I’ll briefly repeat my 6 point (bullet) plan for the NHS to preface my focus for today’s section on 3 Testing.
- Education – underpinned by philosophy
- Screening – underpinned by data
- Testing – from birth to death
- Preventative treatment – promotion of healthy life styles
- Research –on preventative medical conditions
- Evaluation – led by self-scrutiny
- “Testing – from distinction (birth) to extinction (death)”
Well, what I want to try to do today is to explore the theoretical, practical, ethical and moral issues, as well as the financial implications for the people, (patients, doctors and scientists, test developers, manufacturers and distributors, and those further downstream companies, governments and crucially, the people being asked to pay for all such services and other off-shoots, some of which are yet to be even dreamt about) , that do or could shape a framework for what has become one of Medicine’s 20th and 21st Centuries’ most controversial topics, and will become an even greater debate –Testing. Some sentence, eh?
What is testing?
This includes tests used in screening, or ‘speculation tests’ as I’d refer to them, as well as a vast array of actually deliberately used tests as applied to ‘a known patients’ screening profile or ‘work-up’. In other words, at least for patients receiving care or treatment already, tests are part what is done (blood, urine, sperm/semen, saliva, poo, commonly, and less commonly, bone marrow, respiratory aspirate, skin, spinal fluid, amniotic fluid and vaginal scrapings –only if you are female), to make up a range (incomplete) of such samples. For example, someone who suspects they may have become infected, perhaps with Human Immunodeficiency Virus (HIV), as a result of “a good night out and wanton appetite”, may decide to take themselves off for an “Acquired Immuno-Deficiency Syndrome” (AIDS) test to “re-assure themselves”. They’d be disappointed because they would be unlikely to show signs of AIDS at all, let alone after a couple of days, say! The HIV test, however, could be positive and this could predict the future, if not entirely accurately!
Early Government Advertising – warning about dangers of AIDS
Not all tests for every possible condition that could be tested would be tested, but you’d be surprised how much data is collected every time you meet and speak with a NHSHCP! Just ask F, finishing up her shift at the end of the working day. Just look at my notebook I have in hospital, making notes of every pulse, blood pressure and temperature reading, sometimes taken every 30 minutes, sometimes every 60 minutes – even during transfusion of packed red cells for alleviating my temporary (I hope!) anaemia, and to restore my haemoglobin levels and give me a little, if not entirely normal, increase in energy capacity for exercise, resisting the cancer growth or, walking down the corridor for No. 6/4 buzz cut, or whatever!
I have covered the issue of screen-testing specifically so I will try not to repeat this aspect again and focus instead on the broader implications. I have made specific mention of the idea of testing from Birth to Death. What again do I mean? Already, the new born are “tested”, usually a ‘heel prick to obtain a small sample of blood alright but also large enough to generate a lot of data but most often to obtain a bilirubin measurement to reveal whether there may be ongoing destruction of the child’s erythrocytes (red cells) because of maternal antibodies attacking the new born’s ‘foreign’ red cells via attachment to surface glycoproteins such as Rhesus (Rh) antigen, particularly when the mother is Rh -ve and the new baby is Rh +ve. Mum gets a shot in the ass (USA style) if this is the case and no. 2 or no. 3 etc babies become protected against subsequent mum attacks! Alternatively, the bilirubin could also indicate that there may be a liver problem – so, all that delayed onset crying is worth it! A good test – two potential shots (accurate and reliable ones) for the price of one!
A good test is one where “it does what it says on the tin”, measures what it is supposed to – say blood glucose, via a measuring device and ‘strips’ (Blog 23). This is a theoretical minimum, but it is not sufficient. For example, there’s a test that is often carried out on us men who feel that we may be having problems with our Prostate gland and water-works, (a walnut shaped object – no shell thankfully!) wrapped around our urethra which emerges from the urinary bladder. When it enlarges (most old men such as my good self!) it causes funny patterns of pissing! (Time variations, volume variations – including none – even when you think you are bursting silly), not “over the wall wins”!). One test that is used to check whether we may be having problems is the PSA test. Blood is taken and levels of Prostate Specific Antigen (PSA) are determined. I know, I have an enlarged prostate, and take yet another pill, Finastaride, for it every day – on top of my other 9 medications! Anyway, PSA levels are not sufficiently accurate or reliable. There’s a combination of too many false positives – worrying people unnecessarily, and too many false negatives – where too many people get re-assurance, in error, and may not follow up on other positive symptoms. This is the worst of both worlds and demonstrates that a test must have a high level of discrimination to be good; to be effective at what it is supposed to do and minimise the number of people potentially adversely affected.
So we have lots of tests already and there’s likely to be whole lot more coming (and many are already here though you may never have heard of them). For example, in a later Blog I’ll try to explain a little more about all the Scans I have already had, and even more about some of the ones I may yet have such as The PET scan, MRI scan, PET CT scan and so on. However, that is for later. What I want to focus on specifically is the idea of “routine” testing from birth (distinction) to death (extinction). I have already mentioned screening and testing.
What if testing of anyone’s DNA (our genetic code or ‘blueprint’) becomes so accurate, reliable and inexpensive that it becomes possible to produce a full profile of every individual on the planet (at birth) from a heel-blood collection device that looks like a piece of Velcro and baby doesn’t feel it even? The information can be recorded digitally and even placed on a chip which we could carry around with us on a Credit Card type device or a bracelet (like diabetics). This could be linked to our National Insurance, Hospital or ID card and with a swipe of entering a hospital a NHSHCP could access key information about us to help them treat us in an emergency, say! There’s a problem straight away! Why can’t we have only one means (alphanumeric symbols) of identifying ourselves? No mix ups -great! I am not with the il-liberal personal information protection lobby on this issue! One person, one card, one 12 digit encrypted digital signature!
Further data can be added throughout life and contribute to a rich source of our personal medical and scientific data all designed to predict, anticipate, determine and perhaps treat any likely future health condition. For example, about three years ago I finally returned to the UK from Australia and I was still being treated with Warfarin (yes, rat poison) to inhibit blood clotting (Blood thinners- though not like paint thinners!), that had caused me to have two DVTs in my same lower left leg. Deep Vein Thrombosis (DVT) can be lethal even after one event, especially if a small portion of blood clot detaches from the main site and is carried to the brain (stroke) or heart (attack) say. It turns out, after DNA testing on me that I had a genetic condition, Factor V Leiden – an abnormal type protein that contributes to the (abnormal in my case) clotting which follows cutting yourself shaving. I thought my favourite sister-in-law (for tonight only), Jacqueline, might say I was excluding the ladies there for a brief moment of panic (Good conscience, Jacqueline!). However, I realise how Neanderthal I was, of course ladies shave their bits too, and too much, too often, if you ask me?
Had I known that I had inherited one defective gene from either mum or Dad, (I am heterozygous for the condition), then I could have helped out the haematologists in the hospital deal with my own DVT better. But I wouldn’t have needed to under the new system. This information would have been entered onto my records shortly after birth. Of course there’ll be new stuff being discovered all the time, and we will need to have a global economy in sharing advances and for free! And this is my vision of the future.
What about the money I hear you say!?
So now we must mention the elephant in the room! As with screening, testing (especially, if as I suggest, we view this as a lifelong process), must be done, right? And it is going to cost someone! As one of my fellow Geordie travellers, Sting, would say (but I also take good ‘odds-on‘ for other Geordies Eric Burdon, Chas Chandler, Chris Rea, Mark Knofpler, and Brian Ferry), ‘If you love somebody, set them free’, (Best of Sting, Fields of Gold, 1984 – 1994). Protecting my own information is not a priority for me. Ask yourself, if you disagree with me, why isn’t it for me too? I’d be interested in your comments in the ‘leave a reply’ section of this blog!
Sting with it all on!
Yes, we still have a problem Houston. Everyone is dead or dying my be and who is gonnando what ? Could we get a philanthopist or several to club togethet and to underwritebsuch an task sponsored by Gloria Gaynor concerts maybe?), and remenber, somebody is gonna have to pay!
Gloria Gaynor “I will Survive”, Accessed: , 15 December 2015.
So what about the money!
Actually the circle can be drawn very tightly indeed but it is going to depend on reaching conclusions and then taking actions about defining who pays (and who dis’nee! – a wee bit of Scottish there), according to Kev.i.am Bridges, is an ongoing challenge to central UK as well as Scottish parliamentary parties and their policies to deal with the consequences of astronomic levels of debt (1.5 Trillion in the UK, that is 1,500,000,000,000,000,000 (I think, or give or take 3 noughts depending upon British or American definitions of billions!). Governments (of any persuasion) would much rather us not talk about this financial measure (disturbing as it is), but rather, talk about the British Deficit instead.
The ‘deficit’ is a quantum-sized amount of money compared to our total debt, but it is what all political parties across the whole UK were bickering about in their various political manifestos that were written to underpin the financing of ‘their government’ (if successfully elected as such) to implement their values, their mission, their spending, their ‘cuts’, ‘their balancing of the ‘books’’, and how quickly and/or deeply to hit different compartments of the nation’s population to pay for, or to receive it.
Let’s look at the simplest model. Most of us who have to manage a budget could envisage getting a ‘handle‘ on the job. My household has a total income. We spend that on the rent/mortgage, food, power, stuff – including on ‘bucket lists’ (Morgan Freeman and Jack Nicholson) as well as essentials and a few frills (tattoos, a download, cheese and chips or even savings, if we are really lucky!).
Morgan Freeman and Jack Nicholson in “Bucket List”, (2007).
Accessed at http://www.imdb.com/title/tt0825232/, 16 December 2015.
Jack Nicholson getting his own Buzz cut – I’m guessing a No. 3 all over!
In summary, we have ‘outgoings’. In my traditional 1950s ‘mind-set’ my aim was always to ‘balance the books’ – only spend as much as I earn and save a bit towards a future mortgage to purchase a property (and some more power tools and a staple gun!). Of course even if I managed to secure a mortgage from a bank (or Building Society in my day), this then became (usually) my biggest ‘debt’ (though I had this rather nice BMW 520 series once!) and servicing that debt (my agreed interest payments, for how long etc) then contributed to my outgoings (as well as my big debt!), giving me my ‘overall’ debt (The British 1.5 Trillion GBP equivalent!). Now that is the one I worry about and governments should worry about theirs too!
At Government level, Chancellors and their teams juggle the income (Tax ‘gather’) and outgoing spending (Tax spend). The difference between these two measures is known as the deficit or surplus – again depending. Most British Governments have run a deficit. The most recent debate involves the newly elected Tory government’s intention to reduce spending and engage in debt reduction as quickly as possible. This ‘tinkering’ with the budget – especially when it affects ‘dear-to-heart’ items such as the Welfare state, Education, The National Health Service (NHS), Work and Pensions, Defence etc. is very controversial. The House of Lords recently sent the Chancellor, George Osborne, with his tail between his legs, to revise his budget statement to implement cuts ahead of compensation in his unfair tax on welfare payments!
So how do we go about it? Once again I want to hear more of your views but here is a starter:
We need a fully comprehensive insurance-based health plan for all global citizens. This is completely underwritten by Governments but money is raised in lots of creative ways. This would include raising levies (taxes or whatever) on known (or even suspected) harmful substances such as sugar in soft drinks, or smoking, to add extra funding to a much larger share of the tax spend for Health and Welfare. Positive measures could include giving all multi-national companies no choice but to pay their fair share of tax wherever they set up their Tax havens. There should be no escape. Global governments will take their 10% or 20% or 30% or whatever tax percentage ‘pays’ companies not to try and avoid or evade, or face the same bill in fines. And,it will not be possible to write it off against tax in future either! This is the original Parkinson’s Law on Tax. We can’t blame companies for working within the law on tax avoidance; I mean who likes to pay their taxes? Me right? No, me wrong! But I don’t have choice, I am a pensioner on a fixed income all sorted through the PAYE (Pay as You Earn) scheme.
Governments must not give Companies a choice either. Tax legislation needs to be changed and we must get Insurance and Investment Bankers and others out of the corridors of TAX haven power to influence legislation – like having a Vampire in charge of the blood bank. Yes, they have an interest alright – but an unhealthy one, in my view!
Governments must take charge and get a few (actually, make that a lot!) of unemployed people on these committees. If anyone knows how to exploit loopholes then, according to the Government, they do – cos they certainly disproportionally punish them! And having put in place a new legislation it must be ‘future-proofed’. We need an instantly enacted loop-hole closure clause for any future loop-hole discovered by a clever-dick insurance or (b?)anking person. We will have our fair share of company profits!
I don’t believe this will scatter bankers to other countries as claimed by right wing pundits whenever taxing the rich comes up. It is bluff! They want to live here alright, in close proximity to Government ministers, especially the teams surrounding tax legislation – check out, Owen Jones’, a left wing writer for the Guardian. For example,
Don’t sneer at redbrick revolutionaries – some of our best leaders were terrible students
Long live the NHS, But not as we know it!
Tomorrow I am having some me-time! Both Steeds are going to the Blacksmiths to be re-shod with smart new winter hooves’ protectors! And I get to drive the new BMW steed properly!
Au revoir! Bon Nuit – and all that Franglais stuff!