Nuffield Health : adverts and evidence

Nuffield advert

Note the desire for a doctor who 'understands evidence based medicine'

 

This is an advert from this week’s BMJ. I am positively fuming about it.

Nuffield Health are responsible for some non evidence based practices via their ‘health assessments‘. These currently consist of annual mammograms for women over 40, annual cervical smears, pelvic (ie vaginal) examination, urine analysis, ‘hydration levels’ and a chest xray ‘if clinically indicated’.

In practice, this means that people show up to me – within the NHS – with a bundle of paperwork for interpretation and sorting out. (This is a fact, Nuffield.) Very often, people have been told to see their GP because some of their results are abnormal. Very often, said people are anxious and alarmed because their tests have been ‘abnormal’.

What Nuffield are offering are a raft of mainly non evidence based screening tests, some of which are intimate examinations. The NHS Screening portal contains information about which screening tests are recommended for use in the UK. The problem is that screening tests come with strings attached; harm is inevitable. Screening tests require to be properly validated before they can be recommended, and informed consent is required because of the risk of overdiagnosis, investigative harm and overtreatment screening can lead to.

It isn’t fair that the NHS has to sort out the non evidence based testing results. It isn’t fair that patients are often not aware that these tests are done out with national screening guidelines. Doctors should not be doing intimate examinations without evidence of benefit from them.

Nuffield have placed this advert which is looking for “health assessment doctors” who have “a warm heart that can feel what’s right” and who “understands preventative and evidence-based medicine”. I think this presents a contradiction. I don’t think the assessments Nuffield offer to do are evidence based, yet they want doctors who are.

If you apply for the job, do let me know what kinds of evidence they think their screening package is based on.

 

 

16 Responses to “Nuffield Health : adverts and evidence”

  1. Andy November 20, 2011 at 7:47 pm #

    Anybody who considers themselves to have “a warm heart that can feel what’s right” is hardly someone I’d trust to understand “evidence based” anything.

  2. Ted November 20, 2011 at 9:44 pm #

    I’ll bet she isn’t a doctor. If she is they should give her a better stethescope.

  3. Margaret McCartney
    margaretmccartney November 21, 2011 at 7:39 pm #

    indeed…..nuffield have made a big contradiction here….

  4. Dr. Andrew Jones November 25, 2011 at 11:22 am #

    To set out our position on health assessments to assist the discussion. We consider screening as the identification of a disease or precondition in an apparently healthy individual. Health assessments use a combination of screening tests and clinical evaluation of patient symptoms in a professional setting where there is time to complete a full evaluation.

    Our founder was instrumental in introducing screening to the UK

    The importance of screening was recognised in the 1960’s and the McKeown working party was set up by the Nuffield Provincial Hospitals Trust. This party made two key findings as to whether the criteria are met for a screening a test and that any screening test should have an appropriate research and administration framework. (The Nuffield Provincial Hospitals Trust was established in 1940 by William Morris (1877-1963), Viscount Nuffield. The name was changed in 1998 to the Nuffield Trust for Research and Policy Studies in Health Services, retaining “The Nuffield Trust” as its working name.)

    In the UK this work led to the formation of the Joint Initiative on Screening in Medical Care in 1969. All doctors will be aware of the first screening criteria published by the World Health Organisation in 1969 known as the Wilson and Junger Criteria. The concept of uncertainty became more imporortant and in 2000 the concept of risk was added by the UK National Screening Committee. This was formalised by the World Health Organisation in 2003.

    Nuffield Health uses these criteria to evaluate all screening procedures

    1. Simplicity – is the test simple to perform and interpret by multidisciplinary professionals?
    2. Acceptability – is the test acceptable to the patient?
    3. Accuracy – is the test a true measure of the condition?
    4. Cost – is the cost proportional to the benefit derived from treating the conditio?
    5. Repeatable – has the test been validated scientifically?
    6. Sensitivity – positive test when the patient has the condition ?
    7. Specificity – negative test when the patient does not have the condition ?

    Nuffield Health Recognises Uncertainty

    We also recognise a number of benefits and disadvantages to screening

    Benefits – improved prognosis from diagnosing condition, option for less radical early treatment, reassurance and overall resource savings in the health system

    Disadvantages – longer morbidity with diagnosis, potential overtreatment of uncertain abnormalities, resource costs, false reassurance, anxiety and hazard of test.

    Summary

    We consider that the diagnosis of presymptomatic conditions or unknown disease like diabetes and hypertension are part of our charitable responsibility. We will always strive to ensure that patients are informed of the risk and the benefits and where there is uncertainty in the medical evidence. Approximately 5% of our patients are diagnosed with a serious medical issue during health screening which means that over 7,000 people have the chance to receive the best care to improve their health and wellbeing per annum. A further 60% benefit from lifestyle and behavioural advice for two or more known health risk factors. This is health as it should be. We recognise that patients may wish to seek further information from their GP and have a choice in their ongoing care.

    Dr. Andrew Jones
    Group Medical Director
    Nuffield Health

  5. Margaret McCartney
    margaretmccartney November 25, 2011 at 1:58 pm #

    Dear Dr Jones
    Unfortunately you haven’t evidenced your assertion that “5% of our patients are diagnosed with a serious medical issue during health screening which means that over 7,000 people per annum have the chance to receive the best care to improve their health and wellbeing per annum”. Where is your evidence, tested against a control group, that you have done any good at all? Have you looked for harms of the screening tests that you do? The problem is that I see the harms in the medium to long term – for your intervention does not include follow up of the ‘problems’ you diagnose. You expect the NHS to meet the time and cost of follow up for interventions which were not recommended by the NHS Screening Committee or GPs who take long term responsibility for their patients.
    This is not ‘health as it should be’. How much money does Nuffield raise through its corporate and other health screenings? Do you really think that your adverts to the public for health screenings include fair information about the lack of evidenced benefit from your tests, the risks of harm, and the fact that evidence based tests are already available on the NHS?
    Margaret McCartney

  6. jonathon tomlinson November 26, 2011 at 9:50 am #

    Cream skimming.
    One of the worst aspects of this, and one that is, or ought to be, in sharp focus given the coalition’s appalling re-disorganisation of the NHS, is that this is blatant cherry picking/ cream skimming. The reforms open up the possibility for private companies, like Nuffield to perform profitable NHS work without taking any of the risks/ costs.
    If I (GP) order a medical investigation it is my responsibilty to deal with the consequences. Since medicine is being treated as a business, consequences and risks equal costs. These costs come from referral on for further investigations or specialist treatment and, much more frequently, time spent dealing with patients’ worries. It also adds to a prevailing myth that ‘what’s really going on’ is something that can be revealed by a scan; I spend very little time convincing my patients that an investigation is necessary compared to the time spent explaining that they are not.
    When healthcare is treated as a business, profits are to be made by commodifiying processes rather than caring for people, and this is what Nuffield and their ilk are all about.

  7. Witch Doctor November 26, 2011 at 11:37 am #

    This is what we witches call the fifth healthcare market. It has been with us since before the beginning of the NHS and is quite unlike the fourth healthcare market that is currently evolving. Patients may choose to use and pay for this fifth market.

    “However, it is likely that the activities of the fifth market will be selective and will in various ways introduce an extra burden of patient care into into the NHS.”

    http://witchdoctor.wordpress.com/seven-healthcare-markets/

    Here is the fifth healthcare market screaming out again.

    http://witchdoctor.wordpress.com/2011/05/18/mark-britnell-the-scream/

  8. Elizabeth (Aust) November 28, 2011 at 12:35 pm #

    Informed consent? evidence based testing? They are irrelevant in Australia…well, in cervical and breast cancer screening anyway.
    Our cervical screening program is a dinosaur requiring 26 or more pap tests, 2 yearly from 18 to 70 and some “doctors” are testing teenagers – in the “Lancet” there was some research into the effectiveness of Gardasil which showed that some teenagers younger than 17 have been pap tested – what is that about? How on earth could you justify testing someone that age?
    Still…no one cares. I guess it’s helpful for the research and that’s all that matters.

    They have FINALLY announced the review of the program, but the report isn’t due until mid 2014 and then we have to wait for the Govt to make changes – 2018, 2020…with no advocates for informed consent down here, no one protecting women and forcing these programs to be ethical – it might never happen.
    There is always a reason why we can’t use hrHPV triage testing, or self-test kits and why there is STILL discussion about moving to 3 yearly testing or starting the program at 25, even though the evidence is crystal clear and has been for a long time, just look at the UK, Finland, the Netherlands and even the States. (the latter has made a few changes over the last 2 years)
    I suspect those who still see these things as gray areas are protecting their own interests – the program may be harmful and excessive, but it suits their agenda.
    I cannot understand why these people have been allowed to block other options/ better options and prevented change to an outdated program.

    I still can’t believe there is not ONE doctor prepared to warn women to walk away from this program, to make a fuss – our doctors are simply carrying on with serious over-screening and over-treating – business as usual.
    It reflects very poorly on our medical profession, but when there is no discussion or criticism of this program and most women have been deceived, I guess they think it’s “safe” to knowingly risk their patient’s health.
    I disagree, their first responsibility is to us. The sad thing: the women who are being over-tested, worried and harmed are those who trust their doctor to do what’s best for them – and are being let down badly.

  9. Elizabeth (Aust) November 30, 2011 at 7:48 am #

    I was reading that Amerigas “required” their employees to undergo a medical exam or they’d lose their medical insurance. It naturally included pap tests and mammograms for women. (the latter for those over 40) The prostate check was not included and they considered colonoscopies “too invasive”. What would you call a pap test?

    I can’t see how you could legally “require” people to have cancer screening – it must be elective, it has to be, as it carries risk to the healthy symptom-free body.
    I suspect if employees challenged these “requirements” and even sought legal advice, these try-on tactics would stop. Their employees are expected to keep having these exams at least every 2 years.
    Also, this statement irks me:
    “Among women, 44% were getting appropriate mammograms and Pap smears.”
    By appropriate they must mean according to the guidelines, but that also implies that we should have screening, it’s the right thing to do, and that it’s not a choice – something to consider having regard to our risk profile and the risks and benefits of the test.
    It is never inappropriate to reject cancer screening, but we hear those statements all the time with cervical and breast cancer screening. I don’t have cancer screening, informed decisions, and I consider that to be appropriate for me. It’s our business and has nothing to do with an employer or insurer.
    I don’t care if people make informed decisions to have screening, but I hate the dishonesty and unethical conduct that accompanies it, and the pressure/coercion.
    http://online.wsj.com/article/SB10001424052970203577304574274102603258642.html

  10. Margaret McCartney
    margaretmccartney November 30, 2011 at 8:36 pm #

    hello Elizabeth
    I find the language around screening to be very pejorative. You can’ t permanantly opt out of cervical cancer screening in Scotland, and if you write to decline (decline, not ‘reject’, I think) you are sent a letter telling you that you are taking a risk. No one says that you are taking a risk (of overtreatment) if you have the screening. Until we get to a point where people are treated as competent adults able to weigh up pros and cons and make a choice, not be coerced, I fear we are doomed to continue to fail.

  11. Margaret McCartney
    margaretmccartney November 30, 2011 at 8:37 pm #

    and that link is unbelievable. Quite apart from anything else, what evidence do they have that any of this actually works?

  12. Elizabeth (Aust) December 7, 2011 at 4:46 am #

    Can I ask you Dr McCartney….
    Why has cervical and breast cancer screening been permitted to operate outside proper ethical standards for so long? Why is there still so little real information for women on the internet and in the papers to assist in the making of informed decisions? Virtually nothing here in Australia.
    Why do most doctors remain silent and protect the programs?

    The attitudes behind prostate and bowel cancer screening seem totally different – cervical and breast cancer screening seem to be about a lot of “plotting” behind closed doors, keeping the truth from women at all costs and the accepted thing appears to be “we’ll make decisions “for” women and accept risk on “their” behalf” – just the climate around our programs has always been oppressive, arrogant and manipulative – with a full-on verbal attack for anyone who dares question it. It seems to treat women as a herd that can be driven into testing, instead of accepting that women, like men, are adults and individuals.
    I just don’t see those attitudes in prostate and bowel cancer screening – the reaction of a doctor when you decline pap testing is unmatched by anything else – it stands alone and is something I’ve never understood when so few benefit, while vast numbers are over-treated…
    I had hoped that when more women entered the medical profession, that things would change…I’ve been sorely disappointed.

  13. Michael Collinson March 23, 2012 at 4:45 pm #

    From Dr Andrew Jones “We consider that the diagnosis of presymptomatic conditions or unknown disease like diabetes and hypertension are part of our charitable responsibility”

    Why does it cost from £200 to £640 to have a health assessment which includes basic diabetes and blood pressure checks? doesn’t sound very charitable to me.

    I’d be interested to know which charities profit from the money generated from health assessments by nuffield

    MC

  14. Dr A Rhodes July 8, 2014 at 9:08 am #

    I am a registered GP medical practitioner and accredited specialist in occupational medicine. I recently had several interviews at Nuffield; the fifth involving a telephone conversation with a ‘clinical lead’ who requestioned my competency and reported back that I did not understand preventitive medicine. I have professional and ethical concerns that this organisation is not following current NICE guidance and best evidence based practice by carrying out some unecessary and invasive procedures (including intimate examinations) without justification. I am therefore unclear about the adequacy of their clnical governance structures as the quality of care should be measured against gold standards (NICE guidelines and best practice guidance) I recently attended an excellent GP update course where the concerns raised by Dr McCartney were brought up by many of her professional \GP colleagues. Whilst I have much experience and understanding of the practice of medicine in a commercial environment including USA health care system; it does not seem appropriate that some of their adopted methods of health screening are no longer considered best practice in the UK. I would however expect to see more innovative practice such as offering Gardasil vaccine to men against HPV (16/18/6 and 11) and genital warts where the medical evidence is available for individuals to demonstrate effectiveness but the UK cost analysis falls against its introduction because of the cost of a popultation wide programme, not individual needs assessment. I believe that such practice is likely to benefit patients when clinically indicated and support our GP professional colleagues in a constructive manner. Nuffield after all provides an opportunity for a individual to have an individual health screening assessment; it does not provide a public health service

  15. Dr A Rhodes July 8, 2014 at 9:08 am #

    OK

  16. Dr A Rhodes July 8, 2014 at 10:20 am #

    I am awaiting notification

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