(An article by John Furse – LRB, 7th November 2019.)
The Americanisation of the NHS is not something waiting for us in a post-Brexit future. It is already in full swing. Since 2017 Integrated Care Systems (ICSs) have been taking over the purchasing as well as the provision of NHS services in England, deciding who gets which services, which are free and which – as with the dentist and prescriptions – we have to pay for. Known in the US as Accountable Care Organisations (ACOs), ICSs are partnerships between hospitals, clinicians and private sector providers designed – and incentivised – to limit and reduce public healthcare costs, and in particular to lessen the demand on hospitals. Health Maintenance Organisations (HMOs), the forerunners of ACOs, were pioneered by the US health insurance provider Kaiser Permanente in 1953. President Nixon’s adviser John Ehrlichman explained to his boss the basic concept before the passage of the 1973 HMO Act: ‘The less care they give them the more money they make.’ In May 2016 Jeremy Hunt, then health minister, admitted at a Commons Health Committee hearing that Kaiser was a model for his planned NHS reforms. When a trial of ACOs was announced in the UK in 2017, it caused an outcry from campaigners and NHS England quickly rebranded them ICSs. But the Kaiser model isn’t new to healthcare policy in the UK: it has been the inspiration for the long and discreet process of the dismantling and reformation of the NHS since the 1980s.
Stand Up To Cancer scientist, Professor Simon Leedham, is supporting research into an entirely new treatment option for people with bowel cancer by investigating a molecule called GREMLIN1. Watch the following animation, which provides the background to the project…
Our Jazz and Coffee morning on Saturday 22nd June was a HUGE success. Members, especially Erika baked a fabulous range of wonderful cakes. We even had a ploughman’s lunch with delicious home baked bread. The weather shone blissfully, so we could sit in the pretty garden at St Margaret’s Cottage and the band “Work in Progress” provided a background of perfect music for a lazy Summer’s day. Here’s a sound clip of the band, recorded on the day; something to remind those who were there what a great day it turned out to be.
We had an enormous raffle, again thanks to members’ generosity and to Jim Gray who managed to get local stores to contribute several prizes. Our grateful thanks to all those who helped on the day by setting things up, washing up and clearing away. As soon as we know how much was raised by the event, we shall publish it on this website.
This all-day event took place in the foyer of the ASDA stores in Hollingbury, Brighton. It was funded by Macmillan. Our aim was to raise awareness of the first signs of bowel cancer amongst the public and to ensure that they knew what to do should the signs be positive. It was not a fund-raising event.
The event was a multi-agency collaboration with C-Side working with the following organisations: The Macmillan Horizon Centre; Albion in the Community (the charitable branch of the Brighton and Hove Albion Football Club); the Sussex Bowel Screening Programme; the Colorectal Nurse Specialist team from The Royal Sussex County Hospital and members from C-Side Colorectal Cancer Support Group.
Twenty volunteers from all the participating groups gave up their time over the day, engaging with the public and distributing leaflets and information. They were well-prepared with shared information and advice on how to approach the public. When specific questions were asked about Bowel Screening or advice about Bowel cancer was required, volunteers referred people to our clinical specialists: the Colorectal Nurse Specialists or the Clinician representing the Sussex Bowel Screening Programme. These specialists recorded some of the “meaningful conversations” to show our sponsors the sort of impact we were having. We had a large pull up banner, wore t-shirts that showed a unified presence and a table of information in the form of leaflets and posters. We also had tote bags printed by C-Side in which we could put leaflets, and AITC provided us with even more tote bags and pens as freebies. Furthermore, ASDA were extremely generous and provided several trays of free fruit to support us with our healthy eating message.
While it is difficult to be precise about our impact, we ascertained that we engaged with more than 1000 members of the public between us during the day. Even people we did not talk to took leaflets and saw what we were about. Despite being very busy, the clinical specialists recorded 30 “meaningful conversations” – just a sample of the sort of questions we were asked during the day. People were generally very agreeable and interested in what we were offering and all involved thought it was a very worthwhile event.
Some specific comments received by participants included:
It was a well run event
Volunteers were given a clear direction
There were more than enough volunteers but the venue (some thought) was restrictive, so that it sometimes felt crowded
The footfall was high
The separate, private space considered by the nurses was not possible
The t-shirts were very effective and immediately identified volunteers
We had leaflet overkill! Next time (as we hope there will be a repeat) we will be more selective in our choice of leaflets.
In the future we might do a smaller “pop-up” event in a range of different venues.
C-Side is only a small charity, but we feel it was a very worthwhile event to have run. While we clearly had an impact on members of the public, perhaps our biggest achievement was to get the different participating groups working together collaboratively to really raise awareness of bowel cancer.
On 30th April one of our members, Don, gave a presentation on Advance Directives. The presentation was as shown below; click into the image then use your keyboard arrow keys or mouse to advance the content. Several links are included showing in yellowish-green text; clicking on them will open the link in a new tab. When you’ve finished with the link’s content, close the tab to return to the presentation.
In addition, here’s two more links to papers related to the subject:-
Listen to this BBC Inside Health sound clip on Prehabilitation. It’s about 15 minutes in length, but well worth the listening as it describes just how being as fit as possible, before beginning surgery or chemotherapy treatment, increases the favourable outcomes of that treatment.
In thus excellent podcast series Dr Mark Porter demystifies health issues, separating fact from fiction and bringing clarity to conflicting health advice, with the help of regular contributor GP Margaret McCartney. Click on Radio 4 image to see what other health podcasts are available.
To listen to the part of this one, dealing with Prehabilitation, use the play/pause button to play the clip and the volume slider to adjust for listening comfort.
Many of you reading this, either yourself or someone you know, will have been affected by colorectal cancer. Either directly or indirectly, you will have experience of the presentation of symptoms and the subsequent diagnosis and treatment of a worrying disease. You will know, but many others may not, that despite Bowel Cancer being the second biggest UK’s killer cancer it is eminently treatable and curable, especially when diagnosed at an early stage.
It is vital, then, for the general good that the public become aware of Bowel Cancer symptoms – some of the more common amongst which include:
Bleeding from the bottom and blood in poo
Persistent and unexplained change in bowel habit
Sudden and unexplained weight loss
Being easily fatigued with no obvious reason or cause
Pain or a lump in the tummy
April has been set aside nationally to educate the public and raise awareness of these symptoms. Bowel Cancer UK have taken the lead in this and have a variety of educational and awareness programmes set up for April, this link shows their strategy.
For its part C-Side (being representative of Bowel Cancer patients in the Brighton area) felt that there might be more that could be done locally. So, in association with Albion in the Community (AITC), Macmillan Horizon Centre and Bowel Cancer Screening & Colorectal Nurse Specialists from the Royal Sussex University Hospitals, we decided to present a Bowel Cancer Awareness Event here in Brighton. The management from ASDA supermarket in Hollinbury have kindly offered the use of their foyer where we (volunteers and clinical experts) will be on hand to answer questions from the general public on matter related to Bowel Cancer, with the particular objective of educating them in identifying the symptoms listed above, should they ever arise. The event, on Saturday 6th April 2019, will take place from about 10.00 a.m. to 5 p.m.
Notes from the talk given by “JC” at the C-Side meeting on Tuesday 30th October, 2018
JC gave a detailed, personal
and informative talk, answering all the questions we had prepared for him:
How do surgeons combat tiredness? What is the limit on hours they can work?
Do surgeons get nervous?
Regarding long term symptoms : what ought we to
One of our members has a split in the wound
following a stoma. It requires packing
every day. He had no warning that this
might be a result of the operation. How
common is this situation?
How do you deal with a blocked ileus?
Can you explain the research you are doing in Italy regarding the colon when re-sectioned.
What is the current expected waiting times for
treatment and the situation regarding
How much theatre time are surgeons allotted each
How are the cuts affecting Bowel cancer
Do you have any statistics for the year
regarding the number of operations/ survival rates/ costs?
The personal questions provided an insight into the work of JC
and his colleagues. He made the
Operations can take between 1.5 and 6 hours, and
can last 9- 10 hours. He can get tired
and can deal with two major cases in one day.
There are no limits to the hours that he works, although it is supposed
to be 56 hours.
He does get nervous as he has an understanding
of all that can go wrong. He downplays
these but is often working to within fractions of a millimetre. Sometimes difficult decisions have to be made
such as whether to sacrifice the spleen instead of the bowel. There is a high level of stress in the
operating theatre which is difficult to differentiate with nervousness.
There is altered bowel function after surgery
that can take anything from 8 weeks to 2 years for the system to settle. Lower
rectal surgery can cause difficult day to day functioning. Complications in the anal canal system has a
risk of infection. Perineal wound
surgeries can have more prolonged problems.
This is not something that can always be predicted.
Ileum surgery often causes vomiting and there
can be a danger of aspirational pneumonia.
The contents of the bowel must be kept out of the lungs. Tubes are inserted to alleviate
vomiting. Most blockages to the ileum
correct themselves and are often twisted or pinched. If there is a food bolus obstruction this may
require surgery. If there is a
parastomal hernia as a result of a stoma where several bits of bowel stick out
outside the muscle, it can be decompressed to see if it will settle. Further surgery may be necessary.
Italian research has shown that a fluorescent
substance can show up under ultraviolet light indicating blood supply to the bowel
during surgery. This can very
effectively show whether there is a sufficient blood supply for an operation,
which can reduce the likelihood of failure during anastomoses (join in the bowel). Anastomotic failure can be reduced from 10%
to 1.5% using this system. At present
the Consultant Colorectal Surgeons are trying to persuade the Trust to use this technology. NICE should make it a mandatory part of the
surgery. It also has benefits in other
surgeries such as gall bladder surgery.
This massive piece of research adds about 3 minutes to an operation and
costs about £10,000 – £100,00 with the higher figure being for a laparoscopic
stick. It makes operations much safer.
and administrative considerations:
have an issue with waiting times for Colorectal Cancer surgery but is
experiencing the best situation for years – diagnosis, decision to treat and
date for surgery is approximately 2-3 weeks.
But there are still delays before the decision to operate as this
depends on colonoscopies, MRI scans and CT scans. At present there is a shortage of scanners
and radiologists. Ideally diagnosis to
surgery should take 4 weeks. However, although
cancer takes priority, there are cancellations when the hospital is too full or
In Brighton of 300-400
patients are diagnosed, 70-100 need surgery.
There are 150-250 Bowel surgery
operations annually. 4 surgeons are
rectal specialists and 6 specialise in colonic surgery (the 4 who do rectal
surgery plus 2). They are audited
nationally and outcomes are well within the accepted range of mortality.
government cuts do not affect serious health problems such as cancer, heart
disease and diabetes.
As a final note, JC
explained that Dukes staging (A, B and C) is now historic. Now TNM (Tumour, Node and Metastasis) staging
is used to describe where a patient is
in his or her bowel cancer.
On 29th March 2013 BBC News on-line broadcast this:-
“All cancer patients should receive a “recovery package” at the end of their treatment offering ongoing support, the Department of Health (DoH) has said. It calls for care targeting patients’ financial, mental and physical needs. Macmillan Cancer Support, which helped develop proposals for a recovery package, estimated that about 200,000 people were not getting a package of support following their treatment.” You can read the entire news report here: http://www.bbc.co.uk/news/health-21968714
Since then the National Cancer Survivorship Initiative (itself set up in 2008) and Macmillan have developed and refined the Recovery Package; NHS England are encouraging all CCGs, as a matter of urgency to adopt it. Whilst there is no lack of enthusiasm and support amongst front-line NHS clinical staff, the full implementation of the programme is tardy; during a future meeting we hope to be able to report on the actual progress being made. In preparation for this you are invited to click on the above diagram, you’ll be directed to more details of the Package. In summary it has four main components:-
a) Holistic Needs Assessment & Care Planning.
b) Treatment Summary
c) Cancer Care Review.
d) Health and Wellbeing Events.
For a further description of the Recovery Package and one presented in a slightly more patient friendly fashion click on this; there are one or two faces in it that you may recognise!