Happy pills can give you digestive problems and make you MORE depressed

Depression levels in Britain continue to spiral. Last year alone, more than 43 million prescriptions for antidepressants were handed out — 25 per cent more than three years before.

But are antidepressants the panacea we hope them to be? 

Drugs such as Prozac were hailed in the early Nineties as wonder pills that would banish depressive blues for good. But in the past five years, growing scientific evidence has shown these drugs work for only a minority of people. 

And now controversial research in a respected journal claims that these antidepressants can make many patients' depression worse.

This alarming suggestion centres on the very chemical that is targeted by antidepressants — serotonin. Drugs such as Prozac are known as selective serotonin reuptake inhibitors (or SSRIs). Their aim is to boost the level of this ‘feel-good' chemical in the brain. 

But the new research, published in the journal Frontiers In Evolutionary Psychology, points out that serotonin is like a chemical Swiss Army knife, performing a very wide range of jobs in the brain and body. 

And when we start deliberately altering serotonin levels, it may cause a wide range of unwanted effects. These can include digestive problems, sexual difficulties and even strokes and premature deaths in older people, according to the study's lead researcher Paul Andrews.  

‘We need to be much more cautious about the widespread use of these drugs,' says Andrews, an assistant professor of evolutionary psychology at McMaster University in Ontario, Canada. 

Previous research has suggested that the drugs provide little benefit for most people with mild and moderate depression, and actively help only a few of the most severely depressed.

Eminent psychologist Irving Kirsch has found that for many patients, SSRIs are no more effective than a placebo pill. Two years ago, the Canadian Medical Association Journal reported a 68 per cent increase in risk of miscarriage in women on antidepressants.

And research in 2009 on Danish children found a small, but significant, increase in the risk of heart defects among babies whose mothers had used SSRIs in early pregnancy. There is also growing evidence that long-term use in adults is linked to bleeding in the gut and increased risk of stroke. 

The key to understanding these side-effects is serotonin, says Andrews. Serotonin is also the reason why patients can often end up feeling still more depressed after they have finished a course of SSRI drugs.  He argues that SSRI antidepressants interfere with the brain, leaving the patient vulnerable to a ‘rebound' depression of even greater intensity than before.

‘After prolonged use [when a patient stops taking SSRIs], the brain compensates by lowering its levels of serotonin production,' he says, adding that it also changes the way receptors in the brain respond to serotonin, making the brain less sensitive to the chemical. 

These changes are believed to be temporary, but studies indicate that the effects may linger for up to two years. Relapsing is not exclusive to SSRI drugs — it is, in fact, seen in all the classes of antidepressant medications — but Andrews believes that the risk is particularly strong with SSRI drugs. 

Moreover, he warns that antidepressants can disrupt all the physical processes that are normally regulated by serotonin, adding that animal studies show only about 5??per cent of the body's serotonin resides in the brain. Most is housed in the gut. 

It is used, among other things, to control digestion, form blood clots at wound sites, and regulate reproduction and growth. 

So a drug that interferes with serotonin may cause developmental problems in infants, problems with sexual stimulation and sperm development in adults, digestive problems such as constipation, diarrhoea, indigestion and bloating, and abnormal bleeding and stroke in the elderly. 

The drugs may also raise the risk of dementia. 

Most disturbingly of all, Andrews' review features three recent studies which, he says, show that elderly antidepressant users are more likely to die prematurely than non-users, even  after taking other important variables into account.

One study, published in the British Medical Journal last year, found patients given SSRIs were more than 4 per cent more likely to die in the next year than those not on the drugs. ‘Serotonin is an ancient chemical,' says Andrews.  ‘It is intimately regulating  many different processes, and when you interfere with these things, you can expect that it is going to cause some harm.' 

Stafford Lightman, professor of medicine at the University of Bristol, and a leading UK expert in brain chemicals and hormones, says Andrews' review highlights some important problems, yet it should also be taken with a pinch of salt.  ‘This report is doing the opposite of what drug companies do,' he says.  ‘While drug companies selectively present all the positives in their research, this selectively presents all the negatives that can be found. 

Both approaches are simplistic. And while SSRIs might possibly cause rebound depression, it is also sadly natural to expect that people with severe depression will see their illness come back, and often in a worse state.  ‘Nevertheless, the study is useful in that it is always worth pointing out that there is a downside to any medicine.'

Professor Lightman adds that there is still a great deal we don't know about SSRIs — not least what they actually do in our brains. ‘It's a bit embarrassing, but the bottom line is that we don't really know how they work,' he says. ‘Basically, we started using these drugs before we understood what they do, because they showed some effectiveness.'

When it comes to understanding why the drugs work only for a limited proportion of patients, U.S. scientists think they might now have the answer.  They think that in many clinically depressed patients, it's not only the lack of feel-good serotonin causing their depression, but also a failure in the area of the brain that produces new cells throughout our lives. 

This area, the hippocampus, is also responsible for regulating mood and memory. Research suggests that in patients whose hippocampus has lost the ability to produce new cells, SSRIs do not bring any benefit. 

But why the hippocampus should do this — and how it should be treated — is not clear. 

And even if those answers were found, they might still not produce a cure for many cases of depression, because the condition varies so widely in its causes and is so little understood.

What should be sure is that the days of doctors habitually prescribing SSRIs to all and sundry on the basis that they might work, and won't do any harm anyway, really should be behind us. 16.5.12

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We need an Office for Scientific Responsibility

Politics doesn't value evidence-based policy, but policy-based evidence. It's time for ministers to realise that science matters.

It was classic Malcolm Tucker.

Informed that scientific evidence had led the minister to question government policy, the Downing Street spin doctor fired back: "Yeah, but I've got an expert who will deny that."

Who was this authority, the minister inquired? "I have no idea, but I can get one by this afternoon." As so often with The Thick of It, the exchange captured a truth.

Politicians of all parties love to portray themselves as champions of science who follow the evidence wherever it leads. But they rarely want all the evidence – just the bits they can use to justify decisions they're taking anyway. What politics really values isn't evidence-based policy. It's policy-based evidence.

When the Gordon Brown government decided to reclassify cannabis as a class B drug, home secretary Jacqui Smith ignored the misgivings of the Advisory Council on the Misuse of Drugs (ACMD). Instead, she sought more convenient evidence – already weighed and found wanting by her advisers – to support "a compelling case to act now rather than risk the future health of young people".

The coalition has been just as bad. Stung by the ACMD's insistence on banning "legal highs" only on a scientific basis, Smith's successor Theresa May abolished its statutory scientific membership. It can now be packed with the "right experts", as Tucker might put it. Caroline Spelman claimed her long-promised badger cull as "evidence-based" over the protests of the scientists behind the very research she cited. And to justify his NHS changes, Andrew Lansley embarked on a wholly misleading comparison of heart attack deaths in Britain and France.

Each of these policies emerged from political calculation, to appeal to supporters or public opinion. Yet none of the ministers responsible had the guts or the honesty to admit that.

In search of cover for populism or ideology, they cherry-picked data to create a veneer of scientific authority for an unscientific case. This is evidence abuse, and the ease with which politicians get away with it has two pernicious consequences. They feel less pressure to act on scientific advice to make policy that is properly fit for purpose. And it devalues evidence as a currency that voters can use to make up their minds. When every policy is presented as evidence-based, it becomes difficult to know which are genuinely founded on science.

This damaging culture of evidence abuse is partly born of the staggering under-representation of science in the House of Commons. Some 158 of our 650 MPs have a background in business. Another 90 had prior careers in politics, 86 in law, and 38 in the media. Yet just a solitary MP – Julian Huppert, the Lib Dem member for Cambridge – has worked as a scientist, and only two more have scientific PhDs. This shortage denies politics a cadre of people who understand that evidence isn't a kind of magic dust you can sprinkle on a policy to give it credibility, but that you have to look at it all. We need more MPs whose instinct is to consider research in the round before they decide, not twist it afterwards.

For those who lack that instinct, however, policy-based evidence will always be catnip for as long as it carries no political cost. We need urgently to create one, so ministers who aren't ashamed of evidence abuse avoid it out of self-interest. This government has already established an independent Office for Budget Responsibility as a disincentive to fiddling economic figures. It should set up an Office for Scientific Responsibility as well.

Like the OBR, this body wouldn't limit the executive power of ministers, who would remain free to act without, or even in the face of evidence. But when science is cited to justify a policy, the OSR would audit it, naming and shaming those who bend it to their political advantage. The Smiths and Spelmans who reject scientific advice would thus have to admit to it, or face an official rebuke that their Malcolm Tuckers would struggle to spin. It's only by making evidence abuse politically painful that we can hope to put a stop to it. 11.5.12

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Screening has over-promised and under-delivered

What could possibly be wrong with having a mammogram? Or a PSA test for prostate cancer? Even a full body CT scan? Finding the signs of illness before it strikes you down is always the best course of action – isn’t it?

You might have similar thoughts when offered a routine screening test, ultimately believing that screening for illness before it happens can only do good. So, you may be in for a shock, as I was, when I discovered how often medical screening has overpromised and under-delivered. And how frequently the “screen early, screen often” paradigm — including even simple blood tests to check for high cholesterol — can rapidly turn perfectly healthy people into patients.

Some medical screening, such as early testing for colon or cervical cancer, has a long lineage of strong evidence that it can save lives. Others, not so much.

The poster child for inappropriate and harmful screening is probably the full-body CT scan, which is routinely promoted with a “better safe than sorry” message that is compelling, but neither supported by independent experts or good science.

Here’s what not advertised: a full-body scan is pretty much guaranteed to find some kind of abnormality that likely won’t hurt you. In a study published in Radiology, 86 per cent of patients of 1,000 symptom-free people who had full-body CT scans had an abnormality detected.

The average person had 2.8 abnormalities revealed by the CT scan – items which appeared unusual, but either disappeared on their own or were so slow-growing that they never went on to threaten the individual.

Even for screening programs that are well-studied, such as those for breast or prostate cancers, the chances of being saved by the test are often outweighed by the possibility that the individual will be hurt by the testing or possible treatments which follow.

Yet, since most of us know someone whose life has been “saved” by a test, we submit. The PSA test, which screens a man’s blood looking for risks of prostate cancer, might seem like a no brainer for many men, especially those who have lost brothers or a father to the disease. But what most of us aren’t going to hear is that when an individual has a high PSA score (which could be caused by many things), the doctor can’t tell if the patient has the slow growing-type of prostate cancer that the majority of men eventually get (and won’t die from), or the fast-growing type that can be quickly lethal.

Here’s the data, taken from a study published in the New England Journal of Medicine: to save a single man dying from prostate cancer, 1,410 men need to be screened, and of those, 48 will undergo treatment (with chemotherapy, surgery or drugs). About 30 of the treated men will end up impotent or incontinent (a possible consequence of the treatment).

Screening can be a terribly difficult and emotional decision because many of us don’t think in terms of numbers like these. Medical screening falls under the spell of the “popularity paradox” where despite high levels of false positives for many tests (common in breast, lung and prostate cancer screening especially), people still rally behind them. We ask our friends and relatives to help raise money for “the cure” and are cheerleaders for the message of early detection.

In the world of breast cancer screening, many of us know a woman who has dealt successfully with the disease, and are led to believe that early screening saved a life. The truth is that some women, even with screening, will die. And many women, without screening, will be treated successfully. What’s often not factored into the decision-making process is the potential harm incurred from the many false positives, the subsequent radiation from repeated testing, and the pain and suffering from potential biopsies and treatment.

One of the most common side effects of medical screening — the wrenching psychological impact of telling someone they may have cancer when they don’t — is rarely taken into account. And it’s significant.

The latest research for breast cancer screening, from the Canadian Task Force on Preventive Health Care, says that you’d have to give mammograms to 2,100 women aged 40 to 49 every two years for 11 years to save one life. In the interim, screening will result in almost 700 false positives (think more testing, more X-rays and investigations) and about 75 women will have an unnecessary biopsy.
Early screening on its own, without the evidence to back up its usefulness in saving or improving lives, is not only costly to our public healthsystem, but may even cause patient harm.

The principle here is that even when saving a life by screening seems the intuitive and right thing to do, it’s not a deal you should ever enter into without understanding the probabilities first – your chances of being helped or hurt by the test. Talk to your health provider, and always ask for the evidence.

Alan Cassels is an expert adviser with EvidenceNetwork.ca, and a researcher at the University of Victoria. His new book, Seeking Sickness: Medical Screening and the Misguided Hunt for Disease (Greystone Books) will be released this month.10.5.12

End of anti-depressants? Magnetic pulse therapy eases depression in third of patients

Depression affects one in four of us at some point of our lives, but controversy still reigns over how to best treat the debilitating condition.
Now scientists have found that a type of 'magnetic therapy' - which involves no brain-altering drugs or invasive procedures - could be a potent new treatment.

A team from the University of California Los Angeles were testing NeuroStar TMS Therapy, which works by beaming magnetic pulses through the skull. These trigger small electrical charges that spark brain cells to fire. Results from tests on more than 300 patients with severe depression found 58 per cent achieved a positive response while more than a third (37 per cent) went into remission. The study was released at the annual meeting of the American Psychiatric Association. 

Research leader Dr Ian Cook, said: 'The improvements we observed show that non-drug therapy with NeuroStar TMS not only reduces the symptomatic suffering of patients, but lessens the disability of depression with important implications for these individuals' ability to return to functioning effectively at home, in the workplace, and in the community.' All the patients filled in a health questionnaire before and after the treatment.

During each half-hour session the patient was placed under a treatment coil which is the size of a cupped hand. It sent a pulsed magnetic field an inch under the scalp to the prefrontal cortex, the ante cingulate cortex and the limbic system, which are the three areas of the brain thought to regulate mood. 

The magnetic field is similar in strength to that created by an MRI machine and sparks off very small electrical currents within the brain. This stimulates neuron activity thought to provide relief from depression. Anti-depressants are released into the blood, which can cause widespread physical side-effects such as hot flushes and nausea. However, supporters of Neurostar say because it's a targeted therapy it only causes mild scalp pain.

After an average of five weeks of NeuroStar treatment, the percentage of patients reporting extreme problems with anxiety and depression decreased by 42.2 per cent.  A previous study had found that the therapy was twice as effective as a placebo in reducing depressive symptoms.

Dr H. Brent Sovason from Stanford University, said: 'These data reinforce the clinical efficacy of TMS Therapy as a viable option for patients living with major depression who have not achieved or maintained symptom improvement with oral antidepressants. 'The most meaningful takeaway for patients is that TMS Therapy has the potential to make them feel better, in addition to potentially allowing them to experience a level of physical and social functionality they haven't had with their depression.'

In the UK depression for depression involves either medication or talking treatments such as cognitive behavioural therapy, or usually a combination of the two. 10.5.12

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Think the drugs your GP gives you are safe? Well, don't be so sure

We are all swallowing an increasing number of pills, not just to treat disease but to cut the risk of getting a disease in the first place. Even in a time of austerity the NHS is spending nearly £12?billion on drugs and the total keeps rising. People believe the drugs are effective and safe because they have all been properly tested in clinical trials. But this is a dangerous delusion.

Failures in our system for testing drugs mean not only are drugs often no better than a placebo, but, at worst, they end up damaging the health of tens of thousands of Britons every year. Pharmaceutical companies spend billions conducting trials to come up with evidence for the benefits of drugs, but they have a number of ways of making small benefits look impressive.

Then they play down or conceal damaging side-effects. There are a number of examples of drugs with serious side-effects that the pharmaceutical companies have actively hidden from drug watchdogs as well as patients. Recent well-publicised cases include the anti-inflammatory painkiller Vioxx that caused heart attacks, the diabetes drug Avandia that also caused heart attacks and anti-depressants known as SSRIs that raise the risk of suicide.  

Patients have been paid billions of dollars in compensation in America and Vioxx and Avandia have been taken off the market — but the SSRIs are still widely used. And these are just the drugs we know about.

We are in this disastrous situation because clinical trials today are part of what might be called ‘results-based medicine'. The original objective of clinical trials was simply to find out if the drug in question was effective and safe — but that ideal is at death's door.

What has taken over is a hard-nosed ‘whatever it takes' commercial approach. For instance, despite repeated requests by researchers for the full results that were used to license the blockbuster anti-flu drug Tamiflu, the company has refused to make them available. Researchers wanted to see the data because of a strong suspicion the drug was far less effective than claimed.

But it wasn't supposed to be like this. More than 50 years ago, following the Thalidomide disaster, a scientific system of properly testing drugs was set up. Before any drug could be prescribed, trials should prove it was safe and more effective than an inert ‘sugar pill', a placebo.

But drugs have been turned into just another commodity, supported by brilliant marketing of the benefits, while problems and dangerous side-effects are brushed under the carpet, turning what should be a huge benefit into an increasing problem.

Before a drug can be widely prescribed, it has to go through an intensive period of testing, first on animals, then on a small number of patients to see if it is more effective than a placebo. Finally, there are two larger trials, usually involving several hundred people treated for between three to six months. Information from these is then passed on to the drug regulators in each country — the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK — who then check it before issuing a licence.

So how have drug companies managed to get round this system designed to protect patients?

The simplest way is just not to publish unfavourable results. Another way is to publish negative trials but to make them look good. There are plenty of cases on record of senior consultants being paid handsomely to present findings from trials in a favourable light. Meanwhile, doctors who speak out about drug dangers can be vilified and journals who try to publish their work can be threatened with litigation.

As a psychiatrist who has spent nearly 15 years uncovering concealed evidence of how SSRIs can cause patients to commit suicide, I'm very aware of the ability of drug companies and drug regulators to keep asserting there is no problem in the face of the most damning evidence.

In a system committed to patient safety, reports of side-effects would be carefully investigated. But when I uncovered evidence that the companies making the SSRI drugs for depression were hiding studies that showed a raised suicide risk, no one wanted to know. The UK drug watchdog — the MHRA — did nothing. Another technique to play down unfavourable results is ‘ghost writing'. In theory, the scientist heading a clinical trial analyses the findings and the results are published with his or her name on it. Not so in the distorted version of evidence-based medicine created by drug companies.

We are talking here about the controlled trials, which doctors and  regulators rely on to tell if a drug is more likely to work for you or to cause you harm. Worryingly, many that appear in top journals such as the New England Journal of Medicine have actually been written up by ‘ghosts' employed by the pharmaceutical company that has a patent on the drug, and so are far more likely to provide the results they want.

However, the name that appears on the paper is often that of a senior consultant who is well paid for lending his name and authority to the work.

Sometimes, there can be a shocking gap between what the trial had found and how it was written up.

Then there is the reclassifying of patients. Every trial has patients who drop out — for personal reasons or because they couldn't stand the side-effects. But they are all simply classified as being ‘non-compliant', meaning they didn't take their drugs. There is a fundamental reason why doctors and patients can't get reliable information about side-effects from supposedly ‘scientific' clinical trials.

It's not just that they are downplayed or hidden — the trials aren't designed to find the problems in the first place.

Trials run for only a few months with a few thousand people. That's not enough time or numbers to detect rare but serious side-effects when millions of people take a drug for years.

Also, the side-effects are often the same as the ones caused by the disease. Depression raises the risk of suicide but so do SSRI anti-depressants. Cardiovascular conditions cause memory loss and diabetes — as do statins. The way to isolate the side-effects of the drugs is to test them on healthy volunteers, which companies have to do, but the results are rarely released to the public.

Just how much the system allows drug companies to accentuate the positive and eliminate the negative was shown in the way a tranquiliser called Zyprexa (olanzapine in the UK) was promoted. It was licensed on the basis of four clinical trials involving just over 2,000 patients.

Yet the company was able to carve up the results into separate articles that appeared in 234 medical publications all saying how effective this drug was. The evidence for its benefits appeared overwhelming when it was just the same data being repeated.

Sales soared. There was no mention of the potentially deadly side-effects, even though it was known to increase the risk of diabetes and heart disease — as well as being linked with suicide. The companies cut the risk up into small bits so that overall it looks safe.

But until trial data is freely available for independent researchers to examine, these abuses are likely to continue.

Professor David Healy's book, Pharmageddon, is published by the University of California Press, £27.95. 24.4.12

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NHS Leadership Academy launched to create managers of the future

The NHS Leadership Academy has been launched in a bid to become a “world class” national centre to produce and inspire current and future generations of NHS leaders to drive improvements in patient care.

It is hoped it will help develop outstanding leadership in order to improve patients’ experiences, their health outcomes and their wellbeing.
To do this it will work with doctors, nurses, health professionals and managers from across the NHS. It will also work with public health and social care, and with local government, where Health and Wellbeing Boards are key to improving health and care outcomes.

Secretary of state for health Andrew Lansley unveiled plans for the Academy in July last year.

NHS chief executive Sir David Nicholson said: “The ethos is simple. NHS success is dependent on great leadership right across the service, across clinicians and managers. Great leaders create working climates where people working with them feel engaged, empowered and satisfied. Those people in turn have a direct positive impact on patients’ experiences and their health outcomes. Everyone working for, with or on behalf of the NHS has a crucial role to play in this, as we focus on our purpose of improving health outcomes for our patients.”

“We face huge challenges across the world of health, social care and public health. Our leaders must be better equipped and more innovative than ever before. Vitally, they must be able to work in an integrated way across health and social care, to make sure people have a consistently good experience of our services.

“Developing outstanding leadership has never been more important than now.”

Jim Easton director of transformation for the NHS Commissioning Board, added: “The Academy will provide expertise and support to help the leaders we have now. At the same time it will support the development of a new generation. They will steer the NHS into a future, which builds on our existing strengths and adds new ones, championing clinical leadership, inclusion, equality and diversity, and encouraging innovation.
“People will be able to access this learning and support from an ‘entry’ level to the most senior and experienced leaders.

The Academy will give them all tools, techniques, support and behaviours to help them engage and enable their staff, partners and patients, as well as continually improving standards.
“'With change at a scale and pace the NHS has never seen before, the fundamental difference between success and failure is the calibre of leadership.”

The Academy launches its new website (www.leadershipacademy.nhs.uk) with video stories from some of the NHS’s most inspiring clinical and managerial leaders about their work and its impact on the NHS and patients.
The Academy has four main areas of work:

• Developing the approach to leadership: defining and promoting what good leadership looks like, based on the recently developed Leadership Framework; setting national standards for leadership development and talent management with frameworks and toolkits; rewarding and recognising outstanding leadership (the 2012 NHS Leadership Recognition Awards are being run by the Academy and nominations have now opened www.nhsleadershipawards.nhs.uk)
• Providing and commissioning a range of cutting edge national programmes: in total these will make up the single largest training programme for leaders in the world and culminate in the professionalisation of leadership in the NHS. They include: the Graduate Management Training Programme for the most; Breaking Through to support leaders from BME communities; Top Leaders for those in the most senior roles; the Clinical Leadership Fellowship Programme, along with career development programmes with different entry levels for different staff
• Supporting the development of local leadership capability: providing expert support for local NHS and key partner organisations to sustain and promote leadership in their area
• Supporting changing and developing parts of the NHS system: developing shared leadership approaches with local government and providers of NHS services; providing frameworks for Foundation Trust governors and Clinical Commissioning Group development; supporting leadership for innovation and QIPP. 13.4.12

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Surgery and drugs couldn't fix my 13 years of crippling back pain. But six months of physio did: Emma Forbes on her last-ditch remedy

Ever since the birth of her first child, Lily, 15 years ago, former Radio 2 presenter Emma Forbes has suffered back ache, although those two words barely do justice to the agony that has often left her bedbound, shedding tears of frustration, unable to walk or to rest, sleep or eat. 

In her darkest moments, after surgery failed, she admits to wondering if she would ever know a life without pain. Just like 80 per cent of pregnant women, Emma first suffered the condition during pregnancy.  Known as postpartum back pain – and dubbed ‘baby back' – the problem is due to hormones such as relaxin being released to soften the joints and tendons, particularly in the pelvis and lower back, preparing the body for labour.  

In one fifth of cases, this develops into chronic (long-term) back pain, and numbers are spiralling as a result of increasing obesity rates in women, say experts.  

Although never overweight, Emma was one of the unlucky ones. ‘Before being pregnant, I'd never had back pain,' she says. ‘It started in the base of my spine and travelled down one leg. 'Everyone I spoke to seemed to have a remedy – try Pilates, try yoga, see a chiropractor.

‘If I lay down flat, I could relieve the pain, but when I stood up it returned.'It was worse when I was driving, or having to sit still or stand for any length of time. I thought it would disappear after I gave birth.'

Emma had a 38-hour labour with Lily and required an epidural. ‘I put on two-and-a-half stone in pregnancy, which is a lot for my size ten frame,' she says. ‘Because I had an epidural, I couldn't feel any pain, and I think I had extremely bad posture when I was giving birth.'

Hers was a classic case of baby back, according to orthopaedic specialist Dr John Outhwaite, of the Nuffield Orthopaedic Hospital.

He says: ‘It's common in pregnant women, not simply because of the weight of the child, but also the fact that the mass inside the abdomen distorts the transverse abdominal muscle, which is the key muscle for switching on and off our core stability. ‘It is stretched and squashed in pregnancy and its movement and efficiency are disrupted when carrying a baby. If you have weak core muscles, you will get a bad back.'

Key blood supply is also affected by pregnancy. ‘Metabolically, the baby is very active, and a huge percentage of a woman's blood supply is diverted to feed the child.  'This creates a weakness in the back muscles because they are being starved of blood. 'A prolonged birth can cause acute injury to the soft tissue in the lower spine, causing chronic pain.'

Emma says: ‘I struggled on, trying cranial massage, a chiropractor, acupuncture and massage, but nothing worked. 'Then I became pregnant with Sam (now 13) and after his birth the pain became unbearable.' 

The 46-year-old, who lives in London with banker husband Graham Clempson, 47, visited her GP, who referred her for a magnetic resonance imaging (MRI) scan showing the inside of the body. ‘I was told, to my horror, that I had two slipped discs,' says Emma.

The spine is made up of 24 bones called vertebrae stacked on top of each other. Discs are the protective, circular pads of gel-filled cartilage that act as cushions between the vertebrae. A slipped disc occurs when one ruptures and the gel inside leaks out.

The damaged disc can put pressure on the whole spinal cord or on a single nerve fibre. This means a slipped disc can cause pain in the area of the protruding disc and in any part of the body that is controlled by the nerve the disc is pressing on.

In Emma's case, the damage was in the lumber – or lower – spine. ‘The surgeon said I could hope it would go away but the only real option was surgery. I knew this would be debilitating, that I'd be flat on my back for a while. I said, “I just don't have time!” His expression said it all.

‘I soldiered on but a few weeks later, in 1999, I was being driven down the King's Road in London with my sister Sarah and I said, “Stop the car.” The pain was so unbelievable I was in tears. 'I then knew I had to do something. I rang the Wellington Hospital in London and they rushed me in as an emergency patient and I had one-and-a-half hours of surgery. ‘When I came round I was euphoric – the pain had gone. I'd had 42 metal clips inserted in my spine, and I had to learn to walk again.'

Emma had a microdiscectomy, where the surgeon cuts away the bulging part of the disc via an inch-long incision in the back. This relieves the pressure on the nerves, alleviating pain. After five days in hospital, most patients are allowed home.  However, recovery can take six weeks and some studies suggest that up to 25 per cent of patients will need further surgery for recurrent pain.

Emma's initial recovery was a false dawn. ‘I carried on happily for a year – and then the pain came back with a vengeance.  'I was mortified. I felt I couldn't go through it again. It was ruining my life.'

Emma struggled on until 2009, when a physiotherapist, David Bolton, was recommended to her by a friend. ‘He was a last gasp for me, because otherwise I could have been facing surgery again. 'Some people have this operation two or three times as the problem often recurs. 

'By the time I went to see David, I was in so much pain I could barely walk into his consulting room – I shuffled in sideways. ‘His approach was calming and he taught me how to let go of the fear of my pain.  'I was walking around holding myself tensely upright, as if someone was about to punch me in the back. 'I was over-protecting myself, and making things worse.'

Twice a week, for half-hour sessions, he manipulated her back and legs with gentle movements.  Emma says: ‘He wasn't pummelling me, rather gently moving me about, manipulating and rotating my spine. 

‘Every day I had to do set exercises of twisting and stretching involving my spine, often lying down. 'Within six months, I was pain-free.'

Emma has now been without back pain for two years, and David's treatment has allowed her to begin exercising gently. ‘I can't play tennis but apart from that my life has improved immeasurably,' she says. ‘Every morning I wake and realise with a jolt of happiness that I have no back pain.'

Emma sees David every two weeks for maintenance sessions – not cheap at £90 but, she says, well worth the price. ‘I know I will always have to take care of my back, as the damage has been done. 'At least now I have got rid of the awful grating pain that had been dominating my life.'

Dr Outhwaite agrees physiotherapy is one of the best forms of treatment because it mobilises the spine and is self-correcting, rather than drugs that can just mask the problem.  He says: ‘Operations are vital in some cases. What you should not do is try to ignore the pain and hope it will go away. 'If untreated, it will only become worse.' 14.4.12

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Physiotherapists not allowed to touch patients in 'barmy' NHS initiative

 Physiotherapists have been banned from touching their patients in a new set of 'barmy' NHS plans.  Patients in one part of the country are instead being offered 'advice and guidance' instead of hands-on treatment after health bosses barred medics from using their skills.

Instead of massage or the manipulation of joints and limbs patients in Rushcliffe, Nottinghamshire, are now being directed to websites and handed information leaflets so they can teach themselves exercises at home.

Before January 1, 2011, the Principia clinical commissioning group, which plans and buys healthcare services in Rushcliffe, offered one assessment and up to four treatments for physiotherapy patients. This includes patients who are suffering from soft tissue injuries and pain in their back, neck or joints.

But, following a review of services, it has changed from a treatment service to an advice and guidance service.

This means that physiotherapists are no longer allowed to touch patients, and instead give advice on what exercises they should be doing and information on how to manage their condition themselves.

The Chartered Society of Physiotherapy has labelled the scheme ‘barmy'. Chief executive Phil Gray said: 'They seem to have invented a new form of physiotherapy that no one has heard of - do-not-touch physiotherapy.' 'Physiotherapists can't actually physically touch you at all under this system. It is deeply unscientific.

'There is no research or evidence to back up hands-off physiotherapy. 'Patients have been reporting back to GPs a very strong disappointment, and the physiotherapists providing this service are saying that basically "you are preventing us from doing a professional job".'

The professional body asked all primary care trusts in the country about their physiotherapy services and any budget cuts.

Mr Gray said that Principia was the only group not to offer a hands-on treatment to physiotherapy patients. He added: 'It is a completely barmy form of treating people, which means that the only solution will be to go to the private sector and pay for themselves.'

Patients in Rushcliffe are also capped to a maximum of two physiotherapy appointments a year and have to visit their GP twice, six weeks apart, to get a physiotherapy referral in the first place.

Mr Gray said this was too long to wait. He added: 'Getting people quickly into early intervention services makes a real difference to their ability to go back to work.  'The less treatment they go on to have and the longer it is left, the more complex problems it causes for people.'

Barbara Venes, of the Local Improvement Network, which represents patients in the county, also raised concerns.  She said: 'I think it is just awful. If you need physiotherapy, you need the treatment, not just advice. 'They are pushing people into paying privately and some people cannot afford to pay for it and so won't get treatment.'

She added that older patients may struggle to access information online, and that people needed practical demonstrations of how physiotherapy exercises should be done to ensure that they were doing them correctly.

She said: 'If you need physiotherapy, it is painful when you start.' 'If you are doing it with a physiotherapist, then they can reassure you that it is normal to get some pain. 'But if you are doing it yourself, then people are afraid that if it is painful then they are going to get more damage.'

A spokesman for Principia said that the change in service had not been a cost-cutting measure, and that costs were broadly the same as before. She said that 'more vulnerable' patients received treatment through other means, such as a hospital specialist. She said: 'Following a review, the service was changed to one of advice and guidance to encourage patients to self-care prior to further review by the GP. 

'In some parts of the county this is done by web-based advice or in group sessions, and is the important first step in patients with back and neck problems.' She added: 'Once a decision to refer to a specialist is made by a GP, patients are seen quickly by a physiotherapist.

'With the advice and guidance service, patients are given practical advice to help them self manage their condition. 'This includes exercises to alleviate and manage their symptoms. This service enables all patients to take control of their condition and get better quicker.'

Janis Powell, of Aspley, who suffered back pain for many years and is part of the Chronic Pain Support Group in Notts, said: 'I think it is really disgusting and is not helping patients whatsoever. 'As a former patient myself, I would feel let down by this new service. Patients might not try and help themselves if there is nobody there to support them.' 10.4.12

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For every life that is saved by breast cancer screening up to TEN women suffer 'unnecessary treatment' including breast removals

•  'We've exaggerated the benefits of screening and we've ignored the harm,' says expert.

Thousands of women are undergoing unnecessary treatment for breast cancer including chemotherapy and even breast removal following screening, researchers have found. Academics from Harvard School of Public Health studied the results from 40,000 women who were screened in Norway.

They found for every 2,500 women offered screening, one death from breast cancer would be prevented - but six to 10 women would be treated for a benign cancer that would never cause symptoms.

This 'overdiagnosis' results in thousands of women receiving damaging treatment including surgery, powerful drugs like tamoxifen and chemotherapy. If the cancer appears aggressive the decision may be made to remove the whole breast - a procedure known as a mastectomy. The Harvard study is the latest in a recent slew of research to question the long-held belief that the benefits of national screening programmes far outweigh the harm they can cause.

In the UK, the NHS screens around 1.6million women for breast cancer every year. Women aged from 47 to 73 are invited to screening every three years as the risk of developing the condition increases with age. Breast cancer deaths have fallen by more than 10 per cent in Britain over the past five years, which Stephen Duffy from Cancer Research UK said was partly due to screening.

However, a recent study from the International Prevention Research Institute in Lyon, France, suggested better treatments are more likely to be causing the recent drop in death rates.

There is currently an independent review underway into whether the UK programme causes more benefit than harm. A Department of Health spokesman said: 'Our screening programme is regularly scrutinised. 'We know that there are some scientists who differ in their views towards screening, so as requested by ministers, the National Cancer Director Professor Sir Mike Richards has commissioned an independent review of the evidence in partnership with Harpal Kumar, chief executive of Cancer Research UK.'

In the latest study the Harvard researchers estimate that up to a quarter of breast cancers found by mammograms won't cause any problems during a woman's lifetime. Once cancer is found, however, doctors must treat it as they do not yet have an effective technique of working out which ones will be dangerous.

'When you look for cancer early and you look really hard, you find forms that are ultimately never going to bother the patient,' said Dr H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice, who was not part of the research. 'It's a side effect of early diagnosis.'

The study from Harvard School of Public Health is the latest to explore overdiagnosis from routine mammograms - finding tumors that grow so slowly or not at all and that would not have caused symptoms or death. Previous estimates of the problem have varied.

The researchers took advantage of the staggered decade-long introduction of a screening program in Norway, starting in 1996. That allowed them to compare the number of breast cancers in counties where screening was offered with those in areas that didn't yet have the program. Their analysis also included a decade before mammograms were offered.

Study leader Dr. Mette Kalager and other experts said women need to be better informed about the possibility that mammograms can pick up cancers that will never be life-threatening when they consider getting screened. 'Once you've decided to undergo mammography screening, you also have to deal with the consequences that you might be overdiagnosed,' said Kalager, a breast surgeon at Norway's Telemark Hospital and a visiting scientist at Harvard School of Public Health.  'By then, I think, it's too late. You have to get treated.'

Kalager and her colleagues looked only at invasive breast cancer. The study did not include DCIS, or ductal carcinoma in situ - an earlier stage cancer confined to a milk duct. Under the Norway program, screening was offered every two years to women ages 50 to 69.

Researchers analysed nearly 40,000 breast cancer cases, including 7,793 that were detected after routine screening began. They estimated that between 1,169 and 1,948 of those women were overdiagnosed and got treatment they didn't need.

Their findings appear in Tuesday's Annals of Internal Medicine.

Commenting on the study Dr Welch said: 'The truth is that we've exaggerated the benefits of screening and we've ignored the harms. 'I think we're headed to a place where we realize we need to give women a more balanced message: Mammography helps some people but it leads others to be treated unnecessarily.'

An editorial published with the study said overdiagnosis probably occurs more often in the United States because American women often start annual screening at an earlier age and radiologists in the U.S. are more likely to report suspicious findings than those in Europe.

Radiologists could help by raising the threshold for noting abnormalities, wrote Dr Joann Elmore of the University of Washington School of Medicine and Dr. Suzanne Fletcher of Harvard Medical School.

A 'watch-and-wait' approach has been suggested instead of an immediate biopsy, but the editorial writers acknowledge that could be a 'tough sell' for some women and radiologists alike. They said most women aren't aware of the possibility of overdiagnosis.  'We have an ethical responsibility to alert women to this phenomenon,' they wrote. 4.4.12

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I warned about the dangers of metal hips 15 YEARS ago: A whistleblower reveals the real scandal over danger joints

The horrifying revelations about the dangers of metal-on-metal hip implants may have come as a shock to the thousands who have them.

Sadly, the news didn't come as a surprise to me. As someone who designs medical devices, I worked with the company contracted to develop and manufacture one of the first of these hip resurfacing devices. What's shocked me is that this scandal has taken so long to be exposed.

With a metal-on-metal replacement, the top of the bone and the socket it goes into are replaced or resurfaced in metal. The first replacements were carried out at the start of the new millennium and were hailed as providing better mobility than the old — but safe and long-lasting — metal on plastic replacements.

Fifteen years ago, I and a number of other colleagues were vociferous in our criticism of the new design. I am not patting myself on the back. An averagely bright teenager knows that running metal against metal will cause friction, and sooner or later friction causes wear. 

This wear results in debris, tiny particulates which, in a car engine, for example, will filter to the bottom and lie in the sump waiting to be drained out. There is no sump in the human body — just highly delicate tissues and organs, a complex vascular system and lungs, in which metal debris could cause untold damage.

The Medicines and Healthcare Products Regulatory Agency, the safety watchdog, has talked about toxins from the particulates causing inflammation in the body. Some studies are linking metal-on-metal replacements with bladder cancer. Certainly, they have a far higher failure rate than other types of replacement hips.

Those who warned against metal-on-metal included people like me who worked on the prototypes as well as engineers and designers who had  heard about the development and were concerned.

But no one listened to us. 

Indeed, when several of us pointed out this basic design flaw to the company I worked with, we were told the surgeon who'd come up with the idea — and who was working with the company to produce and endorse this replacement system — knew better than we did.

The attitude that the surgeons know best has become endemic in our industry. 

‘Designed by surgeons for surgeons' seems to be a slogan that every medical device company wants to trumpet on their new products, without stopping to consider just how ludicrous this is. Certainly surgeons may spot a need for a medical advance or even come up with a rough concept of how this may work.

But unless they happen to also have an engineering or design degree alongside their medical and surgical skills, allowing them to act as if they are design experts is — as we can see now — a dangerous path to take. Unfortunately, instead of enlightening them regarding their limitations, the medical devices companies have been all too ready and willing to foster this illusion.

This is not to do with cost. It is no more expensive to hire an engineer than a surgeon. It is simply that there is nothing a medical device company likes better than to get a surgeon on board to ‘advise' on a product. As a result, virtually every surgical device in the past ten years has got surgeon approval or design input. 

Most vitally, it also gives companies a gateway into that magic world of NHS buyers, who in turn rely heavily on the recommendations of those same surgeons when they spend our millions on medical products.

The medical world, particularly within individual specialities such as orthopaedics, is a small place. The medical device companies know only too well that if one surgeon turns their back on a product, their colleagues may well follow suit, and all those millions of pounds spent designing and producing will have gone to waste.

But if a surgeon endorses it — well, the sky's the limit. It is common knowledge within the industry that items costing just a few pounds to produce are sold to the NHS with profit margins as high as 2,000 or 3,000 per cent above the manufacturing cost.

The argument is that the high prices are necessary to recover the design and development costs, the on-going assessment of the product, surgeon training and possibly royalty payments to the surgeon who ‘assisted' with the design concept.

No wonder then that surgeons are so powerful — and that many of them are becoming very rich.

No longer content to earn a five-figure salary from the NHS, then doubling that with private work, a surgeon involved with a medical device manufacturer can be paid handsomely for that, too.  One surgeon in the North-East told me quite openly that he earned well over £100,000 per year in device royalties alone.

No doubt the device he worked on, will, on his recommendation, be in regular use in his NHS operating theatres.

Even more blatant is the recent development of surgeons forming companies to buy medical devices and instrumentation direct from the manufacturers, often based overseas, at discounted prices and then encouraging their hospitals to buy from them at an inflated price. And all on the pretext that because they are surgeons they somehow provide a more authoritative endorsement of the products they are selling.

In any other profession this would be seen at the very least as a conflict of interest.

No one is saying that surgeons or, indeed, any doctor should not be allowed to come up with ideas for improving patient care. Of course, they are the ones at the front line, who see the need for a new device or a better product. But then they should step away, leave the design to experts who have had years of training in design and engineering to actually create, test and produce the device.

In short, surgeons should stick to being surgeons.

I'm not saying this because I want to protect my profession. I'm saying it because I genuinely believe it is unsafe to allow untrained people so much power and responsibility in producing devices that can have a huge impact on people's health. Maybe the NHS bureaucrats will wake up and realise what is going on under their nose and do something about it. But I'm not holding my breath. 20.3.12

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The doctor who broke up families: Psychiatrist who damned hundreds as 'unfit parents' faces GMC probe

• Dr George Hibbert could be struck off over his conclusions that hundreds of parents had ‘personality disorders’
• Millionaire is now being investigated over shocking suggestions he distorted the assessments to fit the view of social services
• Lib Dem MP writes to Justice Secretary Ken Clarke demanding a full parliamentary inquiry

A leading psychiatrist faces extraordinary claims he deliberately misdiagnosed parents with mental disorders – decisions which meant their children were taken away from them. Dr George Hibbert faces being struck off over his conclusions that hundreds had ‘personality disorders’ after assessing them at his private family centre.

He was paid hundreds of thousands of pounds by social services for the reports which tore children from their parents – many of them young mothers. He is now being investigated over shocking suggestions he distorted the assessments to fit the view of social services.  In one case, he is alleged to have wrongly diagnosed a ‘caring’ new mother –  named only as Miss A – with bipolar disorder because her local authority wanted the  baby adopted.

After being confronted with this allegation, Dr Hibbert offered to surrender his licence to practise as a doctor rather than face a General Medical Council inquiry. But his request has been rejected by the GMC which says there are still ‘unresolved concerns regarding his fitness to practise’. He will now face a full fitness to practise hearing. 

Yesterday John Hemming MP, who has raised concerns about Dr Hibbert in Parliament, described the claims as shocking.  The Lib Dem MP – alerted by a whistle-blower – said he had since spoken to ‘three or four’ other families who said the same had happened to them.  He has written to Justice Secretary Ken Clarke demanding a full parliamentary inquiry.

Mr Hemming said: ‘He is someone about whom a number of people have complained. I am told that at least one person has refused to work for him because of what she saw as his unethical provision of reports to suit the demands of local authorities. ‘Much of the decision making in care proceedings rests on reports from experts such as Dr Hibbert,’ he told Parliament. He added that supposedly independent experts such as Dr Hibbert, 59, were often little more than ‘the hired gun of the local authority’. The lack of transparency over such experts was leading to‘thousands of miscarriages of justice in care proceedings.

Earlier this week, a study for the Family Justice Council revealed how life-changing decisions about the care of children are routinely being made on the basis of flawed evidence. A fifth of ‘experts’ who advise the family courts are unqualified.

Dr Hibbert charged local authorities £6,000 a week for every family in his care and £210 an hour just to read documents such as medical records.
By 2007 his company, Assessment in Care, was making a profit of around £460,000 a year from  his lucrative arrangement with social services. 

He is now worth more than  £2.7million. Last night a black Porsche Turbo, thought to be worth around £120,000, and a grey Porsche 911 Carrera, worth around £80,000, were parked on the gravel driveway outside his £500,000 country cottage.

A former honorary lecturer at Oxford University, who has previously advised the government on care assessments, Dr Hibbert left the NHS to set up his private assessment centre in 2000. Since then, hundreds of parents in contact with social services – usually mothers and babies – have been referred to his centre to  be assessed.

Concerns were first raised in 2007, when mother Miss A complained that Dr Hibbert had wrongly diagnosed her with a bipolar disorder.  One consultant psychiatrist accused Dr Hibbert of having ‘no evidence’ for some of his claims and of deliberately ‘exaggerating’ and ‘misrepresenting’ aspects of the woman’s behaviour. Her report is among a number of documents being examined by the GMC with regards to Dr Hibbert.
Miss A, who has seen her son just a few times since, said Dr Hibbert was ‘corrupt and evil.’ 

‘Nothing will ever make up for what he has done to me and my child,’ Miss A said. ‘I want to make sure this man is exposed and that he can never do this to anybody else.’  In a letter sent to Miss A, a GMC investigations officer confirmed Dr Hibbert ‘has now applied for voluntary erasure from the medical register’. The letter continued: ‘He has no intention of returning to clinical practice in the future.’

However, the GMC officer concluded it was in the ‘public interest’ for his request to be denied ‘in view of the nature of the performance allegations and in the view of the conduct concerns.’  He has not been available for comment at his two-storey detached cottage in the small village of Blunsdon near Swindon. His assessment centre next to his home appeared to be closed.

A spokesman for Dr Hibbert at the Medical Protection Society, the indemnity organisation for doctors, said professional confidentiality meant Dr Hibbert was ‘unable to comment on allegations raised in relation to care of a patient’. 

Paul Grant, of Bernard Chill & Axtell Solicitors, who represents Miss A, said: ‘Our client has instructed us to launch proceedings against Dr Hibbert and the local authority.  ‘We believe this distressing case may be the tip of a very big iceberg.’ 17.3.12

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What every family needs to know about the great NHS health revolution 

It's the biggest NHS shake-up in 60 years and with even medics admitting they're confused, no wonder patients are growing increasingly worried.

Everyone knows they're important - and that they could transform the way you, and those close to you, are cared for when you're most vulnerable. Everyone also knows they're causing one of the most bitter political battles for years. But how many of us actually understand the Coalition Government's plans to reform the National Health Service?

The changes are the biggest shake-up of the Health Service in England and Wales for 60 years. Ministers say their aim is to create a ‘patient-led NHS' and cut bureaucracy by giving power to GPs and front-line clinicians.

This, they promise, will not only improve care but also slash bills at a time when health costs are rising due to our ageing population and the increased cost of drugs and new treatments.

Critics say the very foundations of the NHS, with its promise of free care for all, are at risk. But they, in turn, stand accused of putting the interests of bureaucrats and health workers ahead of patients.  

Meanwhile, even doctors who support the reforms complain that Health Secretary Andrew Lansley has made a terrible job of explaining them, and there have already been hundreds of amendments to the original plans.

So what is all the fighting actually about? And what do the reforms really mean for patient care? Good Health asked the experts to explain how the reforms affect YOU . . .   

Your GP will foot your medical bills
One of the biggest changes is that GPs will be given control over around 60 per cent of the NHS annual budget of £110?billion, with responsibility for planning and buying health services for their patients. 

As well as using their budgets to buy your drug treatments and diagnostic tests, they will be paying for your hospital care. This responsibility previously lay with 151 primary care trusts, which are being abolished together with the ten Strategic Health Authorities which oversee them.

Your GP will exercise his new financial power through clinical commissioning groups (CCGs), made up of groups of GP practices covering around 100,000 patients (although there isn't actually a minimum or maximum size for them). Hospital doctors and nurses will also be involved in the CCGs.

Your GP won't, however, be responsible for arranging dental services or specialist care for people suffering from rarer conditions such as motor neurone disease, or needing neurosurgery. These will be handled by the new NHS Commissioning Board, which will also oversee the CCGs.  

PROS:  
Giving GPs control of the money means, in theory, that you and your doctor — rather than a remote and bureaucratic primary care trust — will have the power to choose the 'best treatment' for your condition. 

For example, this could mean that a man with advanced prostate cancer might now benefit from an effective drug such as abiraterone — even if it is turned down by the National Institute for Health and Clinical Excellence (NICE) because it's too expensive — if his GP chooses to prescribe it to him.

As Paul Bowen, a GP who heads a CCG already set up in Cheshire, explains: ‘Instead of someone else making decisions about what patients need, my clinical staff and I will work with patients, giving them a wider choice of where, when and how they receive their healthcare.'

Supporters claim this is a  long-overdue revolution. 

‘The biggest problem we have is the top-down nature of the NHS,' says Dr Charles Alessi, chair of the National Association of Primary Care, an organisation for those involved in primary care, including GPs and PCT staff. 

‘This is really what is behind the reforms — devolution of responsibility to the frontline.  ‘I will fight to the death for the NHS, but we have to change the way we do things for it to survive. The challenge of people living longer, and the increasing complexity of illnesses, cannot be met by existing processes and bureaucracy.'

CONS:  
The main argument against giving GPs control of the money is that while they're skilled at looking after patients in the community, few have the proven financial and planning skills to manage the business of commissioning services.

The expectation is that GPs will end up employing outside companies to arrange contracts for their  patients' treatment. ‘Our worry is this will mean that GPs will end up rubber-stamping decisions made by vast management companies who have little actual insight about patients and their needs,' says Dr Clare Gerada, chair of the Royal College of General Practitioners.

There is also concern that GPs, under pressure to stick to tight budgets, will make decisions based on their balance sheet rather than what you, the patient, need. Another concern is about potential conflicts of interest when GPs commission services from organisations they part-own. 

The commissioning groups will, for example, be allowed to own cataract clinics, so could in theory commission their own clinic to provide their patients with treatment. Meanwhile, rather than cutting bureaucracy, it is feared that the new NHS Commissioning Board will end up as yet another top-heavy layer of management.

Already, it's expected to employ 3,700 people and have an administrative budget of £492?million. Its responsibilities are growing rapidly, as GPs say they're not ready to take the reins with commissioning.

It's quality of care that matters
A key aim of the reforms is to shift the focus onto quality of care. There will be less emphasis on waiting lists and ‘access' targets (such as making sure you start treatment within 18 weeks of a GP referring you to a specialist). 

Instead, the focus will be on performance targets, which measure patient outcomes — for example, how many patients are dying from  heart disease. The original plan had been to abolish access targets altogether, but there has been some back-tracking on that. (It is not quite clear if the 18-week target will remain.)

So how will the NHS ensure you receive better care?

The answer is through new guidelines called Quality Standards, which set out the best practice for treating patients suffering from different types of diseases.

For example, if you've been treated for early breast cancer, you should expect to be given an annual mammogram for five years after treatment. GPs will be expected to take account of these standards when commissioning services.

As part of the shift to quality of care, patient feedback is also likely to be given more prominence, so you'll probably find yourself filling out even more feedback forms on the quality of care you've received in hospitals.

PROS:  
In theory, you should receive a better standard of care. The Quality Standards will be concise and set out treatment priorities clearly, unlike the current NICE guidelines on patient care (the Quality Standards won't replace these guidelines, but will sit alongside them).

‘The intention to bring forward more Quality Standards is a positive step for patients in disease areas like rheumatoid arthritis, which has been overlooked in the past,' explains Jamie Hewitt, of the National Rheumatoid Arthritis Society.

CONS:  
Doctors are concerned that asking patients if they're satisfied with the quality of their care might not actually be a good measure of best care.

As Dr Clare Gerada explains: ‘There are occasions when  patients want hospital referrals, when the truth is they don't  really need yet another fruitless visit to a specialist.'

The problem, she suggests, is that they won't be ‘satisfied' with their treatment unless they get that referral, even if it's not what they actually need for best care.

Hospitals will be allowed to go bust
Hospitals will now have to generate all their own funding by offering services to GPs for a fee.

All hospitals will be made into foundation trusts — a legal change that means they have control over their budgets and can borrow money. They'll also have greater powers to increase their revenues — for example by offering services to private patients. 

This happens to a limited degree already (in most NHS hospitals, between 2 and 10 per cent of overall revenues come from private practice), but in future hospitals will be allowed to get up to 49 per cent of their revenue from private work. 

For the first time, some hospitals that go too far into the red will be allowed to go bust.

PROS:  
Money from treating private patients could benefit NHS patients  — as currently happens, for example, at King's College Hospital in London, where profits from the private fertility clinic are used to help NHS patients who have fertility problems.

London's Royal Marsden, one of the world's leading cancer hospitals, already gets one quarter of its income from private patients — just short of a 30??per cent cap set in 2003. A spokesman says: ‘The surplus from our private patient income is invested back into NHS facilities and care.'

Letting NHS hospitals increase their revenues from private patients should help make them financially viable. Currently, without Government support, many hospitals, including major teaching hospitals in London, might be technically bankrupt.

CONS:  
Previously, NHS hospitals have not been allowed to go  bust but have been bailed out when in difficulties. Now, if they can't make ends meet, such hospitals could be allowed to go under and shut down.

‘The former NHS hospital sites will probably be sold off for development — the Bill contains new arrangements to facilitate this,' says Dr Lucy Reynolds, a health services researcher at the London School of Hygiene and Tropical Medicine.

The public would be outraged by the loss of a local hospital, even one that is losing money. 

Critics also say that increasing income from private care could produce a divisive, two-tier system, where patients with the same illness on the same ward receive different treatment depending on whether they are NHS or private.

Greater Competition
The Government wants to encourage greater competition throughout the NHS, and encourage the private sector and charities to compete for business with NHS staff and hospital trusts. This was already happening under the previous Labour government.

The private sector won't compete on price — there will be a set tariff for services and treatment — but on quality of service. 

This is one of the most contentious areas of the reforms. ‘What we are seeing is privatisation by stealth,' says Good Health's regular columnist Dr Martin Scurr (himself a private GP).  This is a universal concern among opponents to the bill. However, the Government insists that privatisation is not its aim.

PROS:   Involving the private sector could free up NHS hospital doctors from carrying out straightforward routine procedures, so they can concentrate on more complex cases — and become more skilled at these specialisms.

CONS:   The fear is that the private sector will ‘cherry pick' easy and high-profit services, such as hernia repair, leaving the difficult and costly areas, such as mental health, geriatrics, A&E and intensive care, to be handled by NHS staff.

More power to the patients
Making sure patients are involved in every stage of their own care — and can influence the way decisions are taken throughout the NHS — is a key part of the reforms.

Frustratingly, the reforms don't set out details about how this might be put into effect, but possibilities include more emphasis on annual reviews with your GP if you have a chronic disease such as diabetes, and expanding the Choose & Book programme.

Under Choose & Book, you can decide where you want to go to for specific care. 

On a bigger scale, the reforms will launch HealthWatch, a new patients' organisation that has been described as the ‘independent champion for health and social care consumers'.

It is, essentially, a watchdog for patients, with the power to monitor the NHS and to refer patients' concerns to a wide range of authorities.

PROS:   Involving patients in their treatment is widely acknowledged to be important for their health and for saving money. Research has suggested patients who are involved in this way cost the  NHS around 20 per cent less.

Most people would agree that patients need a stronger voice than they currently enjoy. 

When it comes to making a complaint, patients can find the current system complex and ineffective.

Accountability and public involvement have been ‘muddled' for the past 20 years, says Patrick Vernon, chief executive officer  of health inequality charity the Afiya Trust.  

He says that HealthWatch will have ‘real clout' to ‘influence, challenge and  advocate patients' rights' in improving care, although this will depend on the strength of your local HealthWatch group.

CONS:   Many patients would prefer to hand over difficult treatment decisions to the experts and don't want to take responsibility for their own care, says Dr Clare Gerada. 

Others have expressed concerns that HealthWatch will be toothless and potentially underfunded. This is because its budget is not ring-fenced, so the money could be spent elsewhere.

As Dr Lucy Reynolds explains: ‘This is a missed opportunity, because patients should clearly be given more real powers to partner with the NHS in improving service quality through an independent mechanism with an adequate and protected budget.'There are also concerns that HealthWatch won't, in fact, be independent, as it now looks as  if it is to become part of the  Care Quality Commission, the healthcare watchdog. 6.3.12

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NHS staff cash in on accidents at work, £4,000 for slipping on a potato and £2,500 for walking into a door

• Nurse given £1,650 for blister 'caused by serving mashed potato'
• Hospital staff member awarded £2,775 to hurting shoulder throwing litter into a bin

NHS staff are claiming nearly £20million a year in taxpayer-funded compensation for injuries such as bruises, twisted ankles and blisters. The number of employees seeking damages for accidents they insist were the fault of the Health Service has jumped by almost a third in just five years.

Last year more than 3,200 injury claims were filed by NHS staff, including one that resulted in a worker being paid £6,500 for a bruise. And the Wrightington, Wigan and Leigh NHS Trust paid out £3,980 to a nurse who slipped on a piece of potato on a ward floor.

An employee at the same trust was paid £5,750 after he fell over when the bottom of his trousers got caught on a metal bracket on a wall. In the past five years, the NHS has paid out £91.8million in compensation to 9,042 employees.

The number of claims made by staff has jumped from 2,535 in 2005/6 to 3,287 last year, according to figures obtained after Freedom of Information requests to the NHS Litigation Authority and NHS trusts.  

There are concerns that staff are being egged on by ‘no-win no-fee' solicitors telling them to claim for injuries caused by their own clumsiness or bad luck. A hospital worker at Sherwood Forest NHS Trust was paid £2,250 after suffering ‘tennis elbow' – a common sports injury that he insisted was caused by ‘repetitive moving'.

The same hospital awarded £875 to a member of staff who cut their thumb, while a porter at Blackpool Teaching Hospitals got £3,400 for a ‘whiplash-type injury' that allegedly happened while pushing a trolley.

Brighton and Sussex University Hospitals awarded £10,000 to an employee who twisted their ankle on a step and the same amount to another  worker who suffered a cut finger.  

And at West Hertfordshire  Hospitals a worker was given £2,775 for injuring their shoulder by throwing litter into a bin, while a secretary at Countess of Chester Hospital got £350 for falling off a chair. The same hospital awarded £875 to a member of staff who cut their thumb, while a porter at Blackpool Teaching Hospitals got £3,400 for a ‘whiplash-type injury' that allegedly happened while pushing a trolley.

Brighton and Sussex University Hospitals awarded £10,000 to an employee who twisted their ankle on a step and the same amount to another  worker who suffered a cut finger. 

And at West Hertfordshire  Hospitals a worker was given £2,775 for injuring their shoulder by throwing litter into a bin, while a secretary at Countess of Chester Hospital got £350 for falling off a chair.

Tory MP Stephen Barclay said: ‘I would want to know why someone got £6,500 for a bruise. ‘It seems surprising that some payments are being made for what appear to be relatively minor injuries. ‘I would welcome some clarification from the officer responsible for the payments so that  he can demonstrate that  they were of value for money for the taxpayer. ‘This is money that would otherwise be spent on patients with medical needs.'

Matthew Elliott, of the TaxPayers' Alliance, said: ‘This is an incredible amount of money for the NHS to be losing to compensation claims, and means less cash is available for frontline care. ‘There will be some cases where payouts in the workplace are unavoidable, but health bosses need to ensure these are kept to a minimum by properly managing their facilities and rejecting and fighting frivolous claims.

‘Taxpayers can't afford endless huge payouts – they are a  symptom of a growing compensation culture that needs to  be stopped.'

The extraordinary amounts are being paid out while  the NHS is under severe financial strain. Although its budget has been ring-fenced from Government cuts, it has been ordered to make £20billion of ‘efficiency savings' over the next few years so money can be ploughed back into patient care.

Many NHS trusts have resorted to cutting frontline staff and rationing treatments to try to meet these targets.

Only last month a report from MPs found the NHS was now paying out £15.7billion a year  for medical accidents, with  many claims driven by no-win no-fee lawyers.

Figures compiled by the public accounts committee showed the sum had jumped by 13 per cent in a year and accounted for a seventh of the Health Service's annual budget. 5.3.12

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GPs make £162m out of 'ghost' patients: Anger over bill for 2.5m non-existent people

• 55 million people registered with a doctor in England - despite population being 52.5m
• Surgeries regularly fail to update patient lists when people die or move away
• 32,668 dead patients were on lists, including 157 who died more than 30 years ago
• 10,000 failed asylum seekers who had left the country were on the books

 The NHS is paying GPs to look after 2.5million ‘ghost' patients, ministers admitted last night.

Doctors are receiving an estimated £162million a year – footed by the taxpayer – for non-existent patients on their books who have moved house, left the country or been dead for up to 40 years.

The Audit Commission has counted that in a single year at least 95,000 such ‘ghost' patients were registered with GPs and earning them annual payments. But the Department of Health last night admitted there are probably up to 2.5million such patients on doctors' lists in England.

Every year GP surgeries are paid an average of £65 for each patient they have on their books, regardless  of how often – or whether – they make an appointment or what treatments they receive. Although there are currently 55million patients registered with GPs, there are only 52.5million actually living in England. It means the NHS is potentially wasting £162.5million every year on ghost patients.

Katherine Murphy, chief executive of the Patients Association, said it was ‘outrageous' that money was being wasted to treat patients ‘that only exist within NHS bureaucracy'.

Surgeries are meant to keep their lists up to date and take patients off when they die or move away, but this is frequently overlooked.

In some cases doctors have been found to be deliberately keeping patients on their books to earn themselves extra cash.

Last year the Mail revealed that four doctors at a surgery in Streatham, south London, were being investigated over a scam in which they were claimed to have 3,000 patients on their books who did not exist or had false information on their records that brought in extra NHS cash.

Of the latest findings, Mrs Murphy added: ‘At a time when the NHS is being asked to make huge efficiency savings the Government needs to provide answers as to how money was wasted in this way.'

In its extensive investigation the Audit Commission, the Government's spending watchdog, compared surgery lists to check patients were not registered with more than one GP if they had moved house.

The officials also compared these lists with Government records of deaths and data on failed asylum seekers who have since been deported.

When officials came across patients registered with two surgeries, or those recorded as being dead or deported, they contacted the local NHS body which asked practices to check that their lists were up to date.

The investigation, called the National Duplicate Registration Initiative (NDRI), covered 2009 to 2010. It found there were up to 32,668 dead patients on lists – including 157 who had died more than 30 years ago.

Officials even came across one surgery which was being paid every year to treat a patient who had died in 1969.

A further 29,416 patients had moved house and were registered with a different GP, but both their old and new surgeries were being paid for treating them. Another 20,000 patients were removed from the lists when officials found they were not living at the address shown on the books.

The officials also discovered 10,000 failed asylum seekers were on GPs' books even though they had since been returned to their home country.

Not all surgeries flagged up by the Audit Commission for having high numbers of ghost patients bothered to check their lists.

Health minister Lord Howe said: ‘The NHS needs to make the best use of the funds it has available and avoid giving GPs extra income for patients who have moved away or died. Identifying ‘ghost patients' will ensure that practices are fairly funded only for the patients they are responsible for.'

Andy McKeon, managing director of health at the Audit Commission, said: ‘The NHS and GPs generally manage patient lists well – at any one time there are some  58million records and many movements on and off lists. ‘It is disappointing that some areas did not rigorously follow up the information provided by NDRI.'

David Stout, deputy chief executive of the NHS Confederation, which represents NHS staff, said: ‘It is important to make sure that lists of registered patients are up to date and accurate. ‘Being able to plan and offer the most appropriate care for local people depends on accurate information.' 23.2.12

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PM accused of 'dangerous game of divide and rule' as BMA and nurses excluded from summit over disputed Health Bill 

•  Opponents to Health Bill have been shut out from Downing Street, claims Shadow Health Secretary
•  Health Minister accuses Labour of turning NHS reforms into 'game of political football'

David Cameron was today accused of deepening divisions in the health service after it emerged that opponents of controversial NHS reforms were excluded from a key Downing Street summit. The Prime Minister will hold discussions with chairs of the emerging GP-led clinical commissioning groups along with other health officials.

However, eight royal colleges and several health unions say they have not received an invitation to the meeting, which is intended to shore up support for the Health and Social Care Bill.

No 10 has refused to release the guest list for today's health summit on the Bill, which faces fierce opposition from professionals, patient groups, Labour and reportedly even Tory Cabinet ministers.

However, the British Medical Association and Royal College of Nursing, who represent more than 500,000 medical staff, said they had been excluded after opposing the reforms.

Both have called for the Health and Social Care Bill to be scrapped as it makes its way through the Lords.

Dr Peter Carter, from the RCN,  told BBC Radio 4's Today programme that holding an 'emergency summit' on the health bill without their presence was not 'a sensible way forward' as they were 'intrinsic to making sure the NHS is successful'.

The BMA said in a statement: 'It would seem odd if the major bodies representing health professionals were not included.'

Labour's Shadow Health Secretary Andy Burnham, said: 'The NHS means too much to too many people for the Government to play this dangerous game of divide and rule.'

He added that the major health unions had 'strong and sincerely-held views' about the risks to the NHS from the Government's reorganisation.

'They deserved a hearing - not to have the door of Downing Street shut in their faces,' he said.

He called on Mr Cameron to invite the BMA and RCN along with the Royal College of Midwives and Royal College of General Practitioners to the meeting - all of whom oppose the Bill.

Health minister Simon Burns has denied that key bodies were being excluded from talks on the Bill. He said: 'This (summit) is part of an ongoing dialogue. We have had hundreds of meetings, there have been thousands of people involved in talking and looking into different ways of improving and engaging on the Health Bill. 'That includes the RCN,' he told BBC Radio 4's Today programme. 

The Prime Minister's official spokesman later added: 'We are not excluding anyone,' at a daily Westminster briefing.

However, all those bodies confirming attendance today have yet to directly oppose the Bill. These include the Royal College of Paediatrics and Child Health, which will set out its position on the Bill in the next few days following a membership survey.

The Royal College of Surgeons, which has agreed to 'critical engagement with Government' over the Bill will also attend the meeting, as will the Royal College of Obstetricians and Gynaecologists, which has concerns but has agreed to continue talks with ministers.

The Royal College of Anaesthetists will also go, as will the Royal College of Physicians, which has pledged to continue discussions with the Government.

Mr Burns said on this occasion the Government was meeting organisations that were 'constructively involved' in the process.  

'The meeting the Prime Minister is having today is simply part of an ongoing dialogue with those who are constructively involved in improving the reforms.' He warned that 'in some ways this has become a political football'. At the ‘summit', the Prime Minister will reveal statistics that show handing power to GPs can transform care and keep patients out of hospital.

He will go on the offensive amid growing demands from doctors and unions to drop the Health and Social Care Bill, now going through the House of Lords. Department of Health figures show a 0.5 per cent decline in emergency admissions in 2011, compared with a 36 per cent increase between 2001 and 2010.

Mr Cameron will tell the heads of commissioning boards and some of the royal medical colleges that patients are already beginning to see the fruits of greater GP influence – a key plank of the reforms – in areas where clinical commissioning groups have been set up.

He will point to Dartford, Gravesham and Swanley in Kent, where admissions to hospital of care home patients have been slashed 33 per cent in the past six months. 

In Newcastle, the number of patients admitted with emergency respiratory problems has decreased by 70 per cent. In Bedfordshire a team has been set up to deal with emergency calls from care homes, helping reduce hospital visits by 40 per cent.

But Mr Burnham said: 'The reality is that hospitals are under intense pressure as last week's A&E figures continue to show.'

Those not invited : The Royal College of GPs, the Royal College of Radiologists, The Faculty of Occupational Medicine, the Royal College of Psychiatrists, The Academy of Medical Royal Colleges including the College of Emergency Medicine and the Faculty of Public Health, the Royal College of Pathologists, the Royal College of Ophthalmologists, The Chartered Society of Physiotherapy, the BMA, the RCN. 20.2.12

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Shyness in a child and depression after bereavement could be classed as mental illness in controversial new reforms

Childhood shyness could be reclassified as a mental disorder under controversial new guidelines, warn experts. They also fear that depression after bereavement and behaviour now seen as eccentric or unconventional will also become ‘medicalised'. Internet addiction and gambling might also become forms of illness.

The threat comes in the form of proposed changes to a U.S. manual of mental disorders, viewed as a bible by some in the field.

Although the changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders would not directly affect clinical practice here – where doctors tend to use different guidelines – experts say it would eventually influence thinking.

Millions of people, including Britons, could be given a psychiatric diagnosis which could ruin their lives, warn psychiatrists and psychologists here. 

The DSM5 changes are also opposed by many experts in the U.S., some of whom claim they reflect efforts by drug companies to sell more products.

Simon Wessely, of the Institute of Psychiatry, King's College, London, said: ‘We need to be very careful before further broadening the boundaries of illness and disorder. ‘Back in 1840 the census of the United States included just one category for mental disorder. ‘By 1917 the American Psychiatric Association recognised 59, rising to 128 in 1959, 227 in 1980, and 347 in the last revision. Do we really need all these labels?

‘Probably not. And there is a real danger that shyness will become social phobia, bookish kids labelled as Asperger's and so on.'

Peter Kinderman, head of the Institute of Psychology, University of Liverpool, said: ‘It will exacerbate problems that result from trying to fit a medical, diagnostic, system to problems that just don't fit nicely into those boxes. ‘It will pathologise a range of problems which should never be thought of as mental illnesses. Many who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labelled as “mentally ill”. ‘This isn't valid, isn't true, isn't humane.'

Paraphilic Coercive Disorder – becoming aroused by sexual coercion – is one condition proposed for inclusion in DSM5. Professor Kinderman said there was a danger that rapists diagnosed with it would use it as an excuse. He added that there were ‘huge concerns' about the changes, which are opposed by the British Psychological Society.

Other experts say the guidelines will straitjacket clinicians into ‘ticking boxes' that lead to a proscribed diagnosis. Dr Felicity Callard, of King's College, warned: ‘People's lives can be altered profoundly – and sometimes ruinously – by being given a psychiatric diagnosis.'

Among the U.S. psychiatrists against the changes is Allen Frances, of Duke University, North Carolina. He warned: ‘DSM5 will radically and recklessly expand the boundaries of psychiatry. Many millions will receive inaccurate diagnosis and inappropriate treatment.'

David Elkins, of Pepperdine University, Los Angeles, said individuals could be ‘labelled with a mental disorder for life and many will be treated with powerful psychiatric drugs'. Defenders of the American Psychiatric Association guidelines say they will make diagnosis more accurate and scientific. 10.2.12 Also see here.

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You ARE more likely to die if taken to hospital at weekend: Study confirms that NHS care is worse on a Saturday and Sunday

• Chances of recovery are jeopardised because senior doctors are absent and tests are not always available
• Study finds that Sunday patients are 16 per cent more likely to die than those admitted on a Wednesday
• Health Secretary Andrew Lansley says the findings are 'unacceptable'

Patients admitted to hospitals at weekends are far more likely to die than those taken there on weekdays, a major study has confirmed.

Chances of recovery are jeopardised because senior doctors are absent and tests and scans are not immediately available. A study of over 14million NHS admissions found that Sunday patients are 16 per cent more likely to die within the next 30 days than those brought in on a Wednesday.

Patients admitted on a Saturday are 11 per cent more likely to die in 30 days.

Alarmingly, the researchers warned that patients who go to hospital at weekends tend to be sicker – making it crucial that they receive the highest standard of medical attention. This is due to a higher number of road accidents, drink-related injuries and poor out-of-hours GP care that means patients' deteriorate while treatment is delayed.

Earlier this week, Health Secretary Andrew Lansley ordered a ‘fundamental rethink' of how hospitals are run at weekends.

Responding to this study Mr Lansley said: ‘It is unacceptable that patients admitted to hospital on a Saturday or Sunday stay longer and have worse results. ‘Much of the rest of the country continues to be open for the public's needs at weekends – an NHS that revolves around patients should be the same.

‘By opening some services seven days a week, more patients will get the care and treatment that they need when they need it. In some parts of the NHS, this is already happening. 'On Saturdays and sometimes Sundays, some services have scanners open to provide tests, are doing operations, and have more senior staff around.' 

Katherine Murphy, chief executive of the Patients Association, said: ‘The NHS exists to ensure that its users are given the best possible care, 24 hours a day, seven days a week. 

It is simply not acceptable for somebody to face an increased risk of death just because they were unfortunate enough to suffer an injury or get sick on a Saturday or Sunday as opposed to any other day of the week.' 

Researchers from University College London – whose work was commissioned by the Department of Health – looked at 14.2million hospital admissions in 2009/10.  Writing in the Journal of the Royal Society of Medicine, the researchers concluded: ‘There may be aspects of care associated with weekend admissions which disadvantage patients.

‘Some urgent conditions require prompt treatment and in some cases the way weekend care is organised may lead to delays which can adversely affect the outcome.' 

The study backs up a report in November by Dr Foster Intelligence linking a higher death rate at weekends with poorer staff levels. Most consultants tend to work office hours and at weekends the wards are left in the hands of junior doctors.  In addition, departments responsible for certain scans and blood tests are shut until Monday.   

The researchers pointed out that patients admitted at weekends may be more seriously ill. Some who become seriously ill on Friday try and hang on until Monday, during which time they deteriorate further and end up needing urgent treatment. 

There are also more injuries from road accidents, alcohol and self-harming at weekends.

Dr Andrew Goddard, of the Royal College of Physicians, said: ‘This study is further evidence that patients admitted at weekends are more likely to die following admission than patients admitted to hospital during the week.  ‘There are many reasons for this, but the two most important are that the patients are more ill and there are fewer doctors available.' 

David Stout, deputy chief executive of the NHS Confederation said: ‘There is no doubt that this is something the NHS has to improve.  'Patients should never have to worry about what is the "right" time to visit their local hospital.' 3.2.12

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NHS lawyer who told doctor to cover up a death is given £100,000 after she lost her job

Father of dead patient brand payout 'morally wrong'

An NHS lawyer who asked a doctor to suppress details of how a patient died has won a payout of more than £100,000. Kate Levy was fired from her job as head of legal services at scandal-hit Stafford Hospital after details of the cover-up were exposed. But after taking her former employers to a tribunal, she has now been awarded £103,000 for ‘wrongful and unfair dismissal'.

Her sacking centred on a request she had made to consultant Ivan Phair over a report he had written into the death of John Moore-Robinson.

Mr Moore-Robinson's father, Frank, branded the payout ‘morally criminal'. His 20-year-old son had been taken to the casualty department of Stafford Hospital after a mountain bike accident on Cannock Chase, Staffordshire, in 2006.

An X-ray revealed he had broken his ribs. He was vomiting and in agony but a junior doctor failed to spot a ruptured spleen and sent him home with painkillers. Within hours his parents called 999 because he was still in severe pain. He died minutes before paramedics arrived.

Mr Phair later wrote a report into the death for the coroner, which stated it was ‘avoidable' and there was a ‘high probability that the level of care delivered was negligent'. But when Miss Levy, 56, read the report, she wrote to Mr Phair asking him to delete the criticism to spare distress to Mr Moore-Robinson's family and avoid ‘adverse publicity'.

Miss Levy was suspended and sacked after details of the cover-up were exposed in a Sunday newspaper two years ago.  She lost an appeal against her dismissal and then started tribunal proceedings against the Mid Staffordshire NHS Foundation Trust.  

At the start of this week's hearing, the Trust conceded Miss Levy was ‘wrongfully and unfairly dismissed', and authorised a settlement of £103,000.

Mr Moore-Robinson's parents had received just £13,000 from the NHS litigation authority over their son's death, to cover his funeral costs and their legal expenses during the 2007 inquest. In the end, neither Mr Phair's original report nor the amended version were sent to the coroner.

Last night Mr Moore-Robinson's father said that senior executives at the Trust admitted to him that they had ‘cocked up big-time' over the way Miss Levy's dismissal was handled. He added: ‘In my opinion, the decision to sack her was correct. But it seems they went about it the wrong way.

‘I can accept that technically, the hospital may have been wrong to sack her but giving her a six-figure payout beggars belief. 'What she did was despicable and I hope she can live with herself. I just think it is obscene when you consider what we received for John's death.'

In a statement, the Mid Staffordshire NHS Trust said: ‘Following legal advice we received from our barrister at the start of the tribunal, we conceded that Ms Levy was wrongfully and unfairly dismissed.'

Miss Levy, who had previously been cleared of any wrongdoing by both the police and the Solicitors Regulatory Authority, said: ‘I have always maintained that my actions were entirely consistent with my duties as a lawyer, and that I was not in breach of contract or otherwise guilty of any misconduct.'

Stafford Hospital was first hit by scandal in 2009 when a report by the NHS regulator, the Healthcare Commission, said appalling standards of care there may have contributed to the deaths of at least 400 patients.

Robert Francis QC then chaired an inquiry which concluded that patients were routinely neglected by a Trust that was ‘preoccupied with cost cutting and targets'. 2.2.12

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Tripadvisor banned from claiming its reviews are real

Tripadvisor, the travel review website, has been banned from claiming that all of its hotel and restaurant reviews are real. It follows complaints that some unscrupulous hoteliers have posted fake comments on the site to boost their own business or sabotage others.

Following a four month investigation, the Advertising Standards Authority found that it was possible for “non-genuine content” to appear on Tripadvisor, which is designed to allow holidaymakers to share tips and opinions on places they have visited.

The advertising watchdog said that because reviews can be posted on the site without any form of verification, Tripadvisor must no longer claim that all of its reviews are honest, or even from real people.

In a strongly-worded ruling, the ASA told Tripadvisor “not to claim or imply that all the reviews that appeared on the website were from real travellers, or were honest, real or trusted”.

The ASA's ruling, which applies only to Tripadvisor's UK site, follows a complaint last year from two unnamed hoteliers and a website called Kwikchex, which helps companies manage their online reputations.

They argued that wording on Tripadvisor's website - claiming that the site contained “reviews you can trust” and “honest” opinions from “real travellers” - was misleading as Tripadvisor could not prove that the reviews were genuine.

Chris Emmins, co-founder of Kwikchex, said that there are a “substantial” number of fake reviews on Tripadvisor, which is being “abused by fraudsters”. Fake comments range from unsubstantiated claims of food poisoning in restaurants to theft and credit card fraud in hotels, said Mr Emmins.

Tripadvisor, which has removed the wording from its website, said that the ASA had taken a “highly technical view” of its online marketing copy that was "used in a limited capacity”.

In a statement, the company said: “We have confidence that the 50 million users who come to our site every month trust the reviews they read on Tripadvisor, which is why they keep coming back to us in increasingly larger numbers to plan and have the perfect trip.”

A spokesman added that the average traveller reads dozens of reviews before making an informed decision on where to travel, rather than just “one or two” reviews. Travellers base their decision on “the wisdom of the crowds” rather than isolated reviews, the spokesman said.

“We know that our users approach Tripadvisor with common sense, and make an educated decision based on the opinions of many. If people did not feel the insight they gained from our site was an accurate reflection of their experience they wouldn't keep coming back,” the spokesman said. 2.2.12 Also see: Review site TripAdvisor is useless, damaging and used for blackmail

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Jeremy Laurance: Why spare the drug companies?

We cannot provide every treatment to every patient regardless of cost

Why are Britain 's health charities bent on sucking the blood from the NHS? The very same organisations that do such sterling work funding research, supporting patients and promoting awareness appear to have a blind spot when it comes to assessing what treatments are worth. We see it each time the National Institute for Health and Clinical Excellence (Nice) reaches an unpopular decision to ban a drug on the NHS because it is too expensive, as it did yesterday with the new prostate cancer medicine abiraterone. Cue uproar from charities.

"This decision is a bitter blow to thousands of men and their families and must be overturned," said Owen Sharp, the chief executive of the Prostate Cancer Charity. It was the same last month, when Nice ruled against three bowel cancer drugs. Mark Flannagan, the chief excecutive of Beating Bowel Cancer, said: "This is yet another blow for bowel cancer patients. All bowel cancer patients deserve the best care." Of course – how could anyone dispute that? Nice agreed that some of the drugs were effective – extending life by an average of 3.9 months in the case of prostate cancer. As Mr Sharp said, that could give a terminally ill man the chance to "walk his daughter down the aisle or see the birth of a grandchild". It is a disaster for such a man to be denied such a drug.

But we cannot provide every treatment that is effective to every patient who would benefit without regard to the cost. If we did, we would quickly bankrupt the NHS. Yet that is what the health charities are helping to do. By turning their fire on Nice, and neglecting the other player in the tragedy – the drug company involved – charities are effectively saying that protecting drug-company profits is more important than protecting the NHS.

Nice assesses each drug and calculates how much benefit it delivers for the cost. It mostly approves drugs costing up to £30,000 per Quality

Adjusted Life Year (Qaly – a measure of the benefit), or for terminal conditions, up to £50,000. In this case, the prostate drug came in at £63,000 per Qaly, and the bowel cancer drugs at £110,000 per Qaly. So, in Nice's view, the drug companies Janssen and Amgen were charging more than they were worth. Did the health charities challenge the companies? No. Instead, they lambasted Nice. Do they receive drug company financial support? Perhaps we should be told.

Only Harpal Kumar, the chief executive of Cancer Research UK , struck the right note. Commenting on the prostate drug decision yesterday, he said: "We feel extremely let down that the drug's manufacturer couldn't offer Nice a price they could agree on." This is a £500bn global industry and it is time other organistations joined Nice in holding it to account to ensure fair prices are charged to the NHS. 3.2.12

Other critics pointed out these charities which do the complaining are usually funded by the drug companies to complain on their behalf. Drug companies spend approximately 11% of the budgets on research and development and are heavily supported by the tax system yet spent 45% on marketing and entertaining doctors to prescribe their products.

Instead of complaining about NICE all the time, these drugs could easily be priced to be cost effective but in their desire to milk the system, they often price themselves out of the market and get others to do their dirty work.

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Now patients are denied 'breakthrough' prostate cancer drug as health watchdogs brand it too expensive

• Once-daily pill giving extra months of life is 'too expensive'
• Abiraterone is latest cancer drug facing an NHS ban

A ‘breakthrough' drug that gives extra months of life to men with advanced prostate cancer has been rejected for use on the NHS. The once-daily pill was developed by UK scientists at the Institute of Cancer Research (ICR) and trials were partly funded by British charities.

But it has been branded as too expensive by the rationing watchdog the National Institute for Health and Clinical Excellence.

Abiraterone is the latest prostate cancer drug to face an NHS ban despite being proven to extend life for men with advanced disease. Last month another drug – Jevtana – was turned down as ‘not cost-effective'.

It is a fresh blow for doctors and patients who hoped a new era of drugs could lessen the deadly toll of prostate cancer, which has been described in the past as a low-profile ‘Cinderella' disease.

Trials show men taking abiraterone and a steroid survived for nearly 15 months, while men given steroid treatment and a ‘dummy' pill lived for 11 months on average.

But some patients live far longer than expected, including Britons who have survived on the drug for more than four years after developing advanced disease. The drug also eased pain for twice as many men in the trials.

A year's course of treatment costs £35,000, which Nice says is too expensive.

Campaigners last night condemned the draft decision by Nice. Owen Sharp, chief executive of the Prostate Cancer Charity, which helped fund trials, said: ‘This draft decision is a bitter blow to thousands of men and their families – and must be overturned.'

Patients have been getting abiraterone, also known as Zytiga, through the Cancer Drugs Fund, set up by the Government to pay for treatments not approved by Nice.

But the fund only applies in England until 2014, which denies access to patients in Wales , Scotland and Northern Ireland. 2.2.12

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Pharmaceutical giant AstraZeneca announces 7,300 job losses as it pares back staff to save money

Britain 's second-biggest drugmaker AstraZeneca said today it is axing 7,300 jobs by the end of end of 2014 in its latest round of cost savings. It said the restructuring was needed because of the weak economy and the impact of competition from generic drugs. 

The company, which has 61,000 staff globally of whom 8,000 are in the UK, axed 12,600 positions between 2007 and 2009 and removed another 9,000 roles by the end of last year, when it closed a site at Charnwood near Loughborough.

Its sites in the UK are at Alderley Park in Cheshire , Macclesfield, Cambridge , Luton , Avlon near Bristol , Paddington in London , and Brixham in Devon. The company has not yet disclosed where the jobs will be cut.

Union representatives, who were seeking further details from the company today, warned that it was another blow for the UK economy after rival firm Pfizer announced plans to pull out of Sandwich in Kent.

Allan Black, GMB national officer for pharmaceuticals, said: ‘These cutting-edge research and development jobs are both well-paid and essential for a thriving UK economy. ‘As a nation we do need to find a viable way to continue to make breakthroughs in bringing to safe use much-needed new medicines.'

The jobs blow came as the company announced a 2 per cent fall in revenues to $33.3 billion (£21.1 billion) in 2011, while profits fell 4 per cent to $13.2 billion (£8.4 billion). It said generic competition as patents expire and intervention in pricing from central governments wiped $3 billion (£1.9 billion) from its revenues.

The company said revenues for 2012 are likely to be down by more than 10 per cent while its margins will also be squeezed, leading to lower profits.

It has suffered a number of setbacks in its efforts to secure approval for new blockbuster drugs.

It recently warned that profits would be at the low end of analysts' expectations after ovarian cancer drug olaparib was held back for further development when tests proved it was unlikely to prove effective.

The results of tests on drugs for patients with major depressive disorders were disappointing, although tests are ongoing. The US Food and Drug Administration also recently declined approval of a new diabetes drug dapagliflozin. Analysts have also been underwhelmed by sales of its new blood thinning drug Brilinta.

Astra warned that the coming years would be ‘challenging for the industry and for the company'.

Chief executive David Brennan said: ‘Disciplined execution of our strategy has delivered a good performance in 2011 in the face of intensified pricing pressure and generic competition.

‘While the further expected losses of market exclusivity make for a challenging 2012 outlook, we remain committed to a long-term, focused, research and development based strategy, and today we have announced further steps to drive productivity in all areas to improve returns on our investment in innovation.'

Despite the cost-cutting measures announced today, the Cheshire-based company announced a 10 per cent hike in its dividend and plans to return an additional $4.5 billion (£2.9 billion) to shareholders in 2012 on top of the $9.4 billion (£6 billion) last year. 2.2.12 & FT

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Heartburn pills taken by thousands of women 'raise risk of hip fractures by up to 50 per cent'

Hundreds of thousands of women who take commonly prescribed heartburn pills could be up to 50 per cent more prone to hip fractures, scientists warn. Taking the drugs several times every week has been shown to increase the risk by more than  a third. The figure is 50 per cent for smokers or those who have smoked in the past.

Researchers studied the long-term effects of proton pump inhibitor drugs, or PPIs, which are widely prescribed across the NHS for heartburn, indigestion and stomach ulcers. Some pills are also available over the counter, including omeprazole, which is sold under the brand name Zanprol.

The team from Harvard Medical School and Massachusetts General Hospital in Boston looked at data spanning nearly 20 years involving 80,000 women who had been through the menopause.

Every two years they were asked how often they had taken these drugs and whether they had suffered any hip fractures. The findings, published today in the British Medical Journal, show that women who had taken them  at least three or four times a  week over a two-year period were  35 per cent more at risk of suffering hip fractures. Researchers believe that the  drugs may hamper the body's ability to break down and replace old bone tissue.

They also suspect that PPIs may reduce the take-up of calcium, which is an essential component of healthy bones.

But lead researcher Dr Hamid Khalili pointed out that even though the drugs increased the risk of fractures it was still very low. For every 500 patients on the drugs only one would be likely to fracture their hip in a year.

But he said that middle-aged women – particularly those who smoke – who had been taking PPIs for a long time should consider whether it was really necessary.  The study concluded: ‘Our data suggest the importance of carefully evaluating the need for long-term, continuous use of PPIs, particularly among individuals with a history  of smoking.'

Tobie de Villiers, president of the International Menopause Society, said: ‘Although the relative risk  of hip fracture is significantly  raised in users of PPIs when compared to non-users, the absolute risk increase is small. This is still important in view of the widespread use of PPIs and the significant  burden of hip fractures on affected individuals and the healthcare system.'

Around nine million prescriptions for PPIs are written out every year at an annual cost to the NHS of more than £400million. Many patients with severe heartburn or acid reflux end up taking them for months. However, hip fractures can be devastating, particularly for the elderly who can die as a result. Patients may have to spend weeks immobile in hospital and this can lead to infections such as pneumonia.

The Harvard study only involved women, but other research suggests that men taking these drugs are also at risk.

One by Canadian scientists on both men and women in 2008 found that those who had taken the drugs for five years were 44 per cent more likely to have a hip fracture.

Dan Greer, spokesman on gastroenterology medicines at the Royal Pharmaceutical Society, said: ‘This is a useful study, that has taken account of the other factors that can affect hip fractures such as smoking, calcium intake, and  obesity that has been missing from other studies looking at the link between PPIs and hip fracture. ‘It suggests there may be a small increase in hip fracture risk associated with these medicines in a  high-risk group. Women should be reassured though that the absolute risk is small.' 2.2.12