Examination of Witnesses (Questions 20-39)
9 DECEMBER 2004
MRS LINDA
DE COSSART,
MR DAVID
WARWICK, PROFESSOR
AJAY KAKKAR,
DR DAVID
KEELING AND
DR BEVERLEY
HUNT
Q20 Dr Naysmith: We will come onto that
in a minute. I am interested in what you were saying about people
outside of the hospital. Often DVT does occur after patients have
gone home. How do we raise awareness of primary care trusts and
GPs and so on? Are they aware of the situation or do they need
to be reminded as well?
Dr Keeling: I suppose that one
thing I am guilty of to some extent is that I see a lot of patients
with deep vein thrombosis because I run a DVT service and quite
a few of those have had an operation six weeks previously. Maybe
every time that happens I should be writing a big letter in bold
to the surgeon letting them know what has happened.
Mrs de Cossart: I think that is
a big issue really. I would find that patients have been admitted
under physicians into the hospital who have had a venous complication
from their surgery.
Q21 Dr Naysmith: So there is nothing
like the yellow card system or anything like that?
Mrs de Cossart: No. Again I think
it is people paying attention to detail and how they manage things.
I think the general practitioners are aware of it and if you do
run a good screening service for querying DVT disease in your
hospital—I am sure what we are hearing from David and it
is similar in our place—they do send them in with a very
low threshold. They send them in for a screen or a scan and they
are looked at, so there is reasonable awareness. There is an issue
there, of course, which is workload. Certainly since introducing
duplex scanning in our hospital we have increased the workload
five or six times what it was before which puts an immense strain
on the services that we can offer. We are managing but there is
a workload issue. I think awareness will create more work.
Q22 Dr Naysmith: I do not want to be
political about this but since the Government has been in there
are a fair number more consultants and doctors in the service
than there were in 1997 so presumably they are doing a bit more
work.
Mrs de Cossart: It depends where
they are.
Q23 Dr Naysmith: Yes, it depends which
speciality they are in and where they are. We will not go down
that road.
Mrs de Cossart: They do not have
to be doctors; some of this work can be done by technologists.
Q24 Dr Naysmith: The other thing I was
going to explore a little bit more with you was this question
of counselling because people are counselled before they have
operations about transfusions and that sort of thing, but probably
not very often about the risks of DVT. Is that right? Are people
counselled about that?
Mr Warwick: The new consent forms
which have only just come out actually do have a section that
says: "The probable risks for this procedure include:"
and I think most people would put down thrombosis, but there is
no reason why you should not have a standard consent form for
things like hip and knee replacement which would include that.
Q25 Dr Naysmith: Presumably if you are
doing an orthopaedic operation like that the risk is higher than
it is for other operations.
Mr Warwick: It is, yes.
Q26 Dr Naysmith: Therefore you should
take your patient into your confidence. Does that not happen?
Mrs de Cossart: It does happen.
I counsel patients quite regularly about the risks of DVT but
the question is, what risks do you put to them because you obviously
have to customise it to the operation, to the patient and to their
previous history. Certainly if there is a significant risk it
should be discussed with them.
Q27 Dr Naysmith: In some of the written
evidence we have had it has been suggested that counselling is
not too widespread.
Mrs de Cossart: It is back to
this issue of who takes consent and actually the authority and
knowledge of those particular people and we are struggling with
that with the new consent issues and dictacts of governance in
trusts at the moment where certain sectors of the population of
doctors are now prevented from doing these jobs. Again it is an
issue of education and making sure that people are actually able
to consent people appropriately.
Q28 Dr Naysmith: Why would people be
prevented from doing this job?
Mrs de Cossart: Traditionally—rightly
or wrongly, I am not arguing the case one way or the other—house
officers and senior house officers in hospitals and surgical units
would consent the patients for their surgery and now that has
all changed. The person doing the operation—and I think
there are good reasons for this—consent the patient so they
are fully educated and aware of the complications. That has therefore
driven the need for consent to be done by more senior staff, almost
de-skilling the people at the bottom end because we have not invested
enough time in educating them to make sure they are comfortable
in doing the job.
Q29 Dr Naysmith: We are beginning to
cover all sorts of issues then, are we not?
Mrs de Cossart: That is the case,
I think.
Professor Kakkar: Coming back
to your original point about how we make this happen, if one goes
for a strategy where one recommends that each individual trust
has a written protocol for the prevention of thromboembolic disease,
then I think the point has been made very clearly that we have
to help those trusts to adopt the best evidence. Otherwise one
might get slightly awkward differences in the views of individual
groups of clinicians as to what basis these protocols should be
made upon. I think if we are going to have a strategy to implement
it we have to provide the best evidence that we have validated
centrally made available to trusts so that they can then tailor
that to individual protocols written for practice in their hospitals.
I think then the point of auditing is very important and that
may be achieved in part. The Royal College of Surgeons has done
that very successfully in the national confidential inquiry into
perioperative deaths. For instance, when they looked at surgery
for patients undergoing hip fracture operations as an emergency
they found some years ago—I think in the early 1990s—that
about 40% of patients dying after hip fracture had evidence of
pulmonary embolism. There are those types of audits and the confidential
inquiry into maternal deaths has done the same in obstetric practice.
That is one route forward of auditing. A second route for auditing
could be that in the audits that the Commission of Health Audit
and Improvement undertake in one of their audit rounds they could
look at both the availability of the venous thromboembolism, deep
vein thrombosis prevention and protocol in the hospital and its
uptake across that hospital emphasising again that it is not all
patients but appropriately selected patients who require prophylaxis
in hospital. Then I think it is very important that we do not
ignore the importance of continuing professional education in
this area because the thrombosis field is very active in research
and there continues to be the generation of new data, much more
elegant research in terms of the impact and outcome long-term
of hidden thrombosis on populations of patients and that needs
to be communicated to clinicians I think through the educational
and CPD activities of the Royal Colleges. So it is a combination
of things I think that would help us to get the game up, but primarily
if we look at the recommendations that are published by, for instance,
the American College of Chest Physicians and other authoritative
guideline groups, the one important thing that we can do to raise
awareness in hospitals is to encourage those hospitals to have
a written protocol. Once a written protocol exists in the hospitals
clinicians think about it more. With regard to the patient consent
issue I think it is very important as an abdominal and cancer
surgeon. When I consent patients I always raise the issue of thromboembolic
risk with them because I personally think it is an important problem
in cancer surgery. I describe to them my preferred intervention
which is to use pharmacological prophylaxis to prevent that thrombosis.
I think Mr Warwick has said the same, that most orthopaedic surgeons
now consenting their patients would raise that issue and in general,
using the new NHS consent form, we are obliged to complete a section
where we make it clear to patients the important and common risks
associated with their procedure. For a number of surgical procedures
it would be very clear that thrombosis is a common and important
risk. If we turn away briefly from the surgical to the medical
patients, I think that is where we have a big problem because
often they come in for medical therapy for their disease where
there is not written consent and communicating the thrombosis
risk for that group—the largest number of patients in our
hospitals—I think is more difficult.
Q30 Dr Naysmith: What would you say if
someone said, "I don't want pharmaceutical intervention;
I want a mechanical one"?
Professor Kakkar: I think that
is very reasonable. I think if you discuss with the patient the
benefit in terms of preventing thrombosis and the risk of bleeding—and
they had a real fear of bleeding risk—there is evidence
in the literature for many hospitalised populations that suggests
that mechanical prophylaxis will work. It is not always as effective
as pharmacological but evidence, no doubt, that it will work and
that should not be denied as part of the discussion with the patient.
Q31 Dr Naysmith: Where does clinical
judgment come into this and the fact that you might know what
is best for the patient even against their wishes?
Mrs de Cossart: Could I say one
thing with respect to the patient here? I still think you have
to remember what sort of population we are actually looking after.
They are still very cowed about the idea of asking or challenging
doctors' management plans.
Q32 Chairman: That is changing.
Mrs de Cossart: Absolutely, and
rightly so. I think we should encourage and if we did nothing
more it would be to ask your doctor about what their anti-DVT
plans for you actually are. If we simply did that—in the
same way as we have successfully done, "Do you wash your
hands between patients in the critical care unit?"—these
very small things would begin to raise awareness in everybody's
mind and should not be underestimated in the effect that they
might have with driving the education, the clinical governance
and the whole profession's attitude to this very complicated problem.
Mr Warwick: I think we do need
some help also on implementation of protocol. In our hospital
we have designed a protocol which uses foot pumps early on after
hip fracture or hip or knee replacement because we place a value
on potential bleeding. We also use spinal anaesthetics. The foot
pump allows us to use pretty effective prophylaxis for a short
period of time. We now also recognise the evidence that we should
be using low molecular heparins, for example, for five weeks after
hip replacement. That evidence is crystal clear now; clinical
prophylaxis needs to be used at least after hip replacement and
hip fracture for at least five weeks. However we have hit a brick
wall at both ends of that spectrum of prophylaxis. To try to buy
foot pumps you have to have a business case: where is the money
coming from, can you prove you are going to save money?
Q33 Chairman: What is the cost of a foot
pump?
Mr Warwick: Say £2,000, but
we rotated them round the patients, and so on. There are processes
in which just to try to get something new goes on forever. I then
tried to get extended duration prophylaxis for hip fractures and
hip replacement and that was just impossible. The trust is already
£15 million over spent this year; they are not interested.
The PCT tell us they have set up their costs for hip replacement
and that is not going to include five weeks of prophylaxis. You
hit brick walls all the time. There is a new drug come out which
looks quite effective. We looked at introducing that to our Therapeutics
Committee but when we submitted the evidence it just got thrown
back to us and that was that. I think we need help actually in
getting this stuff on board.
Q34 Chairman: This new tariff system
in terms of costs or individual interventions, does the common
tariff reflect?
Mr Warwick: No.
Q35 Chairman: That is very interesting.
Are you sure about that?
Mrs de Cossart: Absolutely. The
common tariff probably does not include anti-DVT products.
Q36 Chairman: Which interventions are
we talking about here?
Mrs de Cossart: The tariff is
cut to the bone in what it actually covers. Certainly for the
extended treatments you would have to look at re-negotiating the
tariff in order to introduce this and it certainly will not include,
I think, the acquisition capital for the new recruitment that
you might use in order to do things.
Q37 Dr Taylor: We were told very clearly
the Secretary of State himself yesterday that the common tariffs,
if you are talking about hip replacements, would be varied from
one tariff for the cheaper, absolutely ordinary low risk ones
and a different tariff for the more complicated ones. Should we
be making a point very strongly that prophylaxis should be included
in that tariff?
Mrs de Cossart: That should probably
also be covered by the comment that David has just made about
how long you should give the prophylaxis for. That, of course,
introduces a whole new ball game with respect to educating the
patient because obviously if they are having it for five weeks
they give it to themselves and there is a management issue about
looking after them while that is going on.
Q38 Dr Taylor: But that has got to be
included in the tariff for the cost of the operation.
Mrs de Cossart: Yes.
Q39 Chairman: We have also heard that
different clinicians have different views in the approach they
take. This is a very complex area where I am not sure we will
be able to come up with any easy answers.
Mrs de Cossart: I think the individual
clinicians who might not want to do it would play into the hands
of having the low tariff.
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