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INSIDE HEALTH – Programme 5.

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TX:Ìý 31.07.18Ìý 2100–2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Coming up in the next half an hour:Ìý Strokes and a new approach to treating them that can help where current methods can’t.

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Clip

If you have a large blocked drain in the street and you try to put in some drain powder, that doesn’t really work because you need somebody to go in mechanically – a plumber – to take it out, so that’s what basically we had to do, basically go into the brain vessel and take the clot out.

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Porter

We continue our guide to what happens when people lose the mental capacity to make key decisions. This week we discuss best interests and lasting power of attorney.

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And Margaret McCartney reflects on a much-discussed case that is currently being heard by the Court of Appeal – the striking off of Dr Bawa Gaba following the death of six-year-old Jack Adcock.

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But first, aspirin. ÌýIf you are taking low dose aspirin – typically 75 mg day – to protect against heart attack or stroke and you haven’t been weighed then there is a good chance that you’re on the wrong dose, and not as protected as you – or your doctor – might think.Ìý That’s the startling conclusion of new research suggesting that the current one size fits all approach is wrong.

Peter Rothwell, Professor of Clinical Neurology at the University of Oxford led the team who made the discovery.

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Rothwell

I think at the moment a lot of people are taking aspirin, nearly a billion worldwide take regular aspirin, usually to prevent vascular events – heart attacks and strokes – and it looks as though the majority of them are probably taking the wrong dose.

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Porter

Why?

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Rothwell

So far, pretty much all clinical practice and all clinical trials have adopted a one dose fits all approach, so no matter what size you are, how much you weigh, you get the same dose of aspirin.Ìý And what we’ve found is that in fact that doesn’t seem to be effective, that if you’re over 70 kilograms then low dose aspirin, which is the standard now in most countries, is ineffective in preventing vascular events but still causes bleeding.Ìý

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Porter

And yet most people – men and women in the UK – are probably over 70 kilograms.

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Rothwell

Certainly, about half of women, particularly if they’re taking aspirin for vascular reasons, are often over 70 kilos and certainly three-quarters of men.

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Porter

But they’re on a tablet, hundreds of thousands, millions potentially, of people in the UK are on a drug that’s not working for them and may actually be doing them some harm in terms of side effects.

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Rothwell

Certainly, it’s not reducing heart attacks and strokes and it is increasing the risk of bleeding at the higher body weight.

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Porter

Which begs the question why this research wasn’t done before?Ìý It seems a fairly basic error to give a one dose fits all to people and not to account for their weight.

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Rothwell

In retrospect it does and it’s interesting to think how we got to this place in that the early trials use much higher doses of aspirin – 500, 1,000 milligrams a day – and it was then shown in laboratory studies that the way in which we think aspirin works, which is that it blocks the sticky cells – the platelets – in the blood seem to occur with much lower doses and people did a lot of laboratory work to show in fact you can block the platelets with the sort of doses we now use.Ìý But we didn’t check to make sure that that effect on the platelets was really mirrored by an effect on heart attacks and strokes, people assumed that this surrogate outcome of what the platelets did in the test tube was actually going to tell us reliably about what the platelets did in the body.Ìý And it looks as though that probably isn’t the case.

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Porter

So, we’ve historically been focussing on the stickiness, if you like, of the platelets and that’s the protective effect against heart attack and stroke but actually that’s just a marker, we didn’t actually look at outcomes.

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Rothwell

Well exactly right, it’s what people sometimes called a surrogate outcome – we think it probably correlates with the clinical benefits but you really can’t be sure and we’ve been caught out in medicine many times by focussing on surrogate outcomes that haven’t turned out to be correct.

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Porter

So, what are the implications for the way that we use aspirin in the UK?Ìý What you’re suggesting is that most people who are taking it to prevent a heart attack and stroke are probably on too little.

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Rothwell

I think certainly if you’re taking it in what people call the secondary prevention setting, after you’ve had a heart attack or a stroke already, and so the risk of a further event is quite high, then it’s certainly important to get the dose right.Ìý And if you are under 70 kilograms then you’re probably on the right dose.Ìý I think if you’re over 70 kilograms it would make sense to either take double dose or take a low dose twice a day.Ìý And from doing that you wouldn’t really get anymore in the way of side effects but at least you’d get more reassurance that you were getting the benefit as well.

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Porter

What was the relationship between weight and side effects in your research because the side effects can be serious and we’re talking potentially catastrophic bleeding, it’s unusual but it can happen?

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Rothwell

It’s an important point in the sense that even though people over 70 kilograms didn’t get any benefit from taking low dose aspirin they still had the increased risk of bleeding, that didn’t disappear till at least 90 kilograms.Ìý So, you could certainly argue, that between 70-90 kilograms with low dose aspirin we might well be doing more harm than good.

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Porter

This sort of effect is likely to skew the data that we’ve been looking at for decades, is it not, I mean one of the problems with aspirin is that there’s always been a bit of an argument about who should have it and who shouldn’t and if we’re giving say half the people the wrong dose it’s not surprising it doesn’t appear to be that effective.

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Rothwell

Absolutely right and it explains some strange observations in the past.Ìý For example, people have found that looking at the trials aspirin seemed to prevent stroke in women but not in men, which didn’t make much sense but of course when you think of it in terms of body weight that makes very good sense.Ìý And different trials have produced different results overall but then when you look at the makeup of the trails the average weight across the different trials people have done of aspirin ranges from 60 kilograms to 85 kilograms, so you can imagine that the overall trial result will differ quite a lot.

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Porter

Another area that’s created a lot of excitement with aspirin is its ability potentially to prevent some forms of cancer, was that looked at in your study?

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Rothwell

We did yes, we were keen to see whether the largest effect of aspirin on cancer, which is the effect on colorectal cancer, whether that was also weight related and we found that in fact it was in a very similar way to the effect on vascular events.Ìý So, low dose aspirin was effective in preventing colorectal cancer below 70 kilograms but not above, higher doses were effective at somewhat higher weights.Ìý So, in both cases it was again weight dependent.

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Porter

Peter Rothwell.Ìý And there is a link to his research on the Inside Health page of the Radio 4 website. ÌýAnd just for clarity, low dose is generally 75 mg a day, that’s a quarter of a normal aspirin tablet.

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Now from preventing strokes to treating them.

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Baby noises

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Charlotte Smith was just 27 and pregnant with her second child when, out of the blue, she had a stroke.

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Smith

Early on the Saturday morning I woke up with a really bad headache and then it was round about lunchtime when I decided just to take a walk out and meet my partner in town with my four-year-old.Ìý I just put the headache down to part of being pregnant with my son.Ìý I got halfway into town, silly as it sounds, I kind of felt drunk, a loss of feeling in my right side of my body and then I collapsed in the middle of the street.Ìý I was in and out of consciousness, next thing I know I’m waking up and there’s two girls stood over me.Ìý Then my partner, at the time, asked the girls to call me an ambulance.Ìý I was in Telford Hospital for about an hour so they could work out what they could do with me because obviously I wasn’t allowed the normal drug that they give everybody else because I was pregnant.Ìý So, when I got taken Stoke and then the procedure was done within an hour.

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Porter

Charlotte underwent mechanical thrombectomy, a novel way of treating the most common form of stroke where a clot blocks one of the arteries supplying the brain.

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Instead of more established method which involves giving drugs – thrombolytics or clot busters – to restore normal blood flow by dissolving the clot, mechanical thrombectomy grabs the blockage and pulls it out.

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Charlotte was treated in the stroke unit at the University Hospitals of North Midlands NHS Trust in Stoke by Consultant Neuroradiologist Dr Sanjeev Nayak, who had been busy doing the same for other patients just before I met him.

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Nayak

I was up till five in the morning doing these thrombectomy cases, there were two in the night last night.Ìý We had a couple of patients who had serious stroke – they had one of the major vessels of the brain occluded by a blood clot.Ìý A usually these patients have a very bad outcome, either they have serious disability or death and they were referred to our hospital for mechanical thrombectomy.Ìý And from what I heard earlier, so far, the outcomes have been very good.

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Porter

So, you’ve been up most of the night?

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Nayak

Yes, I went home at five in the morning.

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Porter

So, Sanjeev, what’s actually involved?

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Nayak

The story started in 2009 when I started at Stoke, we realised there was a large sub-set of patients with serious stroke.Ìý The intravenous thrombolysis, from the evidence we have, worked in a very small percentage of patients.

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Porter

The thrombolysis drugs – the drugs that we use at the moment to dissolve clot.

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Nayak

Absolutely, they usually work in around 20 or 25% of patients.Ìý Most of these patients who had these kinds of stroke usually either died or had disability.Ìý And for us – I mean this kind of outcome wasn’t acceptable.Ìý I’d done a fellowship in Austria, in Salzburg, when this actually came up in Europe, so I had this experience and I brought this experience with me and we decided with our local team that we have to do something different for these patients.Ìý

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Now for the people who are listening to this, just to give a simple explanation what it means.Ìý Like if you have a large blocked drain in the street and you try to put in some drain powder, that doesn’t really work because you need somebody to go in mechanically – a plumber – to take it out, so that’s what basically we had to do, basically go into the brain vessel and take the clot out.Ìý And that actually made a big difference to the patients’ lives.

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Porter

And using the analogy of the blocked drain, what you’re saying is that the thrombolysis drugs are a bit like pouring drain cleaner on a huge blockage – it simply can’t do the job?

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Nayak

Absolutely.

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Porter

And what sort of proportion of patients having stroke coming to a unit like yours might be eligible for this, how many of them had these big clots?

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Nayak

At the moment we treat around 110 patients a year, which is 10% of our stroke population.Ìý So, I would say around 10% of the stroke population would be eligible for such treatment.

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Power

Well it all sounds very easy – fishing a clot out of a blocked artery – but not when that artery’s in the middle of the brain.

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Nayak

Well the way we can do that is all the vessels in the body are connected to each other, so we go from the groin, there is an artery within the groin we take like a tube or a catheter which goes to the artery in the neck and from there we take a very small meshwork or wire or like a small fishing net into the side of occlusion within the brain and we place that particular micro-catheter across the clot.

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Porter

And you’re being guided all the time, presumably, by some form of x-ray imaging so you can see where you are?

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Nayak

Yeah, you have an x-ray tube which monitors this while we do this, this is on top of the patient’s head, and we actually do it live with screening to make sure that we know where we’re going into the patient’s brain.Ìý We use contrast or dye to identify the blockage in the vessels and once we reach that particular vessel with this smaller tube we then take this mesh or like a stent, sort of open it up into the clot, and once that expands with the body temperature that engages with the clot itself and then what we do is we do the suction with a syringe from the catheter which is there in the neck, the bigger catheter and out of the body.

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Porter

How long does the procedure take if all goes smoothly?

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Nayak

It varies, depending on the complexity.Ìý The one I did yesterday, one of the quickest ones, I did it under nine minutes but it can vary up to an hour.

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Porter

Is there a golden window of opportunity, how quickly do you have to get this equipment in to the patient because presumably the part of the brain that’s beyond this blockage is dying due to lack of blood supply?

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Nayak

So far, the evidence from all the trials and also from our local evidence it’s usually best if it’s performed within six hours of the stroke, I would say ideally within four to six hours.Ìý But there has been new evidence which has come up and we are using that new evidence in our practice at the moment.Ìý The new evidence shows even if somebody has got a stroke and they’ve got good other vessels supplying the other parts of the brain, what you call as collaterals, that particular patient may be eligible for a longer period of treatment, up to 24 hours, depending on advanced imaging.

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Porter

What about safety?Ìý I mean of the problems of using clot busting drugs is that they can cause catastrophic bleeding sometimes.Ìý What can go wrong if you’re just extracting the clot?

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Nayak

From our experience difference in safety when you compare with IV thrombolysis but if it’s being performed by somebody who is not so well experienced there can be a lot of problems, especially you can rupture a brain vessel, you can cause part of the clot actually going from an abnormal artery to a normal artery and causing a stroke elsewhere.Ìý So, there are a lot of other things which we have to look for.

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Porter

You were one of the earlier doctors but what’s happening in units around the UK?Ìý Indeed. what’s happening in units around the world?Ìý Where does this fit in to current modern stroke management?

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Nayak

I think there is a big drive now to incorporate mechanical thrombectomy into normal stroke treatment practice and I believe there is a change of stroke strategy as well, which is going to be announced by the – I think NHS England very soon.Ìý As far as the UK’s concerned, it’s still lagging behind many other parts of the world.Ìý That’s mainly because there is a lack of infrastructure, there is a lack of many things to support this procedure.Ìý We are running this service on a 24/7 goodwill basis, most of the other hospitals they run I think up to 5.00 pm, some even don’t have to 5.00 pm.Ìý It needs a lot of resources from the Department of Health.Ìý I do not see the resources in place.Ìý It saves lives definitely, there’s no doubt about it, but also it saves a lot of money to the NHS because patients go home early because of this procedure, previously these patients would be staying in the hospital up to 90 days because of the large stroke now they go home as early as 14 days, some of them go home within a couple of days.Ìý So, it saves a lot in terms of bed days.Ìý From our hospital we did a cost analysis and we showed that from our patient population we are making a saving of around £2.4 million a year by doing this procedure for our local population.

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Baby noises

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Smith

I was quite amazed, in all fairness, and silly as it sounds I thought that having a stroke wouldn’t affect you until you were much older.Ìý Now I feel fine, I’m back to normal and looking exactly how I was before I had the stroke, which is a very big positive.Ìý I was 33 weeks pregnant and it didn’t affect the baby at all, so I think we are both very lucky.

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Baby noises

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Porter

A grateful Charlotte Smith who was treated by Dr Sanjeev Nayak.

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It is estimated that around 8,000 people every year in England alone could benefit from mechanical thrombectomy, but not all currently have access to it, at least not 24 hrs, seven days a week. ÌýBut as Sanjeev indicated, that could change following the release of a new stroke strategy by NHS England later this year.Ìý To find out more I called Professor Tony Rudd who’s the National Clinical Director for Stroke.

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Rudd

It’s the first time that thrombectomy’s been featured in a national plan which is under preparation at the moment.Ìý And following on from the National Stroke Strategy that was launched in 2007 and finished last year, elements of the plan are prevention – and that’s really critically important because probably up to about 70% of all strokes could be prevented but that needs to be taken on a bit more.Ìý Then there’s the acute care and that’s around getting all stroke patients to the really high-quality stroke units as quickly as possible and to units that are able to deliver the clot busting treatment that we’ve already got available and the new thrombectomy.

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Porter

Where does thrombectomy sit in this new plan?

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Rudd

So thrombectomy is a relatively new procedure, it’s really been only in the last few years that we’ve had the evidence available to show that it is something we should be offering patients.Ìý So, the original strategy from 2007 didn’t mention it.Ìý So, this is all new.Ìý Although NHS England agreed to fund it over a year ago now and we’ve been very active really in terms of rolling it out.Ìý And that’s going to be appropriate for about 10% of the stroke population.

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Porter

Do you see the number of patients being treated acutely with thrombectomy, that’s likely to increase significantly because at the moment this is focused on areas of excellence where there’s a lot of goodwill behind – and places like Stoke, like Sanjeev’s department in Stoke?

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Rudd

Well it’s happening in pretty much all of the 24 neuroscience centres scattered around the country.Ìý Now not all of them are doing it 24 hours a day but we have plans to develop that.Ìý I think it’s a treatment that we hope within the next few years will be available to everybody regardless of where they live or the time of day that they have their stroke.Ìý But the key thing is to make sure that we introduce it in as safe a way as possible.Ìý So, what we don’t want to do is to rush in and just let anybody do it because it’s a potentially highly dangerous treatment and something which needs very high skills in order to be able to do safely.Ìý So, there is a plan to increase the workforce so that we have enough people available to do thrombectomy 24 hours a day, seven days a week and available to the entire population of England.

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Porter

Your role is in England but do you know what’s happening across the rest of the UK in this context, when you speak to your colleagues?

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Rudd

Northern Ireland is already quite well developed, Wales and Scotland still have some way to go.

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Porter

What will be the plan going forward for monitoring how this is used?

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Rudd

NHS England have implemented a series of contracts with the thrombectomy centres and one of the things that those centres have to do is to submit data on a very regular basis in terms of the number of patients they’ve treated and what the outcomes are and any complications and those are data which we’ll be keeping a very close eye on.

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Porter

Tony Rudd, and there is more information on mechanical thrombectomy on our website.

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Time now to continue our guide to the help available when people lose the capacity to make decisions about their care. ÌýThis week health and social care consultant Toby Williamson explains what’s meant by best interests, and why it is important to consider a lasting power of attorney.

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Williamson

Best interests has a very specific definition in the law.Ìý So, a best interest decision is a decision made on behalf of someone who lacks capacity to make a decision.Ìý So, let’s say typically a gentleman with dementia clearly not coping at home to keep himself safe, he’s perhaps wandering out at night or leaving the cooker on and there is a decision-making process around perhaps he needs to receive more care at home or perhaps even go into residential care.Ìý If he can’t make that decision then the law says a best interest decision must be made on his behalf.Ìý

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The Mental Capacity Act defines what best interest is, there’s a so-called checklist you have to go through.Ìý So, you have to, first of all, try and take into account what he would want – his wishes, his feelings, his beliefs, his values – so trying to take into account all the factors that would inform a decision.Ìý You have to try and take into account the views of everybody involved in the person’s care – other family members, perhaps a neighbour if there’s a close neighbour, other professionals or staff who are involved, perhaps a doctor for example.ÌýÌý But it’s worth pointing out that it’s not an absolute requirement to take into account the views of everybody else.

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Porter

You can’t do it by committee.

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Williamson

That’s right, yeah.Ìý And also, people may be able to indicate what they like and don’t like even if they don’t have the capacity to make the decision.Ìý So, you still try and involve this elderly gentleman in finding out his views.Ìý The other important aspect around best interest is another principle in the Mental Capacity Act, which says that one should always try and use the less restrictive option when deciding someone’s best interests.Ìý So, for example, if it’s a choice between moving someone into a care home or them staying at home but with extra care, the person can’t make the decision for themselves, the more restrictive option would be the person moving into the home, so therefore if the less restrictive option can be implemented that’s the option that should always be chosen.Ìý I mean there are other issues that come into that around resources and availability of care but it’s trying to make sure that the person has as much autonomy and independence even if they can’t make a particular decision.Ìý

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Porter

What happens if they have a lasting power of attorney?

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Williamson

In the Mental Capacity Act, which covers England and Wales, there are two types.Ìý You can make a financial LPA, which also covers property matters and as someone who has capacity you fill out some forms and you authorise a person or people, who you trust, so usually family members or very close friends, who in the future can make decisions on your behalf about your financial affairs, your property, bank accounts, so on and so forth.Ìý Now that power of attorney has to be registered with something called the Office of the Public Guardian and it can only be used by someone else, who’s called the attorney, to make decisions on your behalf once it’s been registered.Ìý And a financial and property LPA can also be used when you still have capacity, so it can be used, for example, by someone who’s housebound who may need someone to go to the bank.Ìý There’s also something called a Health and Personal Welfare Lasting Power of Attorney and the same system applies – you would delegate, authorise, someone to make decisions on your behalf in the future around consent to treatment, hospital admission, admission to a care home – you can specify what decisions it covers.Ìý But that can only be used when you lose capacity.

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Porter

But the idea behind both would be to pre-empt any worrying changes.Ìý I mean you might have the financial one because you’re housebound but in many cases people are worried about cognitive decline as they get older, they might not be able to look after their own affairs – that’s the idea.

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Williamson

I think – no, I would encourage people to think very seriously about making an LPA.Ìý They are quite straightforward to make, you don’t need to have a solicitor.Ìý Obviously if someone develops dementia and then really hasn’t got the capacity to authorise anyone to make decisions on their behalf then it is too late.Ìý And for any financial decisions, even about £2.50 in a National Savings account that still has to go to the Court of Protection.Ìý Any decisions about health, housing, personal welfare, social care – those can still be made through the best interest process.

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Porter

Does the attorney’s decision trump everybody else’s?

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Williamson

If they have a lasting power of attorney and the attorney is authorised to make a decision, say about where someone lives, they have to make that decision in the person’s best interests but if they do that correctly then yes, their decision does trump everyone else’s.Ìý Now that can sometimes cause potential disagreement because if professionals are involved, for example, they may have a different view.Ìý And unfortunately, sometimes those decisions do end up by going to court.

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Porter

What happens if people can’t agree on what’s in the person’s best interest?

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Williamson

Well in certain situations the person who lacks capacity to make the decision has the right to an advocate and they may provide an independent voice which may…

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Porter

And where does this advocate come from?

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Williamson

Advocates are generally employed by third sector organisations, local charities such as MIND or Age UK or the Alzheimer’s Society – referral usually is made by a doctor or a social worker who’ll bring them in.Ìý And they aren’t, strictly speaking, available where there are other family members who can be consulted about the person’s best interests.

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Porter

Because they’re designed to represent people who don’t have any family normally.

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Williamson

Normally speaking but sometimes through other ways, or advocates – other advocacy processes – you can get some help.Ìý But if the decision cannot be resolved, if the disagreement continues, then it may have to go to the Court of Protection ultimately.

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Porter

Toby Williamson and there is more information on setting up a lasting power of attorney on our website.

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Seven years ago, six-year-old Jack Adcock died from sepsis in Leicester Royal Infirmary following a number of errors in his care. ÌýThe doctor looking after him, Hadiza Bawa Garba, was subsequently found to be negligent, convicted of manslaughter and given a two-year suspended sentence. ÌýFinally, she was struck off by the General Medical Council – a decision that is currently being reviewed by the Court of Appeal.

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It is a tragic story, particularly for Jack’s family, and one that has had an impact on many doctors.

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While we wait for the Court of Appeal’s decision Margaret McCartney has been reflecting from her perspective.

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McCartney

This case has caused an enormous reaction from the medical profession.Ìý Many doctors, including myself, have felt there but for the grace of god go I.Ìý When I was at medical school representatives from the General Medical Council came to explain to us what standards were expected.Ìý There was no doubt the standards were high but they were also attainable.Ìý The impression I had was as long as I worked hard, was honest and did not abuse the position of trust I was in there was nothing to fear.Ìý

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Bawa Garba’s case has changed that.Ìý Safer healthcare needs professionals who openly talk about mistakes and errors they see or make but the prospect of criminal convictions is likely to mean fear of speaking out.Ìý Safety in healthcare is often unfavourably compared to aviation safety.Ìý If aeroplanes need a checklist before taking off so too do surgeons before they start operating.Ìý The problem in healthcare is that the aeroplane only has one engine, is trying to take off in a hurricane and is half the staff down.

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There is a safety model called Swiss cheese.Ìý We know that human error happens and I understand that to many Bawa Garba made unforgiveable mistakes but all doctors do, me included.Ìý That is one whole in a slice of Swiss cheese.Ìý But by putting many layers of Swiss cheese together, safety systems, we should be able to stop a hole going all the way through.Ìý

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Bawa Garba was just back from maternity leave, without an induction, working a very busy shift with a computer failure meaning that lab results weren’t available when they should have been, with the consultant on-call not available for much of the day and another colleague absent.Ìý There were too many holes in too few layers of Swiss cheese.

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The hospital’s internal review found multiple failings in the system.Ìý Is it fair to blame one individual for a horrendous outcome with so many causes?Ìý And is blaming one person really going to make the system safer?Ìý You can remove one junior doctor from the equation but the unsafe system persists.

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Many consultants have said they feel Bawa Garba is now a safer doctor.Ìý I certainly have learned from the mistakes that I have made.Ìý Criminal convictions don’t seem to stop these kinds of awful tragedies.Ìý A better more honest safety culture might.

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Porter

Margaret McCartney.

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Just time to tell you about next week when we investigate the growth of social prescribing – offering patients help on prescription with everything from their finances and housing, to joining a gym or local choir. ÌýAnd it’s coming to a surgery near you. ÌýJoin us next week to find out more.

ENDS