Thursday, 28 February 2013

Prime Minister is wrong to fight an EU cap on bankers bonuses.

The news that Prime Minister, David Cameron, intends to 'fight' EU plans to cap bankers bonuses is perhaps not surprising. He failed to take any action or position on excessive bonuses two years ago. It simply demonstrates that his hand wringing over excessive bonuses bankers give themselves is just that,  gesture politics.

The government are concerned that a cap on bonuses would affect the position of the city of London as a financial centre competing for top talent globally. But this is why action must be taken at an international level and the EU move is a step in that direction.  Precisely what level the cap should have and what conditions should be subject to debate and decision.

There is always the argument that if you seek to restrict greed, and it is greed, then the wealthy will find other ways to satisfy their avarice. We mustn't increase taxes, else they will move their money elsewhere etc. We cannot go on allowing these greedy people to blackmail us in this way. So, yes there are valid arguments not to cap bonuses, but the question is whether the benefits outweigh them. I believe in a time of austerity they do.

Any bonuses incorporated contractually should be dependent on long term results and not simply short term gains that might be wiped out over time. The current bankers bonuses are obscene. Through incompetence and greed, the banks brought the financial system to its knees. Failure to apply due diligence has now led to an austerity programme from which the rich bankers have ring-fenced themselves. This cannot be justifiable. If ordinary people are having to make adjustments, then so too must those in the financial sector.

Since the bailout, losses at RBS have now reached £34bn. Yet, despite this loss, the bank has paid out £679m in bonuses, some £287m of which is to its investment bankers. Of course RBS needs to attract good people, but it also has a duty to the public and consumers.

Sensible rules regarding salaries and bonuses are good for shareholders, consumers and taxpayers. We are all stakeholders in one way or other in the banks. There needs to be transparency and accountability in setting bonuses. It is said that if bonuses are capped, then salaries will increase and flexibility will be lost. In bad times it would be difficult to reduce salaries whilst it is possible to reduce bonuses. If only that was true, but history has told us that bonuses have been set on short term gains rather than sustainable profits or improvements for customers and shareholders. Salaries can be based on clear goals, and should there be 'failure' of the magnitude we have seen in recent times, then those salary holders can be shown the door. Bonuses have reeked havoc in the business, an contributed to the development of speculative and toxic debt. From that we have all suffered.

I agree with Mr Cameron when he said of bankers and their bonuses:  "They have got to have proper regard in terms of restraint when they have had so much money from the taxpayer and they have made so many mistakes in the past."

Absolutely, which is why they should not be surprised we may wish to cap and impose sensible conditions on such bonuses.

Postscript

Swiss voters have have backed executive pay and bonus caps in a referendum. 70% voters backed proposals to give shareholders more control an impose the world's strictest regulation of boardroom pay and bonuses.


Wednesday, 27 February 2013

There is an alternative and the British Chambers of Commerce spell it out.

Today the Prime Minister, David Cameron, adopted the strategy of economic madness. Whilst his Business Secretary, Vince Cable, has described the loss of the triple A status as being largely 'symbolic', Mr Cameron once again nailed his colours to its mast. It is a bit like crashing a car into at a tree and then declaring that it indicates they were travelling in the right direction. Mr Cameron continues with the line that there is no alternative. This is wrong, blind, foolish, obstinate and rather arrogant. It rejects advice from those economists who call for a change in direction.

The economy is in a bad shape. It is insufficient to point to the odd 'green shoots', the odd indication that things might turn out all right in the end. The coalition is missing its targets by a wide margin, and with the current strategy, austerity is set to last at least until 2017 and beyond. A decade of austerity will leave the economy considerably weakened, the poor poorer.

Nor is this a party political issue. Groups across the political spectrum, and of no political colour, have called for a strategy for growth.  Today, in light of the absence of growth, the British Chambers of Commerce has called for immediate action to stimulate growth. This would be a major change of direction. Growth should be the objective, and not simply cutting the deficit.

The Director General of the BCC said today:

"The Chancellor should seize the opportunity in next month's Budget to be radical, and introduce measures that creat“e an environment of enterprise, stimulate export growth, kick-start infrastructure projects and create a structure of business finance which supports growing companies. Above all, these measures should create confidence. Our own research shows that firms across Britain believe they can drive growth this year, but they can’t do it alone. The government must be bold and do all it can to boost confidence so that businesses can create jobs, wealth and ultimately long-term growth.”

The government strategy is counter productive as blind austerity reduces revenue it becomes more difficult to cut the deficit. It is bad economics and bad for the country. There is an alternative.


Tuesday, 26 February 2013

Economical with the truth on cutting the deficit.

It is unworthy of coalition ministers to repeat the absurd claim that the government has cut the deficit by a quarter. I hear it repeatedly. It is untrue, or in as much as it has any truth it is an unethical manipulation of statistics; unethical because of the consequences of misrepresenting the financial situation to the public. So where does the claim come from and does it stack up?

The claim comes from a comparison of Public Sector Net Borrowing (PSNB). It is convenient to choose the periods of comparison, for example a low year with the  high year. This is an old statistical trick. The problem of doing this is that the years chosen might contain elements that were exceptional and not typical of the underlying trend or position. This is why it is better to compare longer periods to iron out anomalies, exceptional one off items of expenditure or revenue. Furthermore, running deficits in a given year or period is not necessarily bad. Cutting PSNB is not in itself 'good'.

And this is why the claim made by government ministers is disingenuous. Statistics from the ONS show that for the period April to September 2012, the public sector net borrowing, excluding the temporary effects of financial interventions (PSNB ex), was £37.1 billion, which was £25.4 billion lower than in the same period of the previous year, when PSNB ex was £62.4 billion. It all looks good until you consider exceptional elements, or what factors contributed to the fall.


The April 2012 the net borrowing figures included two one-off transactions. The first was a £28 billion transfer of the Royal Mail Pension Plan and the second was a £2.3 billion transaction to the Government from the closure of the Special Liquidity Scheme.

When the effect of these two one-off transactions is removed, then PSNB in the period April to September 2012 would be £67.4 billion, which would be £4.9 billion higher than in April to September 2011. A decreasing deficit turns into one that has increased.

A better indication of the financial situation would be to consider debt as percentage of GDP, as this would be a measure of its sustainability. By this measure debt has been increasing. Public sector net debt was £1,065.4 billion at the end of September 2012, equivalent to 67.9 per
cent of gross domestic product (GDP).

Running deficits is not in itself an indication of bad financial management. It depends on what underlies the budget deficit. Running deficits resulting from investment, building infrastructure, getting people back to work and increasing productivity and high street sales, can be strategically sensible if it leads to increased revenue in later years that then cuts the deficit.

Bad deficits are of the opposite kind. They result from falling revenue against a background of increased spending on unemployment and welfare, the result of recession. This leads to a bad cycle of cutting spending further which simply aggravates the problem. This I believe is the situation Osborne has got us into.

Cutting budget deficit should not be the aim in the short to medium term. The target should be policies that stimulate growth and increased tax revenue. Simply cutting the deficit is bad strategy.

Postscript

An update on PSNB: For the period April 2012 to January 2013, public sector net borrowing (excluding the capital payment recorded as part of the Royal Mail Pension Plan transfer in April 2012) was £93.8 billion; this is £1.5 billion higher net borrowing than in the same period the previous year, when net borrowing was £92.3 billion.

Public sector net debt was £1,162.8 billion at the end of January 2013, equivalent to 73.8% of gross domestic product (GDP).

The Director General of the British Chambers of Commerce has today called on the government to act speedily with measures to stimulate growth.

“The Chancellor should seize the opportunity in next month's Budget to be radical, and introduce measures that create an environment of enterprise, stimulate export growth, kick-start infrastructure projects and create a structure of business finance which supports growing companies. Above all, these measures should create confidence. Our own research shows that firms across Britain believe they can drive growth this year, but they can’t do it alone. The government must be bold and do all it can to boost confidence so that businesses can create jobs, wealth and ultimately long-term growth.”

Monday, 25 February 2013

There is an alternative

I am always suspicious of political arguments that suggest there is no alternative. There is always an alternative; the question is which is the best alternative. When the 'no alternative' argument is deployed it usually suggests a fundamental weakness of the position; it is an argument from weakness, not strength. And so it is with the arguments deployed this weekend by the government in the wake of the loss of the triple A rating for the economy.

All governments whether Labour or coalition would have to 'tackle the structural deficit' Mr Cable told us. As if this suggested there was no alternative way to deal with it. What we know is that the coalition adopted a savage strategy of cutting spending to 'deal with the deficit', and they did so without a clear strategy for growth. The alternative would have been to make growth the priority rather than cutting the structural deficit; such a strategy if it worked would have cut the deficit by increasing revenue. As it is, the cuts in spending have reduced revenue and made the deficit worse not better. There is an alternative.

The government also adopted a position determined to protect the triple A rating. This was an absurd approach. Now Mr Cable tells us that it doesn't matter; it is merely symbolic. Indeed it is; so what it means is that the slash and burn of public services has been about protecting something that was simply 'symbolic'; a kind of macho economics! The poorest have suffered for a symbol. Again there was an alternative, which was to consider policies that would deal with the structural deficit through growth and income and not blindly savage cuts.


Mr Cable likes to set up an Aunt Sally that is easily knocked down. He likes to suggest that the alternative would be to 'simply spend our way out of trouble', which won't work. But that is not the alternative, although I suspect the coalition as they panic in the approach to 2015 might just adopt such a strategy. It would, of course, be irresponsible. No we can't 'spend our way out of trouble' but what we can do is be strategic about spending. We could recognise that not all spending is 'bad'; some is vital to oil the wheels of the economy and increase revenue.

It will be interesting to see what strategy Osborne adopts in the coming budget, but I bet there is an alternative. Let's see.

Thursday, 21 February 2013

Something isn't right in the world of pharmaceuticals. Alarm bells are ringng.


Something is not right in the world of pharmaceuticals. But it isn't reflected in the number of new drugs coming to market.

The widely held belief that the UK supply of innovative new medicines has conspicuously dwindled in recent decades, is not borne out by the evidence, or at least this is what is suggested by research published in the online journal BMJ Open.

The prevailing view is that pharmaceutical industry innovation has been in decline, with fewer new drugs launched in recent decades than before—despite more cash being pumped into research and development—prompting a good deal of hand-wringing, say the authors.

They tested whether this view was justified, by looking at all new medicines added every year to the prescribing and dispensing drugs bible, the British National Formulary, or BNF for short, over 30 years. The BNF is updated every six months.

In terms of the drugs industry, the UK punches above its weight. After the US, the UK is the second largest source of new drug development, generating more than 10% of all new medicines around the globe.

All new synthetic chemical entities and new biological drugs, such as vaccines, blood products, and gene therapies were included, based on their first appearance in the BNF between 1982 and 2011.

New products covered modifications of existing drugs as well as radical breakthrough treatments. Different doses and formulations containing the same active ingredients were only counted once, and generic versions of brand drugs were excluded.

The researchers found no significant linear trend pointing to a decline in the number of new drugs introduced into the UK over that period, which averaged just under 24 a year.

But the authors did find a pattern of peaks and troughs, with dips invariably followed by a surge in new arrivals. New drugs, in seems, come in waves.

After a dip in the mid-1980s, with around a dozen new drugs coming on to the market between 1985 and 1987, new arrivals increased every year, peaking at 34 in 1997.

This peak was again followed by a dip, with around 20 new drugs a year between 2003 and 2006, followed by a further peak in 2010.

And extending the timeline back to the 1970s indicated an overall slight but significant increase of 0.16 new drugs every year between 1971 and 2011, “contradicting the widely held view that the number of new medicines being launched is declining,” say the authors.

They conclude that the perceived “innovation dip” is a product of the time periods studied in the past. A product of the cyclical nature of new drugs entering the market.

“Although there was indeed a dip in new drug introductions during the decade from 1997 to 2006, this was largely an artefact of a peak in 1997, which was itself preceded by an unusually low number of launches in 1985-87,” they write. “Additionally, the peak number of new drugs added to the BNF in 1997 was matched in 2010.”

The authors point out that their study does not distinguish between varying degrees of innovation, and launches are not the only indicator of pharmaceutical industry health. But theirs is the most up to date UK study of new launch trends, they say.

There are however, reasons to be concerned. As the authors point out, the costs of drug development have soared. and the time taken to bring a new drug to market has risen from 3 years in 1960 to 12 in 2000.

My own view is that the authors of the study published today may well be asking the wrong question; or at least using the wrong measure. It isn't the number of 'new' drugs that count; it is really how innovative they are and whether they really make a difference.

Alarm Bells

Alarm bells rang when it was announced recently that the world's leading pharmaceutical companies are downgrading the search for new treatments for Alzheimer's disease after the failure of a series of high-profile drugs trials.

Nor has there been the expected windfall following the sequencing of the human genome. Many leading scientists are disappointed that there have been few gene-centred drugs coming through from this project.

Tragically the genome project has sucked funding away from more traditional areas of research with little reward. A decade ago drug companies invested billions of dollars in genomic research and development. The shares of small genomics based companies went through the roof in a 'genomic bubble'.

In 2000 the then head of the drug company Novartis was reported to have observed “Data, data everywhere, and not a drug, I think.”

Genomics may be a misdirected quest for new drugs. There are few diseases or condition for which there is a specific gene. This is not surprising; genotype doesn't translate into phenotype.

Misdirected funding

Funding has been directed at 'translational' research in the absurd hope that this could somehow leap beyond the usual steps of scientific endeavour and discovery. It can't and it won't. But another problem of translational research is that it draws funding away from solid basic biomedical science from which new ideas will eventually come. 

Some of the really good innovative drugs have been founded on basic research. Genomics is more like a fishing expedition rather than good science. Major breakthroughs in treatment often come serendipitously rather than from targeting a problem and throwing money at it; but luck usually rides on good science.

This was certainly so for the developments of treatments for Asthma. It involved good basic science, good pharmacology and a bit of luck. It came in stages over time; first with the finding that adrenal extract could relieve symptoms, then the discovery of adrenaline and the categorisation of different adrenaline receptors which enabled drugs to be targeted at the right ones. It also involved understanding of how some drugs could act over time, and that more than one kind of drug was needed; one to relieve symptoms acting on the adrenaline receptors in the airway, and another, corticosteroid, to ease the inflammation.

The pharmaceutical industry needs to take stock and rethink its drug development strategy. Putting their eggs in the genomics basket will produce fewer answers then originally anticipated. Government and funding agencies need also to consider how to rejuvenate basic biomedical science and systems biology.

It is scandalous that drug companies should be giving up on diseases such as Altzheimer's. We should stop looking for magic bullets. Good science takes time and funding. Pharmaceutical companies looking for a quick buck have forgotten those basic ingredients.

Tuesday, 19 February 2013

The government's proposals for social care are neither fair nor sustainable.

The government have missed an opportunity to establish a consensus on the reform of funding social care. They are ignoring the key financial recommendation of the Dilnot Commission.  By focusing on the 'scandal' of people 'losing' their homes to fund their social care, they have missed the point, and by setting the cap at £75,000 they have missed it by a large margin.

The unfairness of the current arrangements for funding social care is not the 'scandal' of people 'losing their inheritance'. That is not where the 'scandal' lies. The scandal lies in the arbitrary and unpredictable impact the need for social care has, and the lack of coherent and sustainable ways to meet it.

There is nothing inherently unfair about having to use equity invested in our homes to fund our care. For several decades we were encouraged to buy our homes rather than rent them; we were encouraged to see it as a relatively secure investment for our hard earned savings.  For some time we even got tax relief on the interest which encouraged us to lock more of our money in our homes! But if we are not then willing to use the proceeds of that investment to help pay for our social care in the future, then what have we been making the investments for?

But if we are expected to contribute to our social care in later life then that contribution should be predictable, fair and transparent and the means-testing needs to be applied fairly. As the Dilnot commission concludes,  we need a system that is "fair and transparent" and what people might be expected to pay is established and clearly understood so that they can plan for it.

Under the government's plans, anyone with assets, including their home, worth more than £123,000 will have to pay for the first £75,000 of their care costs. They will also pay “bed and board” of up to £12,000 annually when in a nursing home. It is good that the means-testing threshold will increase from £23,250 to £123,000. But this is an asset threshold and includes the value of property. The average value of houses in London is over £445,000; in the West Midlands it is £165,000. Many will have assets above the means-testing threshold, and a cut off creates an arbitrary unfairness at that level. Many will still need to sell their properties to meet the costs of care up to the cap of £75,000.

The government could have set the cap at £35,000  as recommended by the Dilnot Commission which suggested the cap should be between £35,000 and £50,000.   The level of the cap was determined by Dilnot to be the level that "taken together, the cap and the increase in the threshold for state support in residential care, would mean that those with lower incomes and wealth receive greater protection."   The Dilnot Commission believe that " a cap outside of this range would not meet our criteria of fairness or sustainability." The government have chosen to ignore Dilnot and impose a cap that benefits the wealthiest but not the poorest home owners.

The Government currently spends £14.5 billion p.a. on adult social care in England. Just over half of this is on services for older people. By concentrating on the “scandal” of people having to sell their homes to pay for their care, the government has addressed a political problem but not the real economic and social cost of care. The shortfall in funding of social care will be £10-12 billion by 2021-2, according to the Nuffield Trust. There is little if anything in the government proposals to address that gap. Social care provision needs fundamental reform, with more coordination of care agencies and funding if it is to meet the challenges of a growing elderly population.

As Dilnot says "The Government should both implement our reforms and ensure that  there is suficient, and sustainable, funding for local authorities. Local  authorities will need to be able to manage existing pressures as well as the new requirements resulting from our reforms."

As it is, the government has cut funding for local authority provision for the past two years and with further cuts this is likely to be squeezed further. All political parties need to be honest with the public about the need for increased taxation to make up for this. In the long term, good quality social care will reduce the economic burden on the NHS. But we cannot hope to get a good quality of care by continuing to cut funding. As the Dilnot commission rightly concluded there needs to be better integration of services, the current ‘postcode lottery’ of care should be  addressed, there should be more transparent assessment processes, and there needs to much better information and advice.

Friday, 15 February 2013

Passive smoking stunts fetal growth and harms unborn babies.

Smoking bans are associated with a “consistent pattern of reduction in the risk of preterm delivery,” finds a study published by bmj today. The study supports the notion that smoking bans have public health benefits from early life and protect unborn babies from the effects of passive smoking.

It has often been argued that prohibition of smoking in public places is an attack on civil liberties. Some leading public figures have campaigned for a lifting of the ban in pubs and clubs.  In 2011 TV chef and publican Antony Worrall Thompson launched an e-petition calling on the government to review the smoking ban.

The publication of this new study today should lead them to reconsider their position.

A key argument in favour of bans on smoking in public places is the potential impact of secondary smoking, or passive smoking, on the unborn child. 

Maternal smoking during pregnancy is associated with a decrease in placental function and can lead to intrauterine growth restriction. The fetus stops growing and the baby is born small and undernourished. 

One way smoking does this is to interfere with the function of mitochondria in placental cells. Mitochondria are the tiny packages in cells that produce the energy needed for function. They are the power-packs making and supplying energy in all our cells and without which the cells cannot function.  By limiting energy availability in the placenta, the fetus is no longer able to obtain sufficient nutrients for growth and the baby is born stunted. 

Exposure to second-hand smoke, passive smoking, has also been found to affect birth outcomes in the same way, yet little is known about the impact of recent smoke-free legislation on birth weight and preterm birth.  A key question for any public health strategy is whether it is producing sufficient benefits. 

To answer this question, a team of researchers, lead by Dr Tim Nawrot from Hasselt University, investigated whether recent smoking bans in Belgium were followed by changes in preterm delivery. In Belgium, smoke-free legislation was implemented in three phases (in public places and most workplaces in January 2006, in restaurants in January 2007, and in bars serving food in January 2010).

The researchers analysed 606,877 live, single-born babies delivered at 24-44 weeks of gestation in Flanders from 2002 to 2011. Preterm birth was defined as birth before 37 weeks.

They found significant reductions in the risk of preterm birth after the introduction of each phase of the smoking ban. No decreasing trend was evident in the years or months before the bans. This shows that it was more likely to be the bans that had produced the improved outcome.

The results show a reduction in the risk of preterm births of 3.13% on 1 January 2007 (ban on smoking in restaurants), and a further reduction in the risk of 2.65% after 1 January 2010 (ban on smoking in bars serving food). These changes could not be explained by several other factors - both at the individual level, such as mother’s age and socioeconomic status - and at the population level, such as changes in air pollution and influenza epidemics.

Given that even a mild reduction in gestational age has been linked in other studies to adverse health outcomes in early and later life, the current study has important public health implications. As the authors of the report say:

"Our study shows a consistent pattern of reduction in the risk of preterm delivery with successive population interventions to restrict smoking. It supports the notion that smoking bans have public health benefits even from early life. More and more countries in Europe are adopting stricter legislation on smoking in public places. These results underscore the public health benefit of smoking ban policies."

Smoking is the major preventable cause of death in the UK. Sadly, lung cancer has now overtaken breast cancer as a major cause of death in women. Lung cancer death rates have increased by seven per cent among European women since 2009. The UK has the highest female lung cancer rates in Europe. We still have a long way to go in preventing needless deaths from smoking. 

What this study demonstrates is that measures taken to prevent passive smoking have benefits in early life. Babies are at risk from passive smoking. Such public health concern should outweigh arguments about civil liberty and smoking. Banning smoking in public places where it may harm others is a sensible and beneficial approach. Civil liberty is not predicated on freedom to harm others.

Thursday, 14 February 2013

Poor public understanding of HIV is costing lives.

Stigma and discrimination may be preventing people with HIV coming forward for diagnosis and treatment.

A report published today in the online journal Sexually Transmitted Infections suggests a significant proportion of HIV positive patients may not be disclosing their infection to NHS staff, when turning up for treatment at sexual health clinics.

If the findings reflect a national trend, this could have implications for the true prevalence of undiagnosed HIV infection in the population, which is based on the numbers of “undiagnosed” patients at sexual health clinics, say the authors.

Currently, it is estimated that around one in four people in the UK who is HIV positive doesn’t know s/he is infected with the virus.

It is thought that a proportion of patients who do know their HIV status nevertheless choose not to reveal it to NHS staff when attending for services elsewhere, so the researchers set about trying to find out whether there is any basis for this belief.

The reasons why they don’t "come clean" about their HIV status may be that they don’t want to be “judged,” given that they have come to the clinic with another infection, which implies they are indulging in risky sexual behaviour, the author of the report suggests.

But by not revealing their HIV status, they could be missing out on the chance to be treated more holistically and discuss other aspects of their health which might be affected by HIV.

If this problem is to be tackled we need to change the cultural attitude about HIV and AIDS to end the fear of discrimination.

People living with HIV are particularly vulnerable to discrimination, as HIV remains a highly stigmatised condition. One in three people diagnosed with HIV have experienced HIV-related discrimination at some time. Sadly in the last decade public understanding of HIV/AIDS has declined and public health campaigns have withered on the vine. At the same time the number of damaging myths and misconceptions has increased.

Sadly also there has been no positive change in public attitudes towards HIV, and a significant minority of the public still hold stigmatising and discriminatory views about people with the virus.

Such attitudes and lack of public awareness, by stopping people coming forward for diagnosis and treatment, is costing lives.

Wednesday, 13 February 2013

Calcium pills could more than double risk of heart disease and death.

Taking calcium pills could more than double your risk of heart attack, a study published today in the British Medical Journal suggests.  The risk of death from cardiovascular disease is doubled in women with high calcium intake who are also taking calcium enriched supplements.

There isn't a month goes by without publication of new research that demonstrates a link between some dietary factor or supplement and increased risk of cardiovascular disease and mortality. The information in the end I suspect is so confusing it is little wonder that for the most part it is ignored. It is the problem of information overload.

Nonetheless there are good reason for taking this new study seriously, not least because experts recommend a high calcium intake for women in middle age and increasingly people are turning to calcium supplements.

As a result more than 60% of middle-aged and older women in the USA now take supplements and it is estimated that up to 5 million people in the UK take them. What this study demonstrates is that more care should be taken in assessing the need for dietary calcium supplements.

Normally the level of calcium in the blood is tightly regulated and does not fluctuate with changes in dietary intake. What the authors of the study in today's bmj suggest is that this essential regulation may breakdown due to calcium overload if calcium supplements are taken over long periods.  The mechanisms regulating calcium in the body become disturbed.

Calcium is important for a variety of functions in the body. Indeed there is no function in the body for which calcium at some stage or other is not essential. It is involved in the beating and contraction of the heart, the function of skeletal muscle and of the brain, and also in the secretion of hormones from glands. It is essential at the very start of embryonic life and the fertilisation of the egg.

A healthy balanced diet should provide all the calcium we need. But there are times when this might have to be supplemented. To maintain constant concentrations of calcium in blood, muscle, and body fluids the body uses bone tissue as a reservoir. Some 99% of the body's calcium is stored in our bones. But this balance changes with age.

As we get older the balance of bone loss and reformation deteriorates. As a result the bone becomes less dense and more fragile. This is particularly so in post menopausal women with the risk of osteoporosis. Women with osteoporosis have lower total-body calcium levels 

Blood calcium is regulated by two hormones: parathyroid hormone and calcitonin produced by the thyroid and parathyroid glands. If calcium falls, parathyroid hormone stimulates the release of calcium from bone into the blood. When calcium levels return to normal parathyroid hormone levels fall. If the levels of calcium in the blood get too high, the thyroid gland releases calcitonin which decreases the calcium released from bones. Some people have medical conditions that cause the glands to continuously release parathyroid hormone, which causes the bones to constantly release calcium.

Other recent trials have indicated a higher risk of ischemic heart disease and stroke with calcium supplements, but these findings have not been demonstrated consistently. In the newly published study, researchers from Uppsala University in Sweden studied 61,443 Swedish women (born between 1914 and 1948) for an average of 19 years to test this association.


Women who had a higher dietary intake of calcium exceeding 1400mg/day and who also used supplements had a higher death rate compared to those not taking supplements. Women with a high dietary calcium intake (>1400 mg/day) were more than twice as likely to die compared with women with a 600-999mg/day calcium intake.

The researchers explain their findings by suggesting that diets either very low or very high in calcium can override normal homeostatic control causing changes in blood levels of calcium. Adults require approximately 1,200 mg of calcium every day. With balanced healthy diet calcium supplements should be unnecessary, and where calcium balance is disturbed, then the underlying causes should be investigated and treated.

The researchers conclude that high calcium is associated with “higher all-cause and cardiovascular mortality rates”. The take home message is that to prevent fractures in the elderly emphasis should be placed on individuals with a low intake of calcium rather than increasing the intake of those already consuming satisfactory amounts in their diet.

Saturday, 9 February 2013

Saving sick fetuses may have bad outcomes


Growth restriction in an unborn child is the single largest risk factor for stillbirth, yet it is currently missed in most pregnancies. The authors of a report published in the British Medical Journal last month say spotting it early could substantially reduce the risk, and this needs to become a cornerstone of safety and effectiveness in antenatal care.

You might think that with modern ultrasound scans growth restriction would be easy to spot. Yet the report shows that detection ranges from 12.5% to 50% in different maternity units. Such a wide disparity is worrying and according to the authors it depends on staff training and adherence to protocols.

But before we rush into investing resources and rescuing poorly growing fetuses, I think we should consider the implications more carefully. In recent times there has been a trend to 'demedicalise' pregnancy. After all, pregnancy is not an illness. Attention has focussed on the birthing environment and where possible keeping obstetrics at bay.

The authors of the report suggest that with better detection of growth restriction, action could be taken to rescue the fetuses. But, simply saving sick fetuses may not produce outcomes we would wish. Measures that can be taken to enhance fetal growth are extremely limited. It is more likely to drive an increase in caesarean  sections and increase the numbers of babies born premature. Many of these babies are likely to be very poorly and require intensive care.  Many would not survive, and for those that do, they may have long-term handicaps.

Recent reports from the epicure study, a long term follow up of the outcome for babies born prematurely, show that survival for babies born very premature has improved considerably since 1995. Just over half (53%) now survive. However, despite these improvements, the number of babies leaving neonatal units with abnormalities showing on their brain ultrasound scans, and with lung, bowel and eye problems has not diminished. Babies born before 27 weeks "face a battle for survival" and many go on to live with long-term health problems such as lung conditions, learning difficulties and cerebral palsy. The rates of premature birth are on the rise in many European countries and are particularly high in the UK.

Professor Neil Marlow, an MRC-funded researcher from the UCL Institute for Women’s Health and an author of the recent epicure reports, said:

“Our findings show that more babies now survive being born too soon than ever before, which is testament to the highly-skilled and dedicated staff in our neonatal services. But as the number of children that survive pre-term birth continues to rise, so will the number who experience disability throughout their lives. This is likely to have an impact on the demand for health, education and social care services.”

Increasing CS deliveries and the numbers of babies born prematurely will increase the burden on already stretched neonatal intensive care units. Deciding which fetuses to 'rescue' will depend on availability of such expertise and resources, and on the assessment of likely outcome. It cannot be based simply on the fact that a fetus stops growing. Difficult decisions will have to be made and these should be made from both the obstetric and neonatal care perspective.


Wednesday, 6 February 2013

Compassion and patient experience needs to be the focus of NHS reform.

It will take time to digest all the 290 recommendations of the Francis report on the failings at Stafford Hospital. Failings at the hospital were root and branch, from top to bottom of the NHS. For me, however, one recommendation stands out and it isn't one of the more legalistic or organisational ones. It is simply that there needs to be an increased focus on compassion in the recruitment, training and education of nurses, including an aptitude test for new recruits and regular checks of competence as is being rolled out for doctors.

The imperative to put patients needs back at the heart of decision making and care in the NHS was highlighted last year by Ann Clwyd's experience of the shameful way she and her dying husband were treated in hospital. It should inform us that something awful has gone badly wrong with health care provision.

The report is right to point to target driven decision making as being one source of the problem. It drives management to consider patients not as persons with individual needs but as statistics. But decisions have impact on persons and not an averaged statistic. I am an advocate of person-centred ethics because I believe that is the only way to build a framework for person-centred care.

This is not mere emotion; it is simply a realisation that people have hopes, fears, anxieties, loves, hates, desires; that the impact of decisions on patients is contextual and circumstantial. They have families and loved ones who care too, and they have particular needs that arise as a result. Yet, these are increasingly lost in the dry calculus of the utilitarian ethics of health care policy. Even the consideration of duty has become driven by calculation rather than imperative (Kant would turn in his grave). Ends become a justification for means regardless of the true meaning of outcome for those who matter, the patient or those in care. Patients become numbers.

We are of course interested in numbers. We tend to set targets by them. Quality is more difficult to measure than quantity. Well-being more difficult than wealth. But we should always look beyond the bare statistic and consider how a policy decision impacts real people and not an average. I have no real idea what an 'average person' looks like. I doubt if an 'average person' exists. You might be 'average' in some calculations but not in many others. The impact of being 'average' in any particular score most often depends on circumstances that are not average; housing, family, relationships, work, stress, but also personality.

A health care system simply charged with obedience to numbers is one that is more likely than not to ignore the individual needs of patients. If patients become a ward statistic to turn around as quickly as possible then nurses will have less time for real patient care. No time for emotional engagement. No time to ensure a continuity of care or of carers; care becomes impersonal; a monetised ingredient. And certainly poor pay, inadequate or non-existent training and low esteem in the privatised care system has produced a cocktail for potential and actual abuse and harm where the needs of the patient take second place in the profit margin.


None of this is to suggest that the majority of nurses and doctors enter their professions with any other than a caring ethos. Many nurses have expressed concern at the quality of care at their hospitals. Cuts in budgets and reorganisation are creating further problems at the font line of NHS care.

This is the warning given by the NHS Confederation in a report published last month. The NHS Confederation, a body representing all organisations that commission and provide NHS services, is worried that the current NHS reforms, by making the system more complicated, will increase still further the administrative burden on NHS front line staff.

Government ministers have argued that the £20 billion cut in the NHS budget would not affect front line services. Yet, between May 2010 and September 2012 whilst the number of managers was reduced by 18 per cent and the number of clerical and administrative staff declined by 10 per cent, a consequence has been an increased administrative load on doctors and nurses. If the administrative burden does not also fall, the report warns, there is a risk that front line staff will be diverted to form filling.

Reorganisation has compounded the problem. Commissioning is becoming more complex; for example, child health services are now commissioned by eight different parts of the system, including local authorities. Providers and commissioners will need to coordinate and build working relationships with more organisations than previously, which inevitably takes time and increases the administrative load. The number of commissioning organisations is also increasing; 211 clinical commissioning groups (CCGs) are set to replace 152 primary care trusts. There will also be a greater number of local bodies involved in providing health care, with health and wellbeing boards, local Healthwatch and more CCGs than there were primary care trusts.

There is already evidence that cuts in spending have driven some hospitals to dangerously low levels of staff, putting patient lives at risk. The Royal College of Nursing has identified 61,276 NHS posts which have either disappeared or are set to go as a result of cuts in spending and warn that the NHS is "sleep walking into a crisis." Nurses say that they "do not have enough staff to deliver good quality care. Demand for services is continuing to rise, however staffing levels are being slashed."

It is time the government abandoned the pretence that cuts in NHS budgets can be managed without impacting patient care. It is putting patients at risk. But it is also time we put the focus on quality and care, the patient experience, back at the forefront of NHS objectives.