Tuesday, May 22, 2012

Money for health - moving to the root of the problem

There has been some debate recently about personal financial incentives to achieve healthy behaviour. The Harvard philosopher Michael Sandel has been brilliantly exploring the issue from many angles [ listen to radio 4 debate here: http://www.bbc.co.uk/podcasts/series/r4sandel ]

The argument against payment incentives is characterised as bribing people to be healthy and wasting money. Needless to say The Sun, The TaxPayers’ Alliance, and The Tories are not the biggest fans [ http://bit.ly/JLmcZB ]

However, the debate to-date largely misses a crucial link. Health and wellbeing are determined largely by behaviours / lifestyles (e.g. smoking, alcohol, diet, physical activity); and also directly by socioeconomic factors (e.g. income, education, occupation, housing, family, networks, culture). These behaviours / lifestyles are also determined by the same socioeconomic factors - "the causes of the causes” if you like. The pattern almost always follows that lower socioeconomic circumstances increases adverse behaviours and so impacts on health. There is plenty of evidence to support these pathways and also that shows that because of the adverse social and economic circumstances the "choice" of the adverse behaviour is not one necessarily freely taken (e.g. healthy foods are not so affordable or available; smoking and drinking often arise out of the chronic stress of poverty and unemployment).

We cannot, therefore, try to really improve lifestyles and behaviours without improving the underlying social and economic circumstances. To change this may be considered as "up stream" or requiring major political change and beyond the remit of health (or other) services. And obviously progressive taxation and / or better distribution of wages are the major solutions. However, incentivising with monetary / payment is an attempt in a relatively small, local, and direct way to address these socioeconomic causes of the causes.

A Dundee programme – called quit4u – offering payment of £12.50 a week (in supermarket food vouchers) to encourage people living in deprived circumstances to quit smoking has been shown to work. The two year evaluation, just published, demonstrates improved quit rates at 3 months and even 12 months [ full evaluation here www.healthscotland.com/documents/5827.aspx ]. At its launch the Dundee initiative was met with much the same aversion, which has dominated the debate on this area. But, at its heart has been an ethos of understanding this socioeconomic link and trying to do something, albeit in a small way, about it. So praise must go to NHS Tayside for taking this bold and groundbreaking action in the face of much hostility. We urge other health boards and Scottish Government to follow suit and take more positive action with the powers they have to make a difference to the lives of those most in need if we are going to tackle inequalities in health and wellbeing.

Monday, May 21, 2012

Hospital Acquired Infections

The closure of eight wards at Royal Alexandra Hospital in Paisley because of an increase in people showing symptoms of the Norovirus bug has thrown the spotlight back on HAI's. Two people suffering from diarrhoea and vomiting died in the hospital. NHS Highland also reported an increase in the number of cases of diarrhoea and vomiting with Raigmore Hospital in Inverness closing two wards to new admissions and a ward at Caithness General is also shut.

Scotland's Chief Medical Officer, Sir Harry Burns has stressed that Norovirus cases were decreasing in number, saying: "The number of cases of norovirus, the number of outbreaks, has fallen over the past few years. So things are stable and probably going in the right direction. It's something we are seeing less of, a 16% reduction in the figures over the past two or three years."

Sir Harry also highlighted the importance of hygiene in tackling the virus: "Hand-washing is probably one of the most important things we can do. It is dealt with by soap and water; conventional clean hands. Hand hygiene among NHS staff in Scotland at an all-time high".

More generally on HAIs, the Health Protection Scotland Point Prevalence Survey, which involved 13,558 patients, 844 wards and 75 hospitals, records a snap shot of all types of infections on the day of the survey. The April 2012 report highlights that prevalence of healthcare associated infections was 4.9 per cent in acute hospitals and 2.5 per cent in non-acute hospitals – a significant reduction on 2006 levels.

Health Secretary, Nocola Sturgeon commented,  "the overall level of infections has reduced by one third since 2006 and cases of some types of infection which cause particular concern, such as C.diff and MRSA blood stream infections, have fallen by over 75 per cent. This is good news but I am in no doubt that there is still more that can be done as we strive to embed quality in all aspects of patient care in Scotland. This is a substantial report and so I have asked the HAI Task Force National Advisory Group to consider the report’s findings and to provide advice on its implications for future HAI policy and priorities.”

So good progress, however, HAI's are a long way from being eradicated. On average at least one patient in every 20 on a ward in acute care at any one time has an HAI.  Scottish Labour's Shadow Health Secretary, Jackie Baillie, said: "The fact six people have died in recent days, 20 wards have been closed and more than 100 people across Scotland are suffering from norovirus symptoms should be a stark reminder the battle against hospital superbugs is far from over."

Hand washing disciplines and infection control staff will probably help mitigate the worst aspect of the problem, but it will not alter the underlying reasons for the development of HAIs. This is beacuse they are an unintended consequence of the factory style hospital care we have developed in recent years. Occupancy and bed turnover rates are at an unheard of level. This together with waiting time targets put constant pressure on hospitals to move ever increasing numbers of sick people through the hospital, together with a similar increase in different vistors.

We also have non-NHS reasons for the increase including farmers using antibiotics. Again, something that is unlikely to change quickly. The overall proportion of bloodstream and urinary infections has risen, with E.coli a growing problem in both. Health Protection Scotland has reported that the prevalence of E.coli was higher (20.8% versus 6.7%) than that reported in the previous Scottish PPS (survey). It confirmed the growing resistance to antibiotics although even this could not account for the rising prevalence of E.coli in Scottish hospitals.

So while an army of protocols, staff and lotions are mitigating the problem of HAIs, we should remember that the underlying cause is in our factory approach to modern acute care. That isn't going to change quickly, if at all.