Antibiotics, Winter Flu, NHS Continuing Healthcare, Snoring

Dr Mark Porter reports on sleep apps, can they help with common sleep problems such as sleep apnoea? A new study reveals the failure of antibiotics for simple infections. Margaret McCartney reviews the evidence and asks is it worth having a flu jab? Plus who is eligible for NHS continuing health care.

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28 minutes

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Wed 1 Oct 2014 15:30

Programme Transcript - Inside Health

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THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY. 

 

INSIDE HEALTH

           

Programme 2.

 

TX:  30.09.14  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  GERALDINE FITZGERALD 

 

Porter

Coming up in today’s programme:  Funding long term care and the NHS – I will be examining claims that tens of thousands of people are missing out on help with the costs of care.

 

Clip

Continuing Healthcare affects a small number of people in a very, very big way.  It can be incredibly stressful.  It can be – it is incredibly emotive and it can be emotionally exhausting.

 

Porter

Flu jabs – it’s that time of year again. Millions will be visiting their surgery for their annual jab over the next month or so, but what do we know about the likely benefits. Margaret McCartney’s been looking at the evidence.

 

And if this sounds all too familiar:

 

Clip – person snoring

 

Don’t miss our item on what your smart phone can tell you about how well you sleep and whether your snoring is anything to worry about.

 

 

But first antibiotics and new research looking at bacterial resistance in the community.  A team from Cardiff University looked at over 10 million prescriptions for four common infections and found that the proportion that didn’t work due to bacterial resistance had risen from 13.9% in 1991, to 15.4% in 2012.

 

Chris Butler is a GP and Professor of Primary Care at the Universities of Oxford and Cardiff.

 

Chris given the recent apocalyptic predictions of a post antibiotic era where people could die from simple infections, were you surprised by your findings, which seem to suggest that resistance really isn’t growing that quickly?

 

Butler

Yes so what we found was that treatment failure from a single course of antibiotics had increased by over 10% overall during this 20 year study period.  But hidden within that were pretty dramatic increases in certain infections like lower respiratory tract infections, for example, that had increased by 35%.  So it’s not a – it’s not a picture that we can relax about across the board.

 

Porter

So the average looked okay or not too bad anyway, what you’re saying hidden within that was some particular – and chest infections are one of the common reasons that people are using antibiotics and potentially a very serious infection?

 

Butler

It is and people are getting older and more frail in the community and therefore we’re using these antibiotics more often for those that consult and as I say treatment failure’s increased dramatically in this.

 

Porter

We talk about treatment failure but what does that actually mean for the individual potentially?

 

Butler

So people who have resistant infections, even in primary care, not just the sick ones in hospital, but even in primary care if they have a resistant infection they’re going to be sicker for a whole lot longer, they’re going to consult more often, there’s more work associated with the healthcare system and they inevitably end up getting more antibiotics which drives up resistance again.

 

Porter

There have been calls for better use of antibiotics for years, I mean doctors like you and me have been told not to prescribe them so often, patients have been given the message that you shouldn’t be getting them for simple coughs and colds.  Yet looking at the number of prescriptions issued the message doesn’t seem to be getting through?

 

Butler

Mark, it is a problem because we do find that overall antibiotic prescriptions in the community is going up despite all the publicity and concern around the issue.  But hidden within that are some good news stories.  So in the study that we’re talking about now we’ve found that fewer people are consulting with respiratory tract infections.  So in a sense the public are getting the message that for most of these infections they don’t need to attend for healthcare.  Secondly, we’re finding that when doctors do choose to prescribe an antibiotic more often they’re choosing narrow spectrum recommended antibiotics.  So it’s not all doom and gloom in terms of practice, both on the side of the public and on the professional side.

 

Porter

Professor Chris Butler, thank you very much. And there is a link to that new research on resistance on the Inside Health page of the Radio 4 website.

 

A GP surgery caused traffic chaos in Colchester when 1800 of its patients converged on the building to get their flu jabs. We may not have had quite that response at my surgery in Wotton, but this year’s £100 million programme is now well underway across the UK.

But what do we get for our money? Inside Health’s Dr Margaret McCartney has been looking at the evidence.

 

Before we discuss that, Margaret, there have been some changes to the criteria for who is eligible in recent years haven’t there?

 

McCartney

Yes, so the two big changes are that pregnant women are now very much encouraged to have flu vaccine as soon as they know they’re pregnant and also for children, so there’s been a big programme rolled out for both pre-school and primary school children.  There is actually quite good evidence that says that children have got a fair bit to benefit from getting the flu vaccination and what’s interesting is that it’s not just the children that benefit but it’s also the community benefits because it seems to be that children are the vectors of flu in the community, they’re very good at getting infections and then spreading them around.  And you only need to vaccinate seven children in order to prevent one case of flu, which for a medical intervention is actually pretty good.  And other studies have come out and said that you can actually half the amount of flu suffered by pre-school children.

 

Porter

What about pregnant women?

 

McCartney

Again for pregnant women there is a fair bit of evidence that would say that not only are pregnant women more likely to have significant complications for flu, not just for them but for the baby, but it does seem to be something that is more likely to help pregnant women than not but it certainly does seem to cut down flu in women and cuts down premature birth.

 

Porter

What about people with asthma – they’re another group that are included?

 

McCartney

Asthma is one of those uncertainties.  So there was a Cochrane Review in 2013 that came back and said basically we’re not sure whether it helps or not.  However, if you have chronic obstructive airways disease, COPD, bronchitis, then there is quite a good chance that having the flu vaccination will prevent you from having an exacerbation over the winter.

 

Porter

What about the biggest group of all and that’s the over 65s, the elderly?

 

McCartney

Yeah and here’s where there is the biggest contention.  There was a big Cochrane Review that was done looking at all the evidence in 2010 that came out and said that we really do not have the evidence to say that flu vaccination is useful or provides benefits for people in the over 65 age group, this is otherwise healthy people who are not getting it because they’ve got bronchitis or anything else, just normal 65 year olds and above looking for a bit of extra protection.  We don’t have the evidence to say that it works.

 

Porter

Well given the cost of the programme why do we offer it to that group, is it that most of them will or a large proportion of them anyway will have some other underlying criteria for having the jab?

 

McCartney

Well I’m not sure and it really is a bit of a tragedy because there’s lots of things that we could be doing to find out whether it works or not and it would be a pretty easy thing to set up a trial, we’re giving out the flu vaccine an awful lot.

 

Porter

Okay, here’s a controversial one – what about healthcare workers?

 

McCartney

Well the rationale is that by vaccinating healthcare workers we keep the staff at work, we prevent them from passing on bugs and we prevent them from getting bugs that they’ll get into contact with during the course of their day.  Unfortunately we do not have the evidence to say that healthcare workers get a benefit to themselves or to their patients.  Now there have been some studies that have been done looking at people who work in long term care homes and some studies have come back and said that it’s beneficial, others haven’t and the most recent Cochrane Review has said that they can’t support vaccination of healthcare workers.

 

Porter

And it would seem that many healthcare workers are aware of that because the uptake’s not great is it amongst doctors and nurses and other clinical staff?

 

McCartney

It’s not, it’s not, I would be delighted to have the vaccination as part of a randomised control trial, so we could really try and sort out is this beneficial or not.

 

Porter

I think I know the answer to this Margaret but what you’re saying is that you haven’t had a flu jab?

 

McCartney

That’s entirely correct but I would be delighted to have one as part of a randomised control trial so please set one up and invite me.

 

Porter

Thank you very much Margaret. And that list of who is eligible this year is on the Inside Health page of bbc.co.uk/radio4

 

Now have you ever wondered how you are going to fund you care in old age? Or what would happen if you were to fall ill and need ongoing care earlier? Perhaps it’s a dilemma that you - or your family - are already facing.

 

Most people are aware that social services will provide means tested support for care. But only if your savings or assets – and that includes your house - amount to less than around £25,000, depending on where you live in the UK. Which means most people end up paying themselves, at least to start with. 

 

But there is a third way. The NHS will sometimes pick up the bill for your care – in a home or in your own home - if you have ongoing complex medical needs.

 

It’s called NHS Continuing Health Care but most people have never heard of it. And applying for the funding is fraught with difficulty, as I’ve discovered here at the Oxford offices of Beacon, a social enterprise organisation that spun off from Age UK to help people understand their rights and get what they are entitled too.

 

People like Ivan Lax who struggled to get the financial help he thought his mother-in-law Betty deserved.

 

Lax

She was diagnosed with Alzheimer’s in 1992 and from there until 2001 we pretty well managed that.  Her husband, Jack, was also in need of medical care and support so between them they were described as “book ends”.  Jack needed physical support, Betty needed mental support.  Unfortunately in 2001 Betty needed to go into hospital for some surgery and the week before that Jack died.  And we’d already arranged some respite care.  It was very obvious once she went into nursing home that it wasn’t going to be possible for her return home alone and we decided to – discussions with everyone – that it would be best that she stayed there.  And everything was fine for the first few months but later that year it became clear she couldn’t stay in the nursing home.  She was being disruptive, she was trying to escape – as they put it – and we were told we needed to find a secure environment for her.

 

Porter

Who was paying the bills?

 

Lax

Well we sold the house, the family house, to pay the bills, that’s the conversation with social services at the time – we would need to sell the family home.  Social services paying the bills initially until the house was sold then they were repaid from the sale and then we just was self-funding.

 

Harbour

My name is Dan Harbour, I’m the managing director of a social enterprise business called Beacon and what Beacon does is to help people at any stage of the Continuing Health Care assessment or appeal process.  NHS Continuing Health Care is a package of care which is arranged and funded by the NHS.  It’s for people who have a certain level of ongoing healthcare needs which result from an accident or a disability or indeed an illness such as Alzheimer’s disease.  And this is significant because people who are eligible have the full cost of their care and accommodation paid for by the NHS.  And what Continuing Care attempts to do is to clarify the boundary between health – what is a health need and what is a social care need – and that’s important because of course in this country health – healthcare is provided free at the point of need whereas social care is means tested.  Beacon helps families and individuals at any stage of the NHS Continuing Health Care process, so we can help people for example who have gone into hospital for the first time and are thinking well who pays for my long term care, how does this whole system work.  And we can help people all the way through to the appeal process, right the way to the ombudsman and beyond.

 

Press

My name is Martin Press and my mother, who will be 100 in six weeks’ time, has been in long term care since 2002 following my father’s death.  She had become increasingly confused and she became also progressively immobile to the point where she is now completely paralysed from the neck downwards.  She’s virtually mute – she will occasionally get a word out but there is no way of communicating with her which makes it very hard to assess whether she’s distressed and the extent to which she understands what’s going on.

 

My parents sold their house when my father had a stroke in the ‘90s and that money, together with the family savings, paid for nursing home fees of something like £40,000 a year from 2002 when she went into the home till in 2008 we got a message that she might be eligible for NHS Continuing Care for funding. 

 

Porter

Now you were a hospital doctor, had you heard of this before?

 

Press

No really not, I don’t think I had any more information than if I’d been an accountant or a grave digger.

 

Porter

So you didn’t know about it, it was news to you but obviously it must have seemed attractive at the time to apply for it?

 

Press

Well clearly and we were faced with coming to the end of our money and the ghastly thought that we might have to move her to somewhere else.

 

Harbour

People come to us for two reasons – firstly, there has either been a significant event such as a loved one has had a stroke or a fall, been diagnosed with dementia and they just don’t know how the long term care system works.  Or they come to us following completion of a Continuing Care Assessment where the care is already in place, they feel that they have significant health needs and the NHS have deemed that they don’t have a primary health need, that i.e. they’re not going to pay for the full cost of their care.

 

Press

Well it was a long process, we said yes we would like her assessed.  Three months later I phoned them because we’d heard nothing, three months after that I phoned again because we’d still heard nothing and she was finally assessed and the assessment done by the nurse who visited my mother in the home went before a panel of the primary care team who downgraded her on some of the assessments, even though they’d never met her, and so she didn’t qualify.  It was odd to me because the purpose of the assessment was to determine whether her primary needs were health or social and there was no arguing with the fact that she required long term hospital care for her immobility and confusion.  So on the one hand you had a questionnaire which she hadn’t scored highly enough to pass and on the other hand nobody argued with the fact that she had to be kept in the nursing home for medical reasons.  So we appealed.

 

Porter

So that appeal you were refused at that appeal?

 

Press

Yes.

 

Porter

What happened next?

 

Press

Well she then got reassessed and this time she passed, although in all conscience she wasn’t really very different from the way she had been previously.  So in 2012, 10 years after she went into the nursing home, she was approved and it was backdated to 2011.  And she remains funded though she has to be reassessed every year.

 

Harbour

The decision rests with the Clinical Commissioning Groups, which are GP led.  The CCGs have to make the final decision as to whether somebody is eligible or not.  However, there is a whole assessment process, a very, very important assessment process, which feeds into that final decision making process and this is a really important point because this is one of the areas that we feel is breaking down in the assessment process.

 

Porter

So let’s say that we’re aware of NHS Continuing Health Care and we start this process off what are our likely chances of success, even if we’re entitled to it – is it an uphill struggle?

 

Harbour

Many people do find it an uphill struggle.  Unfortunately it does partly depend on where you live in the country, some Clinical Commissioning Groups are assessing people according to the processes laid down in the national guidance, others are not, and that makes for a degree of postcode lottery. 

 

Porter

I mean looking at the figures there’s a threefold variation in the odds of getting this which suggests that some people are giving it much more freely than others.

 

Harbour

Yes.

 

Press

When we moved mum to the EMI registered residential home…

 

Porter

So this is a home that’s capable of looking after people with dementia for instance?

 

Lax

Yes it provides them with a safe secure environment where they’re properly cared for - we were advised to go and talk to the charity who advised us that actually there was a thing called NHS Continuing Care and in reality they felt that mum should have been assessed for that when she was discharged from the hospital.

 

Porter

From the moment that you were told for the first time that there might be a source of NHS funding how long did it take you to get that funding?

 

Lax

Well actually I wouldn’t say we ever did get that funding, we never got NHS Continuing Care and that took a 10 year battle, right up until when Betty died in September 2012.

 

Porter

So you battled for a decade for something that you felt your mother-in-law was entitled to but she actually died and you still didn’t get it?

 

Lax

The people that were supporting mum’s application were her GP who saw her probably two or three times a week and the psychiatrist who was looking after her.  They both supported her application along with the home manager.  And yet their opinions were ignored and even questioned by people who either neither met mum or the assessor who completed the paperwork who met her once for less than an hour.

 

Press

And I appreciate you’re dealing with a very expensive situation because there are an awful lot of people in the same situation but this is not just normal ageing, one end of the spectrum we have the Mary Berry’s of this world and at the other end you have people like my mother.  The fact that she can’t stand up, it’s not because she doesn’t want to stand up, the fact that she can’t talk is not because she doesn’t want to talk, the fact that she doesn’t understand or know who I am, it’s not because she doesn’t want to – this is a disease process.

 

Porter

But your feeling is in your particular case that the patient isn’t being put first and that may be finances are?

 

Press

It’s hard to see why somebody as handicapped as my mother is would not qualify as having primary health needs.  I mean it’s just obvious.

 

Porter

Dan, there is a framework for people to follow, providing guidance in situations like this, do you think it’s being followed in all cases?

 

Harbour

No I absolutely think it’s not being followed in all cases.  The overwhelming majority of the cases that come to us at Beacon have problems not only with the application of the criteria but in the way in which the assessment procedures have been carried out the effect on the outcome as to whether somebody is determined as eligible for continuing care or not.

 

Porter

Well it can mean the difference, can’t it, between you getting it and you not?

 

Harbour

Exactly which is the difference between selling your house and spending your children’s inheritance or the health service paying for the full cost of your care.  And what we’re particularly concerned about is that people who are eventually eligible for continuing care will have had to fund that care in the interim period, possibly by selling their house.  They might get the money back from the NHS if they’re eligible in the long run but they’ll never get their homes back.  To be fair to the professionals who are on the ground trying to apply this to real people in real life it’s incredibly difficult, they have an enormous set of guidance but there is no clear distinction as to what this primary health, this golden nugget of the primary health need actually is.

 

Lax

I wonder how much it’s really being driven by the funding constraints of the NHS rather than the real criteria around healthcare needs.  I just believe that’s dishonest.

 

Press

Well the situation now is that she’s got funding so no it’s been well worth it, it’s been essential actually because I don’t know where we would have been if we hadn’t got it but why wouldn’t we get it?

 

Porter

I suppose the point is that if a retired consultant with a mother who’s approaching a hundred who’s paralysed from the neck down and mute and very dependent on the extreme nursing needs decides halfway through the process that actually he might not finish this because it’s too difficult then that’s a sad reflection on the process is it not?

 

Press

Well I think the process does need to be brought up to date with a hefty dose of common sense.  You don’t need to score somebody in 11 domains to know that they require full time nursing care.

 

Porter

And it needs to be easier for people to navigate?

 

Press

Yes, yes absolutely.

 

Porter

Martin Press talking to me at the offices of Beacon in Oxford.

 

We asked NHS England to comment and it sent us this:

 

Statement from NHS England

There are currently around 59,000 people in receipt of NHS Continuing Health Care in England and the NHS undertakes around 133,000 assessment of eligibility annually.  There is a clear process for patients to request a review of a decision with regard to eligibility.  They can request this from their CCG and if they’re still not satisfied they can ask for an independent review.

 

And you’ll find more information on NHS Continuing Care, and how to apply for it, on our website.

 

Clip – Person snoring

 

Not the sort of sound you want to hear during the day, let alone at night, but for around half a million people in the UK heavy snoring may be the first clue of a more sinister underlying issue - obstructive sleep apnoea syndrome.

 

The classic story is someone who snores loudly and then appears to hold their breath before spluttering and resuming their snoring. During these prolonged breath holdings - or apnoeas - which can last a minute or more - oxygen levels plummet and trigger a survival reflex that briefly wakens the individual.

 

The resulting cycle of snoring and waking leads to disturbed nights with multiple, but typically forgotten, awakenings (hundreds in some cases) that leave sufferers feeling sleepy throughout the day. Making them irritable and impairing their ability to perform complex tasks such as driving.

 

But how do you tell if there is more to your snoring than an annoyed partner?

 

Welcome to the world of burgeoning health apps which now includes a number that claim to analyse how well you sleep. So could sleeping with your smartphone provide the answer? Gari Clifford is Honorary Professor in Biomedical Engineering at the University of Oxford and he’s been casting a critical eye over the market and is on the line from Beijing.

 

Clifford

There’s a wide variety, ranging from just checking to see how long you’ve slept to analysing different depths of sleep to trying to diagnose you for different illnesses such as restlessness during the night, insomnia or sleep apnoea.

 

Porter

Gari, what are the sort of clues that somebody might have that they’ve got a snoring related sleep because lots of people snore, so how do we differentiate between simple snoring and more worrying sleep apnoea?

 

Clifford

There are standardised scoring systems which basically ask simple questions such as what is your neck circumference, what is your age, has anybody noticed you stop breathing during the night – simple questions like that.  And if you score highly on one of those standardised questionnaires then that’s something that you could then use to say okay I should actually screen myself at this point.

 

Porter

You could look at these apps and say well a lot of them might be fun but you’ve looked at them with a hard scientific eye, do they actually tell us anything useful?

 

Clifford

In terms of actual scientific validity there’s not a single app out on the market that you could actually say this is useful and I could do something with this to change my lifestyle and improve my health and have any confidence that it might work. 

 

Porter

There’s lots of people out there – you see people wearing these wristbands and I’ve been to a dinner party, someone sat next to me, produced their phone and showed me how – what their sleep patterns were like.  I mean presumably if you’ve got something on your wrist they’re detecting whether you’re moving or not during the night, what does that tell you about your sleep quality?

 

Clifford

It’s rather limited, it’s very hard to differentiate between somebody who’s an insomniac and somebody who’s in deep sleep.  So if I have trouble going to sleep at night because of my insomnia I’ll just lie there very, very still and my wrist worn device will tell me that I’ve gone into either light or deep sleep.  And unless I make some kind of gross movement it’s not actually going to say that I’ve woken up in general.  So the problem comes when you actually have some serious sleep problems and the confusion that can become between the two.  So when we start augmenting these fitness devices with extra sensors then we’re going to be able to have much more accurate assessment of sleep quality.  So things like the microphone in the room is useful and that helps significantly and then other sensors such as a little light based device that can clip on the end of your finger or on your earlobe and passes a light through your skin and tells you how much light is getting absorbed by the blood and that tells you how much oxygen is in the blood.

 

Porter

But at the moment if you’re using one of these fitness devices to monitor your sleep and it’s telling you’ve got good sleep or bad sleep it’s a pretty crude indicator is what you’re saying?

 

Clifford

It can be crude but it can also be informative to the extent that – I mean I wear one and I use it mainly for just judging how long I slept for.  My wife and I had a child a couple of years ago and I’ve seen the number of hours of sleep that I get every night diminish significantly over time and it’s made me start going to bed earlier in the evening because I’ve realised that no matter what I do I can’t get that early morning back.

 

Porter

Too true.  One of the problems we have in general practice – I mean looking at people with snoring related issues like sleep apnoea where they stop breathing is that we don’t really have a simple test that we can use in the community to spot this, we get a good story – someone’s got daytime drowsiness, the partner reports that they snore – but we have to send them into hospital, into a sleep laboratory, to clinch diagnosis, I mean are we at the stage where we might be able to use an app to help us do that in the community?

 

Clifford

As a result of looking at all these different apps on the market we’ve been working on an app that we could have some scientific basis for doing exactly this.  We record the continuous ambient noise that you hear while you’re sleeping and this could be anything from your deep breathing to somebody snoring to a sudden loud choke.

 

Porter

What results did you get – I mean how accurate is the app?

 

Clifford

We found that our app was 85% accurate.  So that converts into a score that tells you how likely you are to have sleep apnoea.  So all it’s going to do is provide you with a certain first level confidence that you should go and do another screening.

 

Porter

Professor Gari Clifford. And that next level for most people would be a chat with your GP.  There’s a link to his free app on our website, but it only works on android phones and tablets and is still work in progress.

 

Just time to tell you about next week’s programme when I will be discovering how to look after your thyroid during pregnancy and why it matters. And meeting a woman who is thrilled that she’s finally got to the bottom of why she was getting so many coughs and colds.

 

ENDS