This is the Thirteenth in the Persecution Series, after The Persecution of Heretics, The Persecution of Vulnerable Adults, Harassment from the BBC to GMC, Harassment from Rolf Harris to James Coyne to Doctor Who, Persecution: Black Riders in the Shire, Persecution: Rumbles from Mordor, and seventh in the SUI Cide Series SUI Cide in Betsi, SUI Cide Trick or Treat, The SUI Cide Note, SUI Cide or Homicide, SUI Cide in the OK Corral, SUI Cide & Peace in our Time.
In a piece in the New York Times two weeks ago, Groopman and Hartzbrand claimed that insurance companies on the basis of a range of evidence and a variety of metrics were increasingly constraining the choices of doctors and patients and were jeopardizing patient safety in the process. This reprises the argument put forward in Pharmageddon, which was written in 2008.
This is not rapacious capitalism gone mad. If what Groopman and Hartman describe is new in the United States, it’s not new in the socialized medical systems of Europe and especially not new in the UK. In 2004, the Quality and Outcomes Framework – a system of payment for results that leads to primary care doctors reaching out to and giving patients problems they never knew they had – was introduced.
The latest twist in the UK came some weeks ago when both the Minister of Health and the Prime Minister announced a payment for all diagnoses of dementia. This shocked most doctors and much of the mainstream media. It felt like a step too far – given that there is nothing useful that can be done for dementia and making too early a diagnosis could have disastrous consequences for families. Speculation is rife as to whose interests are being served here – pharmaceutical or insurance companies.
The Shire and Mordor
Until recently, the rest of medicine has been more affected than psychiatry by the forces that have brought about situations like this. It’s been easier for real doctors to suck people into the new apparatus and make patients of them through their lipid levels, bone densities or peak flow rates than it has been to enslave people within the mental health system – we can’t measure brain serotonin after all.
This has meant that, as noted in Black Riders in the Shire, working in North West Wales mental health care until recently felt like living in an oasis like the Shire where you could be close to oblivious to the rumbles from Mordor. Sometimes living and working in such a place makes it easier to see what is happening elsewhere and this is where Pharmageddon came from.
But all this has now changed and devastation has been visited on the Shire. The instrument through which it has come has been Risk Management.
The apparatus
Two years ago Welsh Government brought a new Mental Health Act into being. The intentions of the politicians and others behind the original version was to empower patients – to make it mandatory that they had care-plans and give them access to what was being said and written about them. Some of us had been doing just this for 25 years – so it was clear that what was once inconceivable could be done and might bring benefits.
But tacked on to this Bill when it came into force was a recommendation that all patients should be risk assessed and risk managed. The recommendation came from the bureaucrats linked to Government who are typically there because they dislike seeing patients and may not have engaged with one for a decade or more.
Risk management is close to the quintessence of Pharmageddon. The statins and related drugs like those for osteoporosis, asthma and others out of which Pharma makes the most money are not treatments that save lives. They are treatments aimed at risks located in you and me. This is a world where the risks you and I supposedly carry around in our bodies are much more dangerous than the risks all around us from others, the environment or Acts of the Gods.
Companies can offer little more in terms of saving lives than they can forestall Acts of God. But in the case of what we carry around within us, they can create perceptions around risk management, and this is what Insurers and Governments want done.
In the new risk management metrics flooding into mental health, we see Pharmageddon in close to its purest form. Who needs a blood test when ticking a few boxes will do? Who cares that we already know that no matter how good the risk metrics, they are totally useless at actually reducing the risk of things going wrong? Giving antidepressants or antipsychotics for the most part increases your risk of premature death. All that counts is that once the boxes are ticked the organization whether hospital or insurer is immediately insulated from blame.
An adaptation of the immortal words of Werner von Braun as channeled by Tom Lehrer in the 1960s seems called for:
“Once the boxes are ticked who cares where they come down, that’s not my department” says Werner von Braun.
“You too can be a big hero once you’ve learnt to count backwards to zero. In German oder English I can count down and I’m learning Chinese”, says Werner von Braun.
The ring of power
The problem is intimately linked to clinical trials, perhaps the most seemingly innocent but at the same time the most dangerous innovation on the planet. RCTs, just like the Ring of Power, need to be handled with extraordinary care.
RCTs are always dangerous and should perhaps only be used in desperate situations when there is something to be gained in terms of damage mitigation that warrants risking the damage the trial will necessarily do.
They were first seen as a possible savior for those desperate situations when some amoral corporation intends to make money beyond the dreams of avarice out of the most vulnerable people on earth – when if the drug reaches the market they will likely extend their efforts to the youngest of children, even those in the womb. In such situations, one of the most wonderful, brave and altruistic things any of us can do is to take the risks of participating in a rigid mechanical exercise to test out the proposed remedy to see what happens.
Or it would be one of the most wonderful things we could do if companies and our governments were prepared to keep to the rules of the game and when the new treatment was shown not to work or was shown to come with an unacceptable risk, if they removed it from clinical use.
Playing by the rules offers a fair chance that if we take a risk that on balance we reduce the risks we might otherwise be exposed to.
But this is not what happens. Instead, companies get multiple attempts to pass through the eye of this needle. They can now outsource the trials to India or elsewhere where the patients might not in fact exist. They can hide the data so no-one sees the drug didn’t work and write up the results with claims the treatment was safe and effective.
As a result if we volunteer to take the risks involved in testing out a new treatment, our actions are perverted so that those we love on whose behalf we take these risks are even more likely to be injured and to have no legal redress in the case of an injury.
A degraded culture
The culture we have has now been so corrupted that very few readers are likely to be still with me at this point, and I will probably lose more with what is to come.
Quantification can be a wonderful thing. My career has been based on quantifying things, in some cases things that no-one else has thought it appropriate to quantify. So what follows cannot be dismissed as the rantings of someone who just doesn’t get numbers, or when it might be appropriate to reduce life to metrics. And in books like Pharmageddon, I have paeans of praise to controlled trials.
But the risks in RCTs stem from the way we quantify. We focus attention on the one effect of a drug that a company wants to make money out of – and bring a lot of metrics to bear on that. To do this we necessarily have to neglect the 99 other effects every drug has. This is a process akin to hypnosis. The doctors, patients and other observers miss the suicides, homicides and other effects happening out of the spotlight. And, in exactly the same fashion as the drunk at the lamp-post looking for his car-keys, companies, academics, journals, regulators and others line up to insist that the only things that are significant in this or any other trial are the things illuminated by the spotlight.
Far from generating knowledge, every trial generates ignorance. This is the risk we take. The culture in which trials happen moreover generate ignorance about our ignorance. And in this respect, companies don’t need marketing departments – the Cochrane collaboration and anyone who advocates RCTs as a way to contain industry do the marketing for them.
The risk within
The ultimate outcome is to locate risks in us that some drug will supposedly eliminate without causing any of the other 99 things that all drugs inevitably cause, and often cause more frequently than the possible benefit we seek.
We got away with this for a while in the 1960s when drugs like the antibiotics were given for short periods of time because poisoning someone for such a short time, given the resilience of the human body, is something we can survive. We aren’t getting away with it now.
Quite aside from the many injuries long term treatments inevitably cause, the greatest injury perhaps is cultural – both we ourselves and those from whom we might seek help are now conditioned into the assumption that the risks to us lie within us rather than in the bullying being done to us, the poverty of our circumstances, or the withholding of data on the risks of the chemicals we swallow in ever greater amounts. In so doing we lay the bodies of our children, parents and friends on the line to keep corporations healthy and tighten the grip that the Apparatus has on us.
Resistance is futile
So when risk management came to the mental health services in the Shire – some of us protested. Some of us drew the attention of management to lives that were blighted by or lost because of tick boxes filled up by well-meaning staff who had little idea of the havoc they were wreaking on patients they thought they were helping.
Some of us pointed to the increasing lunacy of situations where a Minister of Health visiting an over-stretched ER department and faced with queues out the door or patients being kept in ambulances to avoid them spending longer than some allotted period of time in the ER department. muttering they wished it was all over might find staff holding on to them because of possible suicidality that needed to be assessed. The problem then for the Minister is that even with an army of flunkies to guarantee his safety, risk management policies would dictate a wait of several hours for an ambulance to transport him the few hundred yards to the mental health unit for assessment. The very act of bundling him into an ambulance by locating the risk in him would injure him permanently in the eyes of others.
What happens when objections like this are raised? Well when the next government inspection of the Hergest Unit turns up, they are fed a story about an event that didn’t happen that casts David Healy in a bad light and they swallow it hook line and sinker. They are also fed a line from management that everything is fine and all staff think management are wonderful and marvelous except for one or two diehards like David Healy when the reality is just the opposite. Do the visitors attempt to check this out?
They report back to base and the Government calls the CEO of Betsi and demands the Hergest Unit be shut forthwith. That was last December. Only an extraordinary event a few days later prevented this from happening – or at the least troublemakers like Healy and a few others being moved out. Despite this, I still had no inkling anything was going on.
The Government inspection team came back a few months later when one of the visitors overheard a friendly bit of chatter between Healy and two other staff against the backdrop of a patient who had been secluded for three times longer than any patient had ever been secluded in North West Wales history. Rather than be concerned about the extraordinary and unwarranted seclusion, the functionary who remains nameless, despite my efforts to get a name, claimed terrible things were happening in Hergest – Healy was being let talk to staff.
The functionary was either psychotic or something else was going on.
The documents tracking what happened are jaw-dropping.
Equally jaw dropping was that all this took place against a backdrop of sustained illegality that the inspectors missed completely or decided to ignore.
Footnote
The words above about the Cochrane Collaboration are savage. This is unfortunate in that some of my collaborators and friends are linked to Cochrane.
One problem is that any new religion tends to make enthusiasts out of its converts. It’s difficult to live without a religion and more difficult again to live without enthusiasm.
Another problem is that some within Cochrane agree with what is being said here about trials, but figure that ideas like this cannot be aired if we are to keep homeopaths and others out of the medical temple. In their own interests people have to be lied to.
As I have mentioned before, I’m not academic…. but wow a lightbulb has gone on and I see clearly now.
I don’t know what else to say apart from Thank you Dr Healy.
Thank you for caring.
Thank you for being brave enough to stand up for people who cannot do it for themselves.
Thank you for telling the world the truth.
The new Oath First Admit No Harm…
Re “Risk management is close to the quintessence of Pharmageddon” – some 6 years ago (as a midwife who liked improving our maternity department in Bronglais Hospital, Aberystwyth and had finally after years of effort been allowed to update all the (totally out of date and unsupported) protocols set up or just left for decades by consultants who seemed to know nothing and care even less) – and having seen how the so called ‘examination’ of the hospital went (where managers just stayed up the night before retyping or creating protocols that had never existed and would never be used (and dating them back for supposed years ago – ie lying repatedly), and making sure that the only people working that day would be ones who had no negative opinions about the management or organisation of the department … and would say what they were told to – I decided to do a course on Risk Management at Bangor University, hoping to be able to improve things further … It was a shock to discover that of the 2 people teaching the course one was a very psychologically upset (cos his wife had divorced him) who made quite a few unacceptable female comments and had absolutely NO experience of working for the NHS at all, and whose idea of risk management was manager types drinking coffee and chatting at meetings … and the other was the very guy who had always come to (pretendedly) examine Bronglais Hospital, and who really, really did not want to hear what I said to him in front of the other ‘students’ – many of which, though now high up professionals or managers had worked as midwives and nurses etc previously and were aware of the reality of it …I left the course after 6 months, discovering that far from what I had hoped and expected, Risk Management was just Tick Boxing, nothing else, and totally to support the managers, not at all the NHS workers or patients at all …
PS I can tell you lots more about them if you are interested …
Reading your weekly instalment of your trials and tribulations is increasingly making my blood boil.Here I am , on the coastal belt of North Wales, without an inkling of these horrifying goings on.I trust that when we read the final part of this sordid affair you will involve the press in all that’s gone on? The part that pains me is the way that you have been treated for many years – just because you speak out on behalf of those who do not have the knowledge to speak for themselves.I have firsthand experience of some of those,in this area, who feel that they daren’t speak their minds – thank goodness that you are still prepared to make a stand without counting the cost. I strongly feel that it is our duty – if we believe in your findings – to encourage those that we care for who have suffered (or are still suffering) as a result of being prescribed these drugs to question their present medications and their effect on their health at present.To this end, our son has decided that he wishes to slowly decrease and remove his medications to see how he copes without them.The psychiatrist that he saw recently agreed with him wholeheartedly(a rare find!).This week we have a meeting with his usual psychiatrist – it will be interesting to see if there is complete agreement there also. Thanks for all you are doing – hope the ending to this particular story is not too horrific.I shall be out protesting if it is!
I wish every health care worker on both sides of the Atlantic could read this column! It explains so much of the mess we’re in. I hope at least some UK nurses in the RCN will read it. They just put out a report called “Are we turning back the clock on mental health?” which seemed to be groping towards some of the same conclusions:
[Reporting on 3,300 MH nursing posts cut in recent years] “Community psychiatric nurses have seen their caseloads spiral to unsustainable levels, while nurses working in mental health hospitals are dangerously overstretched. But this is not just an issue of inadequate staff numbers … Senior mental health nurses … have been disproportionately affected by cuts. Too often, they are being replaced with cheaper, less skilled nurses or care assistants.
“As a result, our nursing workforce is increasingly ill-equipped to give people with mental illness the specialist, recovery-driven care they need. Nurses are being forced to take a risk-averse approach to care which prioritises keeping people safe, over helping them get better.”
First time I’ve heard it put so plainly: Cutting back staff encourages rigid “quality control” rules … so the over-worked and under-trained staff can fulfil all their target goals without thinking or feeling.
Rigid “quality control” rules lead to lousy care … and more work, caring for patients who don’t get better, in an environment where they can’t possibly. Which means staff are still more overstretched. Repeat until the system collapses. (It also seems like mental-health and developmental-disability services are the #1 targets for private contractors, who specialize in cookie-cutter care and cheap, disposable staff. So maybe the collapse of public care is exactly what they and their friends are hoping for.)
Full report here: http://www.rcn.org.uk/__data/assets/pdf_file/0004/600628/004772.pdf
Re: “very few readers are likely to be still with me at this point, and I will probably lose more with what is to come.” I’m sure many are still “with you” David, and eagerly waiting on forthcoming posts. The issues you raise, as covered in Pharmageddon and RCT blog posts are critical to our field, to society. All of us especially doctors need to pay them close attention. Thanks for your efforts!
Johanna– your thinking here validates what I have only whispered to my small circle of trustworthy nursing consorts:
>>Rigid “quality control” rules lead to lousy care … and more work, caring for patients who don’t get better, in an environment where they can’t possibly. Which means staff are still more overstretched. Repeat until the system collapses. (It also seems like mental-health and developmental-disability services are the #1 targets for private contractors, who specialize in cookie-cutter care and cheap, disposable staff. So maybe the collapse of public care is exactly what they and their friends are hoping for.) – <<
Any wonder that anyone working in this system with a modicum of professionalism and an ounce of compassion for patients, feels like a whipping post for *management*??
Correlating time lines with significant changes within *the system* , I find myself viewing the advent of the electronic medical record(EMR) pivotal to understanding how we arrived at a point where mental health nurses,as professionals, are becoming obsolete.
In 2006, converting to the EMR was billed as everything from a major time saver to the most convenient means for sharing vital patient data amongst multiple disciplines and medical specialties throughout the institution where the patient was receiving treatment. BUT, the EMR was something else on an inpatient psychiatric unit. It was a programmed means for directing the activities of the nursing staff by automating their focus of attention to ticking off boxes. Narrative notes written to describe a nurse's assessments of individual patient's needs and patient responses to interventions— GONE. Replaced by screens with multiple choice selections and little blank boxes for "comments".
EMR admission forms are to be completed during the interview of a new patient. The admission process is now a programmed format. Conversations with patients that supply all pertinent info were discouraged. This was /is a very backwards approach to developing rapport with patients, as well as being an insult to any professional nurse who understood the value of unique aspects of a patient's presentation– NONE,of which can be captured filling in the blanks on the computer screen.
Suicide risk assessments on the EMR yield numbers that dictate the level of *risk* from low to severe, but offer no insight into the patient's mind set. There is no provision on this risk assessment for taking into consideration the context of a patient's thoughts of harming himself. No room for anything that addresses the patient as an individual, or the nurse as competent in conducting a "suicide risk" interview.
Nurse's have traditionally been big complainers about documentation/paper work, as it a time consuming task done away from the bedside and usually at the end of a long, tiring shift. The EMR did not save time, or elevate documentation to a status above where it has always been- *the bane of a nurse's existence*. What it did accomplish is no less brain disabling than the psych drugs nurses are still needed for –administering to patients on locked wards. Ironic.
Ah! I still remember how writing on paper, carefully avoiding errors and processing observations thru an ever expanding data bank of knowledge, produced new information,insights and plans for improving the care of psychiatric patients. It was an activity that broadened the learning curve to encompass the vital bits of data that are unique to every patient as an individual. I can also imagine using a laptop to write my nurse's notes, smiling at the ease of having spell check and not needing to ink through and initial every error– I am no longer so attached to exquisite pens and the feel of writing on paper that I cannot appreciate computer technology as a means for making even a nurse's job easier…
BUT– I can tell you that the EMR has made it possible for just about anyone to provide the data that insurance companies and probably Pharma, too, are seeking. I can say that the EMR and it's streamlined data collection format is a template for dehumanizing patients and getting rid of nurses who aspire to be something more than over paid drug pushers.
I have always believed this axiom "If you fail to plan, you plan to fail"
Is it possible that there could be a PLAN to FAIL ?? Who would benefit from it?
Your comment is awaiting moderation.
“Far from generating knowledge, every trial generates ignorance.”
I believe: the above sentence is only true as long as you lack of knowledge.
But you cannot achieve knowledge only with the help of trials. You always need a basic understanding of a process.
When you already possess that basic knowledge, than a trial can be a very good proof and might even lead you to more detailed and unexpected conclusions.
“Another problem is that some within Cochrane agree with what is being said here about trials, but figure that ideas like this cannot be aired if we are to keep homeopaths and others out of the medical temple.”
If someone REALLY believes that he possesses a reliable basic knowledge of a process, he should not fear to include also other opinions into his trials! If e.g. they are so sure that some “alternative therapy” doesn’t work, so why don’t they include in their trials, proving like this its worthlessness?