather more to this than just a blogger venting off a bit of steam about yet another piece of shoddy health journalism. In matters of public health education, particularly with young people and especially if what one is trying to achieve amounts to behaviour modification, there is nothing more important than trust - and there is nothing more certain to undermine trust than the misreporting and misrepresentation of evidence.

If you want young people to take on board the evidence of possible risks arising from the use of cannabis you have to be upfront in giving them accurate information, because no soon as you are caught cheating and overplaying your hand then that’s it, you’ve blown it and they won’t listen to you.

Moral panics might be good for selling newspapers, but they’re a lousy way of going about public health education.

UPDATE

Having worked your way through all that, this is the Daily Mail’s take on the story…

A single joint of cannabis raises the risk of schizophrenia by more than 40 per cent, a disturbing study warns.

The Government-commissioned report has also found that taking the drug regularly more than doubles the risk of serious mental illness.

Overall, cannabis could be to blame for one in seven cases of schizophrenia and other life-shattering mental illness, the Lancet reports.

The grim statistics - the latest to link teenage cannabis use with mental illness in later life - come only days after Gordon Brown ordered a review of the decision to downgrade cannabis to class C, the least serious category.

I suppose the only saving grace is that neither of the journalists bylined on the story - Fiona Macrae and Emily Andrews - appears to be billed a ‘health correspondent’, although its questionable as to whether they should even be billed as journalists.

One of the more enjoyable (and sometimes inflammatory) habits adopted by the excellent Dr Crippen is his posting of what he calls ‘Quacktitioner Alerts‘, which, in common with Ben Goldacre’s ‘Bad Science‘ provide a valuable public service by highlighting all manner of crap science, piss-poor practice, misinformation and general snake-oilery.

I’m happy to say that I’m very much a fan when it comes to a good debunking, whether its Crippen’s quacktitioners, Goldacre’s bad science, Penn and Teller’s glorious ‘Bullshit‘ or the daddy of the all, and the man who should be regarded as the intellectual father of fisking, James Randi.  And if one wishes to find good quality source material for a good debunking, then I can heartily recommend that you open any newspaper and scour the news sections for the words ‘health correspondent’.

Which bring me to this patronising effort from today’s Indy:

Obese people twice as likely to get Alzheimer’s

By Jeremy Laurance, Health Editor- Published: 29 June 2007

Britain’s obesity explosion could trigger a second even more serious epidemic - of dementia. Experts warned yesterday that our fondness for fast food and resistance to exercise was not only causing waistlines to bulge - it is also damaging our brains.

Obesity is bad for you. This is well established.
It increases your risk on winding up with all manner of nasty shit, like cardiovascular disease, diabetes, sleep apnea, gallstones, hernias, fatty liver disease, renal failure, osteoarthritis, stokes, that most people would much rather not have to deal with.

But clearly none of shit is scary enough to stop people pigging out at Maccy D’s, so now the ‘experts’ are wanting to tack going doolally-tap on to the list to make the whole business ever scarier.

An estimated 700,000 people have dementia in the UK and the number is forecast to rise to as many as 1.5 million over the next 50 years, according to the Alzheimer’s Society.

Yes, very nice. But how does that relate to population demographics?

Look, this is not difficult. If 700,000 people have dementia in the UK now, on its present population, and - hypothetically - the population of the UK doubles in the next 50 years, then we are likely to see double the number of dementia cases, but the risk of being one of them will have remained the same.

Let’s make that a bit easier to understand. If two out of every five cats are black, and you own five cats, you likely end up with two black cats, and if you then buy five more, you’ll get another two black cats, giving you four black cats, which is twice the number you started with - but, you’ll also have ten cats (and a serious cat food bill), which is also twice the number you started with.

That’s the basics, let’s look at the numbers.

Well, the main incidence of dementia, which means not just Alzheimer’s but other forms, tends to be in over 60s, so let’s stick just that population to begin with (to get a general picture of thing), which is currently estimated at just over 12 million people. Track on fifty years, using the National Statistical Office’s population pyramid doodad, and the estimate for the age group is 17.7 million, so it looks as if population change isn’t going to account for the full projected increase.

But, hang on - we can actually be a bit more specific than just ‘over sixties’.

The primary risk factor for the most common form of dementia - late onset Alzheimer’s -is aging. At age 65, 2-3% of people show signs of Alzheimer’s, with the probability doubling every 5 years. As for the second most common form, vascular dementia, there are a number of contributory factors that come into play, but aging is certainly one of them, so its reasonable to take another look at the figures but using a higher age group, where the risk factors and incident are greater - Say the over 70’s

That gives us 5.8 million currently, and an estimate of 9.5 million by 2057. Still not the full doubling effect but the extent to which an increased incidence of dementia in 50 years time may stem purely from population demographics is creeping up as the primary risk factor - age, increases.

Let’s take it up again - to over 80. This give a current population of 1.45 million and a projected 2057 population of 2.62 million, and the gap narrows again, leaving only 10% or so of the doubling effect unaccounted for by ageing and population change - and that’s about as far as we can take as the population doodad tops out at 84 years of age.

The point in all this is that if you want people to make informed decisions about their health, then you have to explain things to them properly, not just lob a couple of big scary numbers at them and hope their shit themselves at the thought that they might one day end up as a statistic. As Stalin correctly noted; ‘one death is a tragedy, one million deaths is a statistic’ - people don’t engage with big scary numbers at a personal level. They can’t form a mental picture of wat 1.5 million people drooling insensately in their hospital beds looks like, let alone picture themselves as being one of them. To get you message across, you have to stop patronising people and explain the risks properly, so they get the message at a personal level and can imagine themselves having that kind of future ahead of them.

As this stand, just on the base stats, population changes look unlikely to account for all the increase in numbers over 50 years, so it does look very much as if other factor are also upping the probability of dementia.

But if the population goes on getting fatter, the total could rise to 2.5 million, said Clive Ballard, director of research at the society. “Obesity is a huge risk factor,” he said. “People who are overweight at 60 are twice as likely to get dementia at 75. We have a public health epidemic of dementia given the ageing of the population, and it is essential to reduce the risks. If these factors are not controlled, it may not be 1.5 million but 2 or 2.5 million people affected.”

Currently one in 20 people aged over 65 has signs of dementia, rising to one in five over 80. Increasing obesity could double the incidence among over-65s to one in 10, said Mr Ballard.

Again, Ballard is lobbing yet more big number into the pot without giving any explanation as to why obesity is such a big deal and unless people understand the causal links between obesity and dementia, the message isn’t really going to sink in.

The mechanism of how obesity affects the brain was unclear but it encompassed diet, exercise and physiological effects. Research has shown that people who eat a diet rich in fruit and vegetables have an up to 40 per cent reduced risk of developing dementia. Exercise has a similar effect.

Studies also suggested that amyloid protein which can build up in the brain, causing damage to nerve cells, is cleared from the blood more efficiently when cholesterol levels are low. High cholesterol could increase build-up of the protein and hasten the onset of Alzheimer’s. Neil Hunt, chief executive of the Alzheimer’s Society, said: “I remain genuinely mystified why this is still such a low priority. The cost of dementia to individuals, families and the state is £17bn a year. Now there is research suggesting dementia is not as inevitable as we thought. There is no cure but evidence is building that lifestyle choices make a difference to risk.”

Let’s stop there.

Having started out by lobbing numbers at people without explanation, we’ve now gone to the opposite extreme of trying to freak people out with indecipherable gobbledygook.

This section starts out by admitting that they don’t know exactly what the link is between obesity and the brain, drifts of into the usual ‘research has shown…’ stuff which tells us that they think that exercise and eating fruit and veg is good for us - no shit, Sherlock - and then heads off into medical country with all the talk of amyloid proteins, which are ’suggested’ could be building up in the brain and causing nerve damage.

In science, if something is ’suggested’ then that could mean anything from ‘we’ve got some promising initial data but not enough to be sure’ to ‘we’ve got a hunch it might be this and would like some cash and a good stock of monkeys to dissect, please’.

We’re still, even at this stage and despite the headline, not entirely sure whether what this all about is dementia in general, of which there are several kinds with different causal factors, or specifically about Alzheimer’s - which is what it looks like from the comments at the end of waffle about cholesterol and amyloid proteins - largely because throughout the article has used ‘dementia’ and ‘Alzehimer’s’ as interchangeable references rather be clear and precise about what they’re referring to.

We’re also told that the Chief Executive of the Alzheimer’s Society is ‘mystified’ as to why it is ’such a low priority’ when ‘dementia’ (type unspecified) costs individuals, families and the state £17 billion a year - that last statement is perhaps best understood if you adopt an Irish accent and a grizzled and slightly aggressive tone of voice and then repeat after me: Give us your fucking money!!!

Call me a tad pedantic, but I can’t help wondering if at least part of the explanation for the ‘low priority’ thing might have something to do with the observation that rather a lot of those trying  to ‘educate’ the public about the risks and consequences of dementia appear incapable of expressing themselves in clear and simple terms that everyone can fucking well understand.

Launching a booklet, Be Headstrong, he said that five steps were necessary to reduce the risks - do not smoke, eat less saturated fat, exercise regularly, lead an active social life and have blood pressure and cholesterol checked regularly. “If we could delay the incidence of dementia by five years we could reduce its incidence by 50 per cent,” he said.

That last statement; “If we could delay the incidence of dementia by five years we could reduce its incidence by 50 per cent” is a staggering piece of logic.

You cannot ‘delay the incidence of dementia’ because incidence is a measurement of quantity and proportion, not time. The incidence of a condition is the number of people with the condition divided by the size of the total population and usually expressed in terms there being n cases per 1,000 to make comparisons between different populations easier.

You can delay the onset, the point in time at which the condition begins to develop, which will push back the increasing probability of developing dementia to a later stage in life, but that, in itself, will not alter the incidence of the condition.

What will alter the incidence of a condition or disease is:

a) prevention, say by vaccination (which is inapplicable in this case),

b) effective treatment of, or cures for diseases/conditions that may cause dementia as a secondary effect, such as syphilis, tumours, hyperthyroidism and vitamin B1, B12 and A deficiencies (which is where some element of the eating fruit and veg comes into play) . These account for only about 5% of all dementias, or

c) a reduction in risk factors/behaviours that does result in a lower incidence because limiting exposure to risk results in fewer people developing the condition. This is particularly applicable to vascular dementias arising as a consequence of cerebrovascular disease resulting in neurological damage by way of strokes, ischemia, aneurysms and embolisms.

If we’re talking about dementia in general, then any of the above could reduce the incidence of the condition overall, but only to a limited extent as time (and ageing) is a also a factor in dementia due to vascular degeneration.

If Hunt is referring specifically to Alzheimer’s, for which the three main causal hypotheses, at the present time, all rely on biochemistry and genetics,  then delaying onset will have no impact on incidence other than in terms of it being linked directly to ageing. In other words, if delaying the onset of Alzheimer’s by five years ‘reduces’ the incidence of the condition by 50% that can only because the 50% who don’t develop the condition have died as a result of other conditions and diseases before Alzheimer’s has had chance to set in.

Its like comparing statistics for cancers and heart disease between now and the 1840’s - the incidence of both will be much lower in the 1840s, not because Victorian England was a healthier place to live but because life expectancy has increased massively since then as public health initiatives and developments in medicine and healthcare have taken out of play most of the nasty shit that used to kill people long before stuff like cancer and heart disease had a chance to kick in.

Great message, eh? If you don’t fancy ending your days covered in dribble and with a vivid memory of the 1979 cup final and next to fuck all else besides then the secret is to die of something else before it all kicks in.

Professor Jeremy Pearson, associate medical director of the British Heart Foundation, said risk factors for heart disease were also risk factors for dementia. “We now know that protecting the heart will also protect the brain,” he said. “Treatments that reduce heart disease also reduce dementia. There are very similar pathological processes underlying both.”

Well, yes. But that information is nothing particularly new, novel or innovative - its not as if medics have only just figured out that fucking up your vascular system by living your life as a Maccy D chomping couch potato is bad for you, whether in the context of cardiovascular (heart) disease or cerebrovascular (brain) disease.

The only plus point to this article is that, for once, they’re not making a meal of blaming smoking for all the ills of old age, even though that’s just as good at fucking up your vascular system as a diet of burgers, Big Brother and deep-fried Mars bars. I guess that what this means is that they figure that lung cancer is plenty scary enough to cover the bases when it comes to scaring the shit out of smokers already, so there’s no need to try and dump Alzheimer’s on top, while when it comes to scaring the shit out of fat boy, heart attacks just don’t have the same kind of scare factor because if it nails you it tends to get the job over and done with pretty quickly and it it doesn’t you can always change things round afterward or get things fixed up with a bypass or transplant, which is why you need to rope in something that offers up the prospect of a long, lingering and fucking undignified exit to nail home the point.

It’s the fucking Freddie Kruger school of public health medicine - scare ‘em, scare ‘em good and keep right on scaring the dumb fuckers until they get the message. Never mind that you could just try treating people like fucking adults, explaining the facts, and lets us figure this shit out for ourselves.

Professor Pearson is not wrong is his remarks, merely stating the bleeding obvious - which I’ve no doubt he is perfectly aware of and could happily explain in much more illuminative fashion were his remarks not simply being used as filler by a ‘health correspondent’.

Similarly…

Tony Rudd, consultant stroke physician at Guy’s and St Thomas NHS Trust, said up to one-third of the over-65s who had a stroke would develop dementia within three months. “Public health initiatives to prevent stroke and related risks are essential,” he said.

Absolutely spot-on, as you would expect from a consultant stroke physician at a well known and high profile hospital, but again he’s talking specifically about vascular dementia arising as a direct consequence of a stroke, and the headline on the article states: “Obese people twice as likely to get Alzheimer’s”

Vascular dementia is NOT fucking Alzheimer’s Disease, and unless groups like the Alzheimer’s Society are operating from a broad remit which incorporates and supports research into all areas of dementia, then they and the meejah should steer clear of conflating their specific field of expertise with other fields simply to inflate the numbers and contrive a slightly bigger scare factor.

If anyone is seriously concerned by the obesity connection to dementia then they’re currently much better served by talking, and making the bulk of any donations to, the Stroke Associations that deal specifically with vascular dementia, which accounts for 20-40% of all dementias in Western Europe - because we know damn well how lifestyle impacts on that and what you can do to limit your risks.

As for Alzheimer’s, more research is certainly needed to narrow down its main causes and any causal links to obesity, so a bit of cash in that direction is certainly not wasted, and the general advice on eating the right things, not smoking (and I am a smoker, btw) and getting your lazy asses off the couch and doing a bit of exercise is sound, if much more likely to do you a power of good in terms of stuff like heart disease and the like, where the causal links are already well established and understood.

So its not a complete washout here, the article is just badly written and rather patronising in its attitude to readers, which may well be a function of the journalism applied to the story and not the sales pitch made by the Alzheimer’s Society, who otherwise do a considerable amount of good work and are deserving of public support.

And the best advice of all - if you need more information or are worried about your health then FFS, go make an appointment with your GP for a check-up and a chat. They can explain all this far better than the health correspondent in the newspaper and may well even treat you like an intelligent human being and not an idiot.

When my oldest child was born - 15 years ago… gulp! - my partner and I made a conscious decision that, I’m glad to say has born dividends and has, so I’m convinced, rewarded my son, and his younger sister, who came along later, with something very precious and yet also something that money can’t buy.

That something is good health, and the decision we took was simply that when he became ill, as children invariably do from time to time, we would look to the NHS for help only when it was absolutely necessary; that we wouldn’t be the kind of neurotic parents who go running to the GP to demand a cocktail of potions and lotions at the first sign of a sniffle.

That decision has given us our fair share of sleepless nights over the years, sitting at our kids’ bed-sides managing routine childhood ailments armed with nothing more than than love, over the counter medicines, a bowl/bucket with a quarter-inch of Dettol sloshing around in the bottom, and a wet flannel to keep the fever at bay, but its decision that in the long run has served our children well. My son, in particular, enjoys not just good health but rude health. If he’s unlucky he may succumb to the common cold once a year and the occasional stomach ‘bug’ and the very worst he’s had to put up thus far in his life has been the humble Chickenpox, which, in these days of near universal childhood vaccination, it pretty much the last of the traditional childhood illnesses that regularly does the rounds.

As for why we took that decision, that’s simple. We looked at the advice coming from the medical profession at the time and some of evidence and came to conclusion - the right conclusion in our view - that nothing the medical profession had to offer would serve our children quite so well as a good, healthy and active immune system and that the best, and only way, to achieve that was to let it do its job as much as possible without unnecessary intervention.

All of which brings me to today’s front-page article in the Independent, which, in keeping with its usual practice of eschewing mere news in favour of pamphleteering, has irritated the hell out of me:

Hay fever: the cure and the catch

A once-a-day pill for hay fever that could transform the lives of sufferers is being denied to thousands of those most severely affected because of the cost.

Okay, so this tells us two things. First, its another ‘miracle cure’ story and second that what follows is likely to be almost entirely made up of propaganda and contain the minimum possible news, and especially, scientific content.

The pill, which is dissolved under the tongue, is the first oral vaccine developed for hay fever.

Well, would you look at that. Not is it a ‘miracle cure’ but, heaven’s to Murgatroyd, its an easy miracle cure as well, a paragon of medical virtue insofar as it requires none of that icky and off-putting stuff involving needles, side-effects or surgery.

But the majority of NHS trusts have failed to fund it.

Note the propagandising language here. The ‘majority’ of NHS trusts have ‘failed‘ to fund the drug (the Telegraph are using ‘denied’ to much the same purpose and effect), which appears to tell us both that a large number of Trusts have already looked at the possibility of providing this new new drug and rejected the idea and that by doing so they’re implicitly letting us all down and denying us something that we should have by right.

That’s not, however, the position that emerges a fair bit later in the article:

Peter Anderson, the UK managing director of ALK-Abello, the Danish manufacurer of Grazax, said the “lion’s share” of NHS Trusts in the UK had yet to decide whether to fund the drug. “About 20-30 have reached a decision and about a dozen have agreed to fund it.”

So the majority of NHS Trusts haven’t actually made a decision one way or the other on whether they will make this drug available. After the last round of reorganisations, there are 152 Primary Care Trusts in England alone, so the number in the UK that have reached a decision is considerable less than 20% even allowing for Anderson’s rather vague exposition of current numbers, with anything from 40-60% (so far) deciding to put up the money.

By now, if you’re of a somewhat suspicious disposition (like me) you may be wondering quite where this story has come from, particularly as the construction of the story and the order in which quotations are introduced appears to imply that it may have come from the charity Allergy UK, who are first in line to put their views over - except that it would appear from the charity’s website that they haven’t issued a press release since the end of May, which rather rules them out of the running.

Another possibility is, of course, the conference cited in the article, at which a paper on this new drug was presented only yesterday:

Stephen Durham, a professor of respiratory medicine at Imperial College London and the Royal Brompton Hospital, London, who led the study presented at the 26th European Academy of Allergology and Clinical Immunology Congress (EAACI) in Sweden yesterday, said: “Reducing symptoms and improvement in quality of life are the number one priorities for hayfever sufferers …

Again, however, there is nothing by way of a news item or press release on either the conference website, or that of the EAACI for that matter, that relates directly to this story… and you may have already guessed where this is going next.

ALK-Abello, the pharmaceutical company that has developed this new ‘wonder drug’ and which, incidentally, is one of corporate sponsors of the EAACI conference, appears to be the only source of press information, in the form of two press releases published on its website, yesterday; one trailing its clinical efficacy (which includes a quote from Stephen Durham) and a second which focusses exclusively on claims about its cost-effectiveness:

GRAZAX® significantly reduces the use of symptomatic medication compared to placebo GRAZAX® significantly reduces the time lost from work compared to treating with symptomatic medication alone GRAZAX® significantly increase the number of QALYs compared to treating with symptomatic medication alone

Quality Adjusted Life Years (QALY) takes into account both direct costs (e.g. medication and physician visits) and indirect costs (productivity losses such as time away from work) caused by a condition e.g. allergy. One QALY is equal to one year of perfect health for a patient. The lower the cost per QALY gained, the more cost-effective the medical intervention.

Quality Adjusted Life Years, on their own, measure only the apparent clinical benefit of a particular treatment in terms of the number of years of ‘perfect health’ added to the lives of individuals by the intervention in question and make no assessment whatsoever of the economic benefits of such interventions; those are assessed by means of Cost-utility analysis, which are general expressed in terms of Quality Adjusted Life Years when making health technology assessments (i.e. evaluating new drugs, surgical procedures, etc.).

How this works through in health policy is by way of calculating the incremental cost effectiveness ratio, which is a measurement of change in costs change in costs of a therapeutic intervention (compared to the alternative, such as doing nothing or using the best available alternative treatment) to the change in effects of the intervention and not actually incremental at all, at least not in terms of the standard economic meaning of the word. What happens next is that the ICER for the treatment is compared to a monetary threshold set by policy makers (believed to be £30,000 per additional QALY in the UK) with those treatments that exceed the threshold likely to be rejected on cost grounds.

The problem with all this is that, first, the value and utility of QALYs is open to question and dispute. All of the methods of calculating the weighting in QALYs are to a considerable degree subjective and contingent on the population being surveyed - those who do not suffer from a specific condition, in particular, show a clear tendency to over-estimate its likely detrimental effect on quality of life compare to those who have the condition and such measures have also been heavily criticised for placing a disproportionate emphasis on physical pain and disability over mental health and for failing to take account of social factors, particularly the impact on the quality of life of others, i.e. carers, family members, etc.

Second, one cannot read up on any of this without coming away with the impression that it all seems designed to avoid putting over the ‘bottom line’ in clear financial terms. There’s no great problem in identifying the unit and per patient costs of particular interventions - drug companies want to get paid, naturally - which in this case amounts to £67.50 per month (or £810 per year, if you prefer to think in terms of annual costs) but to a layman the whole system of QALYs, CUAs and ICER’s is, at best impenetrable, and looks for all the world to be nothing more than a prime example of PNOYA economics - that’s ‘Pulling Numbers Out Your Arse’, by the way.

The other problem that seems apparent in all this, writing as a layman, is that it appears, in traditionally reductionist fashion, to be making assessments of the economic benefits of interventions in complete isolation and without regard to the possibility that patients may have more than one health problem at a given time. Its stands to reason that the economic benefits of a new hay fever treatment will differ markedly depending on whether these stem from an individual in otherwise robust health or one with a plethora of other debilitating conditions on top of their allergy, which reinforced the general impression that this is all amounts to something in between bullshit and voodoo.

Of course, I could be wrong and be walking into a right going over from one of more of our noted econo-bloggers, but sorry, that’s how it looks to me.

With the hay fever season at its peak, millions of people with an allergy to grass pollen are sneezing, snuffling and rubbing itchy eyes. Hay fever affects about 20 per cent of the UK population - more than 10 million people - of whom up to one million are so badly affected it interferes with their lives.

What is this ‘interferes’ business? Interferes is hardly medical terminology and tells us nothing at all as to the extent to which hayfever actually impacts on these people’s lives - interferes could be anything from seriously debilitating and life-limiting to simply a bit of nuisance necessitating the odd day off work. In the context of trying to form an impression about the ‘value’ of this new treatment, the verb interferes is almost entirely without substantive meaning.

The new treatment, Grazax, is the first oral vaccine for hay fever developed to tackle the underlying condition rather than the symptoms. Manufactured by a Danish company, and licensed in January, it contains small amounts of Timothy grass and is designed to “recondition” the immune system’s response to pollen in people who do not respond to normal treatment.

Oh good, at last we’ve got to a real fact - not a particularly illuminating one, admittedly, but nevertheless a fact and therefore something of an empirical oasis in a desert of meaningless subjectivity.

According to a study released yesterday, the vaccine can produce a cumulative and long-term improvement for hayfever sufferers. Results presented at an international allergy conference in Gothenburg, Sweden, yesterday showed that the longer the treatment is taken the greater the protection it offers.

A trial in 2,500 patients in 12 European countries and Canada showed it reduced symptoms by 36 per cent in the second year compared with a 30 per cent reduction in the first year. Patients in the trial were allowed to use their usual antihistamines and nasal steroid sprays and the findings showed a 44 per cent reduction in the need for this “rescue” medication in the second year, compared with a 38 per cent reduction in the first year.

Well, that does sound impressive even if this calling standard antihistamines and corticosteroid nasal sprays ‘rescue’ medication is rather over-egging the pudding - those with peanut allergies also carry what is referred to as ‘rescue’ medication with rather more justification for the use of the term ‘rescue’ as in those context it means a self-administered shot of adrenaline to stave off anaphylactic shock, which, if untreated, can be fatal. Not quite the same thing then.

Still, figures of 30% and 36% percent for reductions in symptoms and 38% and 44% reductions in use of ‘rescue’ medication look fairly impressive, even if one allows for the fact that improvements in year 2 of treatment are left than a fifth of those in year one, which suggests the dear old law of diminishing returns may be kicking in, and that there’s no year three data as yet as this appears only to reflect the interim findings of an ongoing five year trial.

Still, as the Indy’s report (and the Telegraph are carrying a short but otherwise near identical report, which backs up the suggestion that there’s a press release lurking in the background) note, about half the Primary Care Trusts who’ve evaluated the drug thus far have failed to fall at the feet of its manufacturer and beg for supplies. Why is that, do you think?

Well, you can get some insight from this report (pdf) by the Thames Valley Priorities Committee, which covers PCTs in Buckinghamshire and Milton Keynes.

In the main efficacy trial, mean daily symptom scores during the pollen season were 2.4 with Grazax and 3.4 with placebo (symptom scale 0-18). In total, 68% of the active treatment group used any rescue medication including antihistamines and topical corticosteroid sprays compared with 80% of the placebo group. Grazax contains allergens to only one type of grass. There is evidence of cross-reactivity with some other grasses, although allergies to other types of pollens (e.g. tree) will not be covered.

Its product licence restricts it to initiation by physicians experienced in treating allergic conditions pending more information on long-term safety

The Committee noted that:

− No data are currently available for use beyond one pollen season.

-Vaccine is a sublingual tablet to be taken daily starting at least 4 months before the hay fever season and continued for 3 years

− Most patients (68%) still have to take antihistamine medication

− There is no experience with children, adolescence and the elderly.

So, in another trial, our ‘wonder drug’ showed a reduction in use of ‘rescue’ medication of less than half that reported by the drug company’s own trials, it only covers one type of grass for certain and although other grasses may get some coverage you’re still knackered when it comes to tree pollen, two-third of those using it still need antihistamines and there’s no safety data on either long-term use or use by children, adolescents and older people.

Not quite such a miracle after all.

Campaigners for allergy-sufferers are now insisting that the new pill be made generally available. A spokesman for Allergy UK said the incidence of severe hay fever was growing but there was a shortage of allergy clinics. Six specialist centres and 32 allergy specialists serve the entire country. “The hayfever season is getting longer and the condition can be very debilitating. This pill is very effective and it should be available. We need to see more funding for it.”

Ah, I did wonder on first reading this if there was anything significant about Allergy UK having a general whinge about the shortage of allergy clinics/specialists but the Thames Valley report has cleared that up by noting that current product licence conditions mean you can only get the drug from a specialist and not from your local GP.

Of course, if the drug is ultimately successful in completing its full safety trials and taken up universally by the NHS then it seems likely that it’ll make its way on to the list of drugs than can be prescribed by your GP, in which case will we really need a shedload of extra allergy clinics and specialists?

Oh, while we’re on the subject of Allergy UK, the charity’s accounts (pdf) make for somewhat interesting reading as well, especially the Statement of Financial Activity on page 8 of the report, which appears to show that it spent £275,000 or so during 2005/6 on ‘trading operations’ which, so far as one can tell amount to some charity shops which generated an income on the year of around £42,000, unless much of its trading expenditure relates to its ’seal of approval’ scheme which nets it a cool £355,000 a year in payments from companies whose product are awarded this mark.

The hayfever season coincides each year with the exam season. A study released yesterday showed half of children with untreated hay fever suffer reduced concentration, potentially affecting their future prospects.

What did Thames Valley say?

There is no experience with children, adolescence and the elderly.

Not that that makes much difference, of course.

Professor Jean Emberlin, the director of the National Pollen and Aerobiology Research Unit, who led the study, said: “It appears that when suffering from hay fever, children are less able to concentrate on specific tasks. This is a trend that I have previously suspected and heard in anecdotal evidence, and this study offers further evidence to confirm the relationship.

But, the drug isn’t licensed for use with children and adolescents yet and could yet fail safety trials, so all this is irrelevant for the time being, other than, of course, as a means of racking up the emotional pressure in the hope than PCTs will cave in and start buying the drug.

“Often hay fever is trivialised, but this helps to bring it to the forefront of people’s minds, and emphasises the need for parents to take the problem seriously.”

Would the observation that Professor Emberlin appears to be laying on a bit thick here be trivialising things, do you think? After all, the research study cited shows that “half of children with untreated hay fever suffer reduced concentration” which may supports the use of hay fever treatments generally but says nothing at all about whether using this particular product has any impact on children’s concentration over and above that afforded by existing (and much cheaper) treatments.

Professor Pamela Ewan, a consultant allergy specialist at Addenbrookes hospital, Cambridge, and one of the UK investigators on the Grazax trial, said: “The results are quite impressive. It appears safe and it is convenient to take. But we can’t prescribe it because we can’t get anyone to fund it. The problem is the cost and the potential number of patients.”

Note the important corollary that now belatedly enters the fray -the problem is the cost and the potential number of patients.

Treatment with Grazax is recommended to start eight weeks before the beginning of the grass pollen season and to continue daily for three years. In the UK the drug costs £67.50 a month, about £2,400 for the three-year course. The cost of treating the one million worst-affected hayfever sufferers would be £800m a year. Professor Ewan said it was hoped that taking the drug for four months each year over the pollen season would be equally effective, which would cut the cost by two-thirds.

Except that this whole business of taking the drug only during the peak pollen season is not the treatment regime that’s been suggested by its producer and also not a regime that’s been tested, so Professor Ewan’s suggestion is not so much that we cut two-thirds of the annual cost so much as we should spend £267 million a year on a drug treatment for which there is currently no evidence for its efficacy or value when prescribed in the manner she suggests.

The only alternative treatment for severely affected sufferers is a course of immunotherapy injections, which require weekly hospital visits and close monitoring in case of side effects. It is risky, inconvenient and costly, and is limited to a couple of thousand patients in the UK. In contrast, Grazax, does not require injection or attendance at hospital, is safe and can be taken at home. This increases its appeal and the likely pressure on the NHS budget.

Without looking into this exhaustively, one of the immunotherapy options currently available is a drug marketed under the name Pollinex, which does indeed require weekly visits to the hospital to receive each of the four injections that make up a full course of treatment - funny, but the Indy doesn’t mention that. Pollinex is similarly limited to a specific type of pollen - ragwort - and is prescribed only in serious cases where other drug treatments have failed to provide relief and, so far as side effects go, these occur in around 15% of patients, most of whom experience nothing worse than a bit of tenderness and swelling around the site of the injection, although in very rare cases it can trigger anaphylactic shock in individuals with an extreme ragwort allergy.

As for expensive, well judge for yourself - a full pre-seasonal course of Pollinex currently costs £320 for the vaccine, compared to £800 for a full year’s course of Grazax, and if we assume that the Indy’s figures are somewhere in the right ball park, i.e. a couple of thousand people receiving Pollinex injections every year, then the actual cost to the NHS is around £640,000 a year, compared to the project £800 million cost for prescribing 1 million people with Grazax.

By the way, if further comments seem a little strained from this point forward, please forgive me - my bullshit allergy is flaring up something rotten.

Stephen Durham, a professor of respiratory medicine at Imperial College London and the Royal Brompton Hospital, London, who led the study presented at the 26th European Academy of Allergology and Clinical Immunology Congress (EAACI) in Sweden yesterday, said: “Reducing symptoms and improvement in quality of life are the number one priorities for hayfever sufferers … The ongoing trial may also show whether long term remission occurs with Grazax, which would be great news for allergy sufferers.”

Early results from some patients followed up for six years suggest the effects of the vaccine are long lasting. Professor Durham said the treatment was suitable for severely affected individuals in whom other treatments were not effective. “I believe about 10 per cent of the hayfever population, potentially a million patients in the UK, could benefit from this treatment.”

At £800 million a year, and with 68% of people still requiring other treatments on top, I don’t fucking think so…

Peter Anderson, the UK managing director of ALK-Abello, the Danish manufacurer of Grazax, said the “lion’s share” of NHS Trusts in the UK had yet to decide whether to fund the drug. “About 20-30 have reached a decision and about a dozen have agreed to fund it.”

Remember this from earlier? Okay, we’ll move on because the Indy is now going in to helpful mode…

Pollen, pollution and the symptoms that cause misery

* Hay fever is the commonest allergy in Western countries, affecting an estimated 20 per cent of the population in Britain.

* It is an acute allergic reaction to airborne particles of pollen which penetrate the nose, throat and upper respiratory passages.

* Typical symptoms include red, itchy and watery eyes, blocked or runny nose, frequent sneezing, coughing, and wheezing.

* The symptoms are caused by the over-sensitivity of the mucous membrane that lines the inside of the nose, throat and eyes.

* The commonest cause of hay fever is grass pollen. Pollen from birch trees especially causes hay fever in spring and from mugwort and chrysanthemum in autumn.

I’ll pause there for a second to reflect on the fact that neither new miracle Grazax or dear old Pollinex provides treatment for tree pollen, mugwort pollen or chrysanthemum, so if you are allergic to any of those then you’ll still have to keep a hankie a handy and tough it out.

* Hay fever affects many people in towns because of pollution. Pollen grains become attached to particles from car exhausts, increasing their allergy-inducing effect.

Its also thought that over use of antibiotics in childhood may be a contributory factor as this inhibits the development of a robust and effective immune system, which is why I mentioned my kids at the start of all this - neither suffer from hay fever.

* Treatment is mostly symptomatic, with anti-histamines and steroids to reduce the inflammation in the mucous membrane.

What else could the Indy add after all that. Well only the kind of trite ‘human interest’ angle story more usually found in cheap weekly magazines for bored housewives and office workers and those afflicted with an altogether more common and serious problem, congenitial stupidity:

‘I can be sneezing all day in summer’: Lisa Young, hay-fever sufferer, 37

Really? You should think yourself lucky you’re not in ‘Take A Break’ and husband’s not a serial bigamist who’s undergoing gender reassignment after running off with the lesbian dominatrix next door who used to be your best friend.

The first thing Lisa Young does every morning is swallow her anti-histamine tablets in a vain attempt to keep the runny nose and itchy eyes that blight every summer at bay.

“My eyes are the worst, smarting, itchy, continually sore. As soon as I go outside I start to itch. I can be sneezing all day in summer. I have suffered badly for years.”

Awwww… No, sorry. This may sound a bit hard-hearted but you’re still not going to persuade me its worth £800 million a year just to shave a few quid of your Kleenex bills.

Aged 37, she is a teaching assistant in Reading and has to accompany classes outside which can make it difficult to work. Her two children, Jane, eight, and Cain, four, are also affected and under the care of the specialist allergy clinic in Basingstoke.

Ms Young said of Grazax: “It sounds like what I need. If it can ward off the effects of hay fever and is more effective than anti-histamines, then I would be very interested in having it.”

Can’t blame you for that.

“It should be provided on the NHS.”

Houston. We have a problem.

Why should it be provided on the NHS? Or more to the point, at £800 million a year, which NHS services do you suggest we cut - of which taxes should we raise - so you can have an as yet unproven drug treatment that offers limited relief for a non-life threatening condition that, for most people, amounts to not much more than a bit of a bloody nuisance?

Allergies are growing throughout the UK and people who live in towns tend to be worst affected, owing to the pollution interacting with the pollen grains.

Ms Young said she knew many friends and neighbours who suffered in a similar way. “Where we live in the Thames Valley, it seems to be bad for allergies.”

Ohhh shit. This would be the same Thames Valley whose priorities committed has recently decided that Grazax “should be considered a LOW PRIORITY treatment due to lack of evidence of incremental clinical and cost effectiveness when compared to existing therapies.”

Do I get to allow myself a few moments of insufferable smugness for spotting that information when the Indy appear to have missed it, and the chance to play the ‘it’s just not fair’ postcode lottery angle, entirely? I think I do…

…okay, that’s quite enough of that, just one more line to go.

If it is too late for her to have the oral vaccine herself, she would want it for her children, she said. Grazax is not licensed for children, but it may be in the future.

Why on earth would it be too late for her to have this vaccine? Is she planning on dying before it completes its clinical trials or something? Methinks they’ve sent one of the interns out to get cover this bit of the story without explaining to them that this new Grazax stuff is like the flu vaccine that people get every year, not like the TB vaccine or the standard run of childhood vaccinations which are no use at all unless you have your shots before contracting any of the relevant illnesses.

FFS, if you’re going to run a human interest angle, you might at least go to the trouble of not making your subject look a bit of an idiot because you’ve not explained even the basics about how this vaccine works.

Which leaves only the same question posed in the title?

Why is the Indy (and the Telegraph for that matter) shilling for Big Pharma?

I’ve just finished watching tonight’s Panorama, which was a follow-up to a programme earlier this year about continuing care for the elderly.

If you didn’t see it, you can find the link to watch the show online on this page - go on, watch it. In fact if you’re a Labour Party member then you have no excuse not to watch the programme, so go watch it now and I’ll see you in about 45 minutes…

…

…

Now you tell me just how the fuck do we, the Labour Party, justify what you’ve just seen?

It’s impossible, isn’t it.

In fact I’ll go a bit further here - if you’re a Labour Party member and can watch that programme without getting angry then you’re you’re in the wrong fucking party!

If you possess even a shred of compassion, then you’ll have started to get angry about 2-3 minutes in and by the time the programme got the story of the woman with dementia who had to pay for her own care after the NHS had kindly ’stabilised’ her condition by amputating her gangrenous leg you’ll have been more than ready to kick the living shit out of whichever bureaucratic tosser came up with that little gem of a decision.

As a party member I really don’t want to dwell on the footage of Blair at the 1997 Party conference announcing that he didn’t want this to a country where older people have to sell their homes to pay for their long term care - I guess that’s one pledge that never made it onto a poxy bit of plastic card so I doubt he loses too much sleep over the knowledge that nine years on that something he’s done absolutely fuck all about.

What I did take note of was the contribution of Ivan Lewis MP (Bury South), who is now the Parliamentary Under Secretary of State for Health, particularly the distinction he drew between health care, which should be free, and means-tested social care, which he appears to think is the kind of care that is provided to enable older people to continue to live independently.

Now, as far as I can see that’s a fair distinction to make - if only that were the actual test being used to decide whether NHS should be footing the bill for long-term care. Sadly, as Ivan may have realised (hopefully), if he watched the programme, that’s patently not the test that’s being used in practice as not a single one of the older people shown the programme could even remotely have been considered capable of living independently.

Well, Ivan - you suggested the test we should have, now get your arse in gear and get it sorted.

Oh, and if anyone’s off to this conference and thinking to tabling a motion - there’s one here that needs putting forward.

Courtesy of the Beeb…

Impotency rub-on gel developed

A rub-on gel could be the first over-the-counter treatment for impotency, a company has announced.

It is being developed by Futura Medical in collaboration with pharmaceutical giant GlaxoSmithKline.

The treatment, called MED2002, is expected to go into clinical trials at the end of 2006.

But the Sexual Dysfunction Association said it is important to await the outcome of these trials to see how effective the product really is.

Good on the Sexual Dysfunction Association for sounding exactly the right note of caution on this report…

…after all I’m pretty sure I’m neither alone nor being premature (boom, boom!) in spotting the most obvious potential drawback of a rub-on treatment for impotence, am I?

So there no need to make a big splash out of this story just yet a while, okay…

Portrait of Sigmund Freud - by Salvador Dali

At the risk of waking up to find a horse’s head strapped to a red leather couch amongst my Christmas presents I’m going to let you into a few trade secrets.

By training I’m a psychologist.

No, that’s not a secret - although perhaps it ought to be – it just means that for my considerable and multitudinous sins my time at university was spent learning to fathom out the intricacies of the human mind. I don’t actually practice as a psychologist, never have, not because I couldn’t do the job just as well as anyone else with my background and training but because nothing I did learn left me feeling confident in taking on the responsibility for what goes on inside the head of anyone other than myself.

Let me illustrate what I mean.

Like most degree courses, psychology follows a pretty standard format. You spend the first six months covering a few introductory basics to get everyone on the course up to the same starting level (as with any number of other subjects, psychology attracts a sizable number of students for whom the degree course is their first serious entrée to the subject – A level courses in Psychology are not that widely available and, in any case, what you learn to cram at A level and what you’re expected to understand for a degree are two very different things). After that, and the mandatory lecture on professional ethics, you get to study the subject proper, spending the next year and a half covering foundation topics before finally getting to specialise in your final year.

One of the first, if not the first, foundation topic you cover is ‘theories of personality’ – note the plural, it’s important – a series of around twelve to thirteen lectures on the nature of personality and the various theories that try to explain what it is an how it works, which takes you through many of the ‘big name’ in the profession – Freud, Jung, Pavlov, Skinner, Kelly, Rogers, Maslow et al – all with the own distinct ideas of what personality is, what it does and how, as a psychologist, you might eventually learn to influence it’s development.

If that part of the course teaches you anything it’s that’s while psychology is by no means short of ideas, theories and conjectures on the subject of personality, no one really know what it is or how it works – if a psychologist says to you that they’re a ‘Freudian’ or a ‘Jungian’ or a ‘Behaviourist’ or whatever all they’re really saying is that when they sat down to consider what personality is, they simply liked a particular theory best and found it a bit more interesting than the others so that’s what they decided to go with. You could just as easily pick one at random for that it provides any semblance of a definitive view of personality.

(Personally, I always found that Kelly, Maslow and the other existentialists and iconoclasts like R D Laing suited me best, but that’s just my own view of things)

I mention all this in response to yet another brilliant commentary from Dr Crippen on the subject ADHD (Attention Deficit Hyperactivity Disorder) in which he expresses, in my opinion, what are well-founded and well-judged concerns about the growing practice of medicating children for no better reasons than their parents (and often schools) find them a bit ‘difficult’. It’s an issue in which, I must confess, I have a considerable personal interest as my own five (soon to be six) year-old daughter is one such child who falls into this category – although never once have I asked for or wanted her to be medicated because of it.

I’ll get back to my daughter and our experiences of ‘the system’ in a while, but first there are few more observations on the nature of the ‘profession’ I should make first.

I suppose I should try and give some sort of overview of what psychologists – and psychiatrists for that matter – actually know about the workings of the human mind.

Not much.

Don’t get me wrong, we know quite a bit about how the brain works.

We know what chemicals the brain produces (neurotransmitters) and have a fair idea of what happens in situations where it produces a bit too much or too little of a particular chemical and also what happens if you introduce the brain to all manner of other chemicals from the outside world – nicotine, alcohol and whole bucket load of prescription and non-prescription drug, legal and illegal.

We know all about the electrical activity that take place in the brain. We can map it to show that different patterns occur in different places when we do different things. We even know that we can make certain things happen if we go poking around in particular locations in the cranial cavity with electrodes – prod here and a finger twitches, prod there and you get the taste of strawberries.

We even know, roughly speaking, which bits of the brain control which functions; mostly as a result of studying various types of brain injury. Damage this bit a speech goes out of the window, here and you can’t remember anything for more than a few seconds, here and all aggression goes and you guarantee docility – that last one was once a big favourite, back in the days when it was thought reasonable to try to ‘cure’ criminality by liberal use of pre-frontal lobotomies.

We also know that despite it being long thought that the brain was incapable of making new brain cells and replacing damaged cells (neurons) its actually does make some new cells all the time – in the hippocampus – all of which appears linked to how the brain stores memories and, if injured, it does try to repair itself. I was actually at University and taking the module in neuropsychology at around the time this was discovered. Back then it was called simply ‘sprouting’ – cells around the area of injury respond by growing new connections to other undamaged cells in an effort to reconnect across the damaged area, often resulting in the partial recovery of functions otherwise lost to injury.

None of this, however, tells us anything in particular about the process of thought and thinking, which is what psychologist and psychiatrists, in the main, are concerned with – its what’s called the ‘mind-body’ problem, something that has occupied the thoughts of psychologists since the profession came into being in the 19th Century and philosophers certainly since the enlightenment and, perhaps, before. We can study and uncover the physiology of the brain and its pathological functioning fairly well, we just have no real idea how that all relates back to the way we think – not that that’s ever stopped people trying to link the two together, from which we’ve derived both pseudoscientific drivel (phrenology, the ‘science’ of reading ‘bumps’ on the head) through assorted forms of medical barbarity (lobotomy, electro-convulsive therapy) to today’s mood-altering drugs (lithium, Prozac, etc.).

It’s this that sets the use of drug treatments in psychiatry apart from most other fields of medicine. If we take a commonly used drug, say an analgesic like paracetamol, then we know with a considerable degree of accuracy what the drug does, the effect it has, how it does it and why it does it. In the case of Ritalin, which is increasingly prescribed to treat ADHD in children, we may still know all these things in terms of their physical effects on the body but nowhere near as much about how and especially why they affect the mind in a particular way – we can observe and record the effects, just not explain the why of them.

I need to digress here a touch, just to explain the difference between psychologists and psychiatrists.

Psychologists aren’t doctors (they don’t have a medical degree although some, working in the field of neuropsychology do go that route in order to qualify as surgeons), they don’t generally wear white lab coats (apart from some the experimental lot and the odd one or two who do it as an affectation) and they don’t – in fact they can’t – prescribe drugs.

Psychiatrist, on the other hand, are doctors, frequently wear white lab coats (it’s mandatory) and can prescribe drugs.

There is, as a result, quite a degree of professional rivalry akin to that you’ll often find between doctors and dentists (and from some strange reason at Manchester University, in particular, doctors and engineers – no I did get it either) much of which relates to this whole business of having access to the medicines cabinet. Psychologists are firmly of the belief that psychiatrists are far too inclined to reach for the pad of prescriptions rather than tackle problems properly – they’re also firmly of the belief that the majority of psychiatrists don’t enter the profession burning with a desire to cure the ills of human mind, but because they’re too crap at doctoring to become surgeons and too lazy and anti-social for General Practice. As far as psychologists are concerned, psychiatry is to doctors what philosophy and theology are to prospective university students – a means of getting on if your grades or too poor to qualify you do anything more useful.

That being said, I’m sure psychiatrists take a similar dim view of psychologists, although I’ve never encountered one with the courage to speak up and say so – I fully expect what they think of us is near enough what they think of complementary therapists, homeopathy and other assorted unproven therapies.

I point all this out really to make the point that psychology/psychiatry is a hell of a long way from being the kind of empirical discipline that the public are often les to believe it is – most of it is educated guesswork and bit of common sense and experience (hopefully) wrapped up in a whole load of made up words with enough syllable to sound impressive and the make the speaker appear to know what they’re talking about.

It’s frequently impossible to tell whether visiting a psychologist with your problems has any real effect or whether its all just one massive placebo for the mind – talking over your problems doesn’t actually solve them it just makes you feel a bit better for having talked them over with someone.

One of my all-time favourite stories about RD Laing illustrates this point perfectly.

Laing, while practicing as psychologist, was visited for a regular consultation by a patient with depression.

On this particular occasion, the patient seemed particularly down, so rather than do the whole ‘get on the couch and tell me your problems’ routine, Laing just decided to chat to them in general, talk about mundane things like the weather, the football results over the weekend. Just the normal kinds of things that people talk about socially.

About an hour later, Laing notices that the time allotted to the session is over. At no point have he and his patient talked about the patients problems or done anything which might be considered therapeutic – they’ve just talked. By now, however, the patient’s mood has picked up considerably and he and Laing have been swapping jokes and just generally enjoying a social chat.

So, Laing breaks into the conversation to point out that the sessions over, only for the patient to reply by pointing out that they hadn’t actually talked over any of his problems.

The bit of this story I particularly like is what comes next.

Laing’s reply to this was simply to point out to the patient how much he’d obviously cheered up since he’d arrived and that, because of that, he saw no real point in talking about the patient’s problems as it would only get the guy down.

How wonderful is that? You’re happy now so why spoil it?

I’m not going to say outright that psychology is complete con but I will happily argue, as someone trained in it, that its nowhere near what the public are led to think it is.

Take schizophrenia for example – what exactly is it?

Well, this is how it’s described by Wikipedia, which is as good a description as any you’ll find in textbook:

“Schizophrenia is a severe mental illness characterized by persistent defects in the perception or expression of reality. A person experiencing untreated schizophrenia typically demonstrates grossly disorganized thinking, and may also experience delusions or auditory hallucinations. Although the illness primarily affects cognition, it can also contribute to chronic problems with behaviour or emotions. Due to the many possible combinations of symptoms, it is difficult to say whether it is in fact a single psychiatric disorder; and Eugen Bleuler deliberately called the disease “the schizophrenias,” (plural) when he coined the present name.â€?

Does any of that make sense to you? Feel free to go and read the rest of the Wikipedia article if you like but before doing that I’ll let you into one of psychology’s biggest and frequently most closely guarded secrets – we’re no clearer about exactly what schizophrenia is than you are!

We may be better able to describe its symptoms than laymen.

We have no shortage of jargon and complex multi-syllabic terminology to pull out and use in order to impress the unwashed masses with our compendious knowledge of the subject.

But the reality is here that if you do someone, maybe a family member or friend, who has been diagnosed with schizophrenia then all the diagnosis really means is that the psychologist or psychiatrist who made the diagnosis thinks they’re a nutter.

That’s pretty much as good as it gets.

I mentioned my daughter a bit earlier. She’s currently five – she’ll be six just after Christmas – and she has what can only be described (in shrink terms) as a ‘developmental delay’ plus occasional marked ‘behavioural problems’.

She’s actually a very bright and lively child who, physically, has always been very forward – walked at about nine months having only crawled for about a week, tops, and never really resorted to crawling again once she’d found her feet.

The downside to this was that she was, initially, very slow in picking up speech and communication, which was spotted at a routine assessment at around 18 months and which put her, and obviously myself and my partner, onto a treadmill of assessment and, occasionally, treatments that we’re still (technically) on more than four years later without ever really having found out what the problem might be or even if there is a problem.

Initially, we spent over a year tracking backwards and forward to hearing assessments in order to ascertain whether that might be the problem – it isn’t but it took them around 15 months and four or five appointments to arrive at that conclusion, mainly because my daughter has a fairly low boredom threshold and a knack of being uncooperative which meant they found it very difficult to complete their tests.

Since then, she’s been to speech therapy, which I will say helped considerably to bring her speech along – but then so did going to nursery and interacting with other kids her age as well.

As far ‘symptoms’ go, other than the speech thing, she’s prone to periodic bouts of ‘hyperactivity’ – not that she’s particularly destructive just that she constantly on the go, running everywhere, for hours on end and can’t concentrate on anything for more than a couple of minutes when in that mood. One thing we have noticed is that certain foods – ok, well Smarties, Coca Cola and one or two other soft drinks, tend to set her off, so we avoid them (obviously).

On top of that she also ‘fixates’ every now and then on a particular behaviour which she starts to carry out obsessively – there’s one constant which is running backwards and forwards along the same ‘route’ for 15-20 minutes at a time which you might think is something all kids do at some point – she’s been doing it pretty much since she learned to walk and always on the same route (in the living room) and starting from the exact same spot every time. We moved house a couple of years ago and thought that might break the habit as the layout of our current place is very different from the house we were in before – it took her less than a week to find here ‘new route’ and start up again.

In addition we’ve had spate of obsessive hand-washing – we’ve more or less got her out of that one but it comes back very occasionally, and various other things where she just set herself on doing something over and over again, even getting very sneaky about it at times. At the height of the hand-washing phase she’d deliberate find things to do which would get her hands dirty so she could go and wash them.

We also, every now and then, get the bad days, the days when the slightest thing can set her off into tantrums and screaming fits, when her behaviour does get disruptive and sometime destructive. This rarely happens at home anymore, but at school they had a couple of weeks of her kicking off because another child ‘stood too close to her’ – a couple of times this has meant fetching her out of school as she was thought by teachers to be putting herself and others kids ‘at risk’. On another occasion, various teachers and classroom assistants ended up spending a couple of weeks sitting inside with her at lunchtime as she refused point blank to go out an play with the other kids – the school had had some new fencing put around the nursery area and she just decided she didn’t like it.

None of this is constant, she’ll go weeks, months even, without any signs of a problem then just get up one morning in the wrong kids of mood and away we go – sometimes is stuff we’ve seen before, sometimes it something new.

Oh, and as you might expect, educationally speaking she’s not coming on anything like as well as most of her classmates – she’s about a year behind with her reading and the same with writing already.

In the meantime we’ve dutifully trotted backwards and forwards to various professionals while she’s prodded and poked to see if any of them can work out what to do with her. On top of the speech therapy, we’ve had regular trips to paediatric assessments, then off to child mental health services (expect you’re only allowed five appointments while they try to make a diagnosis before you automatically get referred back off their books). We had home observations, an educational psychologist visit her at schools for a whole half and hour observation – not that that was any use as it coincided with one her better spells.

This last year, in particular, has been farcical. It was about this time last year that we finally got the referral to child mental health services and actually saw a developmental psychologist – did I forget to the mention that we’ve never even seen the educational psychologist, let alone spoken to them.

First assessment – the shrink asked questions, we answered, we talked, she observed – all took about an hour at the end of which the possibility of an autistic spectrum disorder was raised. Wonderful, eh? Still, after we got home I talked my partner down of the ceiling, we took a little comfort from having come away feeling that we might just be a little closer to finding out if there really is a problem and, if so, what it is and what, if anything, we can do to help our daughter.

Assessments two, three and four were a waste of time, really. All very hello, how are you, anything to report type stuff and no progress.

By assessment five, they’re now ruling out an autistic spectrum disorder – well actually not so much ruling it but claiming they never said anything it a possibility in the first place – mind you we’re a on a different shrink at this point. Instead they think its just a non-specific developmental delay – read around the subject of psychology for a while and you’ll soon find that there a plenty of things are non-specific as ‘non-specific’ is psychologist-speak for ‘how the hell do I know what it is?’.

Get home. Talk partner from ceiling yet again – hard as it is to hear someone talk about your daughter and use terms such as ‘autistic spectrum disorder’, its actually much harder to deal with the idea that not only do you not know what the problem is but the professionals don’t either – then off to hit the books to find out what this non-specific developmental delay business is all about.

At which point I discover that it either may or may not be part of the autistic spectrum of disorders, depending on which journal you’re reading and whether a particular researcher thinks it is or it isn’t.

So we’re still no closer to diagnosis.

Oh, but there’s more.

In the meantime, the school had asked if the shrinks had come up with anything as they were still having periodic difficulties with my daughter – so naturally we mention that an autistic spectrum disorder has been raised as a possibility.

Now how do you think the school reacts to this?

Yep, you got it – there’s goes my daughter on to the ‘special’ table with the other ‘special needs’ kids, which is fine in one respect as she’s now getting a bit of extra one-to-one tuition with her reading that most of the others kids don’t get. Unfortunately none of this goes anyway towards tackling some of the behavioural stuff, which all relates to interacting with other children, as she now spends much less time engaging in those kinds of interactions.

This goes until she gets a school visit and observation from Child Mental Health Services who points out straight away that limiting my daughters interactions with other children is no help at all.
So what did we actually get out of all this?

The promise of a ‘case conference’ with the professionals to discuss my daughter’s development.

This was around February/March this year – guess when the case conference happened?

Yep, that’s right. It didn’t.

You see the other thing I forget to mention is that where I live the diagnosis of things like ‘developmental delays’, autism and all manner of other psychological problems in children have to be done on a ‘multi-agency basis’. So getting diagnosis is not merely a case of getting seeing a child psychologist/psychiatrist and getting their opinion, you also have to get the agreement of the educational psychologist, who works for the Local Education Authority, the speech therapist (NHS but a different department and hospital in the local trust), because my daughter’s seen one, and god knows who else besides. We were told and there was something like five or six different people who would have to involved in this according to the ‘rules’, all from different departments and places – all of whom would have share information and find the time for a meeting where they could all get together to talk things over with us.

I think you should be able to see why the case conference hasn’t happened – in fact the last time this was mentioned, about three months ago, they were still waiting for written assessments from the speech therapist and education psychologist. They’d only had five or six month to get back to them.

Somewhere is all this I suspect there’s also an accountant and a couple of bureaucrats in the loop for this decision as well – after all, an actual diagnosis would mean my daughter getting some sort of therapy or support, all of which costs money as, let’s face it, the only purpose that multi-agency working appears to be serving here is to keep costs down by not allowing a diagnosis to be made.

I’ll be honest, I have left things alone for the last few months and pushed the issue anything like as hard as I could or should have.

In part that’s because for all that my daughter can be awkward and difficult and her behaviour and lack of progress at school be worrying, she’s still a bright kid with many growing talents and abilities which compensate for the other problems. One of the difficulties that myself and my partner have with helping her with a her reading is that is often difficult to be sure whether she’s actually reading the words on the page or not – there aren’t too many five year olds who manage to memorise the text of their reading book verbatim as they’re learning to read the words and often you only catch her out when she inserts a word into the text that should be there, grammatically, but has been omitted to simply the text for a child her age.

Partly it’s also because after all this time, my partner got to be pretty frazzled by the whole experience. I tend to cope with things like this a bit better, partly because I do understand the complexities of trying understand the human mind and how it works but also because I’m just the kind of person who doesn’t dwell on problems – I go looking for solutions. I’ve not said it to her, as she’s the worrier of the two of us, but I have backed off because she needs a break from this treadmill for her own good, even if she wouldn’t admit or accept it – and she’ll kill me if she finds out I’ve said this.

Still it’s difficult not to get a bit dispirited at times – and impossible not to get extremely frustrated.

I may be more that a bit disdainful of what is, strictly speaking, the profession I trained to enter while at university even if the clinical side of things wasn’t where I was heading had I decided to follow through and practice – I’m actually an organisational psychologist by speciality and do systems not people – but for all its faults, its still the best we have to work with for now…

…and right now what I wouldn’t give for a properly conducted assessment of my daughter carried out by an appropriately qualified psychologist who the system allows to actually make the kind of diagnoses they’re trained to make without a cast of thousands kibitzing over their shoulder.

But you know what really burns here?

It’s the fact that for all that I don’t practice, I know my professional well enough - and the system even better – to know that if I did really start to push the issue hard and use what I know to rack up the pressure on the professionals who, so far, have got nowhere fast, then I could easily get a diagnosis for my daughter.

What I couldn’t be sure of it that I’d get the right diagnosis and not just whatever one I jumped about demanding that she be given.

Damn me for wanting my profession to get it right for once.

First things first, let me point you in the direction of Dr Crippen and his excellent blog - if you’re wanting to know how and why the NHS is pissing money down the drain you’ll find few better sources of information.

All of which reminds me of one of my own brushes with the stupidity that is NHS Bureaucracy.

Quite a few years ago, now, I myself worked for the NHS - not on the medical side but in ‘Community Development’ - Community Development was what the old Health Promotion Units turned to when the government started paying GPs to do their own health promotion work in surgeries in order to aviod becoming redundent.

But that’s, to some extent, by the by and, heretical lot that we were, we actually tended to get some good work done, helped no end by working for a Director of Public Health who understood the value of trying to stop people getting sick in the first place and that that meant dealing with issues like crap housing conditions and all the shit that local factories used to pumping into the atmosphere, etc.

So what I did, for the most part, was information - much of it printed.

So here’s the deal. I got the job and with it - to knock up this information - I got an underpowered PC and some pretty decent DTP software; and budgets being what they were a new PC was out of the question so I talked the team leader into authorising the purchase of a bit more memory so that at least I could work at a reasonable speed.

So, being a bit of geek I do what any good public servant would do (so I thought) and hit the PC magazines looking for the best price I could possible get - which for the memory I wanted turned out to be about £75 from a company on the South coast. So far so good.

Then, I fell in the evil clutches of NHS purchasing…

I dutifully filled in the requisition papers, gave all the details and shipped it off the wherever it was they processed the orders…

…and about a week later I got a call from there to say there was a problem as I’d not chosen to go with one of their regular, approved suppliers.

Not a problem, I thought. This supplier was a good few quid cheaper than anywhere I could find and did a few good deals that might be worth keeping an eye on for future purchase, so just ask them to add them to the system and then place the order. Which I did.

Three weeks later and no memory has arrived - so I phone the supplier, only to get the reply:

“What order?”

Riiiiight!

Back on to NHS supplies to find out what the fuck happened to the order only to find out that this business of approved suppliers is a bit more complicated than was first apparent, the supplier I’d specified couldn;t be added to the system after all and would I like to use one of their usual suppliers instead.

‘Fuck it!’ I thought, ‘You’ve got me’ and agreed.

Wait another couple of weeks and wahey! The memory finally arrives, followed by the invoice a couple of days later…

…at which point I find out that the £75’s worth of memory I tried to order from elsewhere has now cost the project a little over £150 (in the meantime the market price of memory had dropped and the supplier I had originally wanted to use was selling at just under £70).

And what, you might wonder, was the problem with this supplier?

Nothing more than the fact that it only offered 21 days credit terms on purchase orders while companies on the NHS approved suppliers list got there by agreeing to 60 days credit terms - and seeming also by not making too much a fuss if it took anything from 90-120 days to settle the bills.

That’s bureaucracy and the joys of centralised purchasing for you.

I wonder how many people really understand how the NHS works?

I ask this because I’ve noticed that over at Non-trivial Solutions, Andrew has managed to get a little too carried away with Tory rhetoric over a BBC story about opposition amongst doctors to proposals to give specially trained nurse and pharmacists greater powers to prescribe drugs.

Andrew’s right to offer up criticism of what amounts to a bit of blatant protectionism by doctors, but where he goes completely off the deep end and into surreality is with statement:

Just one of the many reasons… why the healthcare unions and the NHS monopoly have to be broken:

First of all, its a hell of a reach describing the British Medical Association as a ‘healthcare union’ - it’s certainly not affiliated to the TUC, nor indeed is the Law Society, the Bar Council or any one of numerous other professional associations which operate as independent regulatory bodies.

Then there’s the business of the “NHS monopoly” as well.

What’s being proposed here is an extending the ability of pharmacists and nurse practitioners to prescribe drug treatments for more serious medical conditions such as diabetes and heart disease, a measure which, if it goes through, will leave only controlled substances like diamorphine as the exclusive preserve of doctors and, therefore, something which will effect, almost exclusively, General Practitioners working in Primary Care.

Now this is something I know a fair bit about, both from having worked in the NHS a few years ago and also because a very good friend and occasional visitor to the comments box here just happens to be a non-Executive Director of a local Primary Care Trust.

And what most people don’t realise about Primary Care is that the vast majority of NHS funds which go into providing GP services are actually paid to private sector businesses.

You see, the vast majority of GP’s don’t actually work directly for the NHS and they are not public sector employees. The vast majority of GP practices and health centres in the UK that hold NHS contracts are private sector businesses - more and more of them being limited companies.

And this is nothing new at all. In fact it’s the way its always been since the founding of the NHS by the Atlee government. GPs are not public sector employees, they’re self-employed sub-contractors who hold NHS contracts.

Now, the whole system of NHS contracts for GP services is a long way from being perfect, starting right from basic contract payments which are based on the number of patients on a GPs list irrespective of how many of those patients a GP sees during the year. This is one of the main reasons why recruiting GPs to work in inner city areas is so problematic - a general practice with a 5,000 patient list based in a nice leafy suburb full of healthy middle-class fitness freaks gets paid the same basic contract payment as one with the same size list in inner city slumsville but does far less work for their money as their patients don’t get sick quite anywhere near so often.

General practice, in terms of what doctors actually do, has barely changed over whole 60 year life of the NHS and, in fact, is little different from how it ran before WWII; not because the NHS don’t want things to change, for services to be delivered more flexibly and efficiently at times which fit in better with the changing patterns of work over the last 20-30 years and for payments to be geared to actual performance but because GPs don’t want to change arrangements which, for many, provide a high basic income without eating too dramatically into their other interest - not least amongst which can be private consultations and other nice little earners.

It’s not the NHS monopoly that the problem here, the real problem is the power of what is effectively a cartel of private sector businesses which uses its privileged professional status to rig ‘the market’ in its own favour.

This is an issue I’m more than happy to debate - it so happens we’d almost certainly get better services all around were the NHS better able to direct GP services to meet local needs and not the convenience of doctors - but let’s at least get the language right here. This is isn’t about unions, the NHS monopoly and state corporatism, its about curbing the power of a privileged professional association which operates as a cartel in the absence of independent regulation and scrutiny.