Plans to insure cosmetic surgery

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20 January 2012 Last updated at 04:04 GMT By Simon Cox BBC Radio 4's The Report PIP implants contain industrial silicone but there is no evidence they pose a health risk An insurance scheme for cosmetic surgery patients could be introduced after the PIP breast implants scandal.

Sir Bruce Keogh, who is leading the government review into PIP implants, told the BBC the scheme would protect consumers.

Although there is no clear evidence PIP implants cause harm, the NHS will remove and replace those it fitted.

But patients who were treated privately are being told by most clinics they must pay for the procedure.

About 40,000 women in Britain have implants made by the French firm Poly Implant Prothese (PIP).

The 3,000 cancer patients who had them for breast reconstruction will have their implants replaced for free by the NHS for compassionate reasons to ease the concern of patients.

But that leaves thousands of women - fitted with implants that contain industrial silicone that is not supposed to be in human bodies - with no official recourse for help.

The three leading clinics which performed breast implant operations, and which would have used the PIP products, are Transform, the Harley Medical Group and Surgicare.

All three have declined to offer free replacements for their patients despite the government saying they have a moral obligation to their customers.

An insurance scheme for future cosmetic surgery patients would offer greater protection for consumers in these scenarios.

Sir Bruce Keogh, the NHS medical director, was appointed by Health Secretary Andrew Lansley in December to lead the review into PIP implants.

Protecting consumers

He told Radio 4's The Report the scheme being considered would work much like the insurance protection scheme in place in the travel industry.

"One of the things my review will be looking at will be... something like the Abta arrangement, which means that when a company runs into trouble for whatever reason, the consumer is covered," Sir Bruce said.

The Association of British Travel Agents (Abta) offers financial protection for its members and their customers should something go wrong.

Companies pay a subscription to become members of Abta, which then provides a fund for people to fall back on should there be a problem.

Sir Bruce said this model "captured the flavour of where we want to go," but said he did not want to pre-empt the recommendations from the review.

Jim Frame, professor of aesthetic plastic surgery at Anglia Ruskin University, supports an insurance system under which the patient would pay a premium but if a problem occurred with implants years after they were put in, there would be "an all-expenses paid replacement of a ruptured implant, absolutely no hassle and we do not have to worry the NHS."

Professor Frame also supports a breast implant registry which is likely to be reintroduced to record details of all operations.

A registry did exist between 1993 and 2006.

The inquiry team will meet in two weeks' time to review the data from private clinics about the failure or rupture rate of PIP implants.

Further tests are also being conducted on the industrial silicone which was used in the implants, to determine how toxic it was.

This edition of The Report was on BBC Radio 4 on Thursday, 19 January at 20:00 GMT.

Listen to the full programme via the Radio 4 website or download the programme podcast.

Source BBC

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'Refer more for epilepsy surgery'

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14 October 2011 Last updated at 00:44 GMT Surgical treatment for epilepsy is being used more and more People who cannot control their epilepsy with medication should be referred sooner for surgery, suggests a study in The Lancet.

The University College London study found that 47% of patients who had surgery were free of seizures after 10 years.

It tracked 615 adults annually over an average of eight years.

But experts say people should be realistic about the risks and benefits of this kind of surgery.

Surgical treatment for epilepsy is being used more and more.

Two-thirds of people with epilepsy have the condition well controlled with medication and experience no side-effects.

The other third, for whom medication does not work, could be eligible for surgery.

The most common type of surgery undertaken on people in the study was temporal lobe surgery, which focuses on the area of the brain behind the forehead between the ear and the eye, where most seizures originate.

Researchers who carried out the study, published in The Lancet, reported that 63% of all patients were free of seizures two years after surgery (excluding simple partial seizures), 52% after five years and 47% after 10 years.

Those with simple partial seizures (SPS) in the first two years after temporal lobe surgery were two-and-a-half times more likely to experience subsequent seizures than those who experienced no SPS.

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Clinical practice needs to change with the early referral of appropriate patients”

End Quote Dr Ahmed-Ramadan Sadek and Professor William Peter Gray This has implications for decisions to stop taking anti-epileptic medication, say the authors.

They found that a relapse was less likely the longer a person was free of seizures after surgery, and more likely the longer seizures continued after surgery.

Realistic about risks

Most patients who were seizure-free after surgery still chose to remain on an anti-epileptic drug of some kind.

John Duncan, medical director at the Epilepsy Society and professor of neurology at University College London's Institute of Neurology, which carried out the study, said the study gave a realistic view of the long-term outcomes of surgery for epilepsy.

"It means people should consider surgery sooner rather than later, while being realistic about the risks too."

The study says that the selection process for surgery and surgical methods need to improve to increase success rates and to more accurately identify those who will not benefit from surgery.

Prof Duncan said the threshold for surgery had come down over the past 20 years.

"Surgery used to be offered to someone having three or four seizures a month. Now it could be offered to someone having one seizure a month, who is in employment but who is experiencing side-effects from the drugs.

"So the stakes are higher. The balance of risk and benefit has changed as surgery is offered to those less severely affected."

Commenting on the findings of the study in The Lancet, Dr Ahmed-Ramadan Sadek and Professor William Peter Gray from the Wessex Neurological Centre at the University of Southampton said the study validated the long-term effectiveness of epilepsy surgery.

But there were still hurdles to be overcome, they said.

"The median duration of epilepsy before surgery in this study was 20 years. In view of the long-term results of surgery shown, clinical practice needs to change with the early referral of appropriate patients."

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New tests for cosmetic surgery

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By Adina Campbell
Newsbeat reporter Sian Welsh says she was too young when she had breast implants at 18

New assessments are being introduced at some private clinics to try to stop people having cosmetic surgery they may later regret.

The test has been developed by psychologists who say patients are being put at risk by firms who don't carry out enough checks.

They are also being backed by the UK's biggest plastic surgery group.

Some clinics in The British Association of Aesthetic Plastic Surgeons (Baaps) have already started using the form.

Nigel Mercer, a consultant plastic surgeon and member of Baaps, says the questionnaires are easy to use and have a scoring system to help identify those who aren't suitable for cosmetic surgery or treatments.

"It's important we are aware of those patients who are vulnerable and that they are appropriately counselled. They need to be fully aware of what they're letting themselves in for if they go for surgery."

"These assessments should act as an aid for surgeons who have a responsibility to ask the right questions. Too many private clinics are more concerned about their bank balance and not their patients."

The test asks questions like how long a person spends looking in the mirror and how much the feature they want to change bothers them.

Nichola Rumsey, a psychologist in Bristol, helped develop the assessment.

"We've worked on this for a number of years. We thought there was a need to provide surgeons with a screening instrument to find out who looks like they will do well from cosmetic surgery and those that may go on to suffer psychological problems."

'Flat chest'

Twenty-two-year-old Sian Welsh from Oldham had breast implants when she was 18. Looking back she says the surgeon didn't give her enough time to think about whether she needed surgery.

"Before my boob job I was a double A cup and it always bothered me having a flat chest. I was really excited about having implants when I turned 18 because I thought it would give me more confidence."

"But looking back, I was definitely too young and probably needed counselling to make me feel better about myself."

The patient must complete 11 questions on body image

"I don't regret the surgery but I should have waited. My surgeon didn't get to know me and never found out where I was psychologically."

The questionnaire takes up two sides of A4 and patients will need to answer the 10 questions before their first consultation with a surgeon.

There is a separate guide for surgeons which helps flag up those who aren't suitable for surgery and may need counselling instead.

It's claimed some patients who are desperate for surgery will able to cheat the test and give false answers.

Newsbeat gave Sian a copy of the questionnaire and she had mixed views.

"I think these assessments are a good idea and if it was around when I had surgery, the outcome may have been different for me.

"However, looking at these questions they're not very detailed and I think some people will put scores down that will guarantee they have surgery."

Nigel Mercer says the questionnaire is only supposed to be an aid for surgeons.

"Good surgeons will be able to tell when someone is lying and we are trained to pick out those who have deeper underlying issues."

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Weight loss bypass surgery may muffle temptation

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By Rob Goodier

NEW YORK | Fri Oct 14, 2011 3:15pm EDT

NEW YORK (Reuters Health) - People who've had gastric bypass surgery might make healthier eating choices than those who opt for the weight loss procedure known as gastric banding, say UK researchers who found bypass patients less tempted by sweets and other fattening foods.

After surveying patients who had either type of surgery, and performing brain scans on several dozen of them, Dr. Tony Goldstone of Imperial College London and Hammersmith Hospital and his colleagues found that even deep down in their brains, the gastric bypass patients seemed to like high-calorie foods less.

"The results suggest that gastric-banding patients had to exert quite a lot of self-control over their eating behavior. Banding patients also had higher concern about their weight," Goldstone told Reuters Health.

In contrast, gastric bypass patients "don't feel they have to exert as much cognitive control over what they're eating," said Goldstone, who presented the findings October 4th at the Obesity Society's annual meeting in Orlando, Florida.

The two weight loss operations have similar broad goals -- to shrink the stomach so people feel full with less food. In gastric bypass, the stomach is surgically reduced and one end of it is rerouted to bypass part of the small intestine. With gastric banding, a silicone band placed around the top of the stomach reduces its capacity.

Although gastric banding is more popular, in part because the band can be removed, previous research has found gastric bypass patients seem to lose more weight and lose it faster than banding patients. The reasons for the differences are still unclear.

Goldstone's team studied 30 gastric bypass patients, 28 gastric banding patients and 20 people who did not have weight loss surgery. All the participants started out obese and the two surgery groups had lost similar amounts of body weight since their respective procedures, an average of 28 percent.

Since banding patients lose weight more slowly, those in this study had undergone their procedure an average of 18 months earlier, compared to the bypass patients at 10 months post-surgery.

Participants filled out an eating behavior questionnaire, and 20 people in each group underwent functional magnetic resonance imaging (fMRI) while looking at pictures of food.

Among the significant differences in questionnaire responses, researchers found, the gastric bypass patients reported having to restrain themselves less, or finding it easier to restrain themselves from eating poorly. They also did less impulsive eating -- eating something on sight, not out of hunger -- and less eating to boost their mood, or "emotional eating."

Those who underwent fMRI had fasted overnight, and then viewed pictures of foods and ate ice cream during the brain scan. The gastric bypass patients rated the ice cream and pictures of high-calorie foods as less appealing than did the gastric banding patients.

Bypass patients also showed lower activity in brain areas like the orbitofrontal cortex (associated with a reward response), the amygdala (associated with emotion) and in the ventral striatum (which would register the expectation of a reward like food).

Goldstone theorizes that gut hormones that trigger a feeling of fullness after eating are released more quickly in gastric bypass patients, and these chemical signals may be influencing those patients' long- and short-term responses to food in a way the gastric banding patients don't experience.

"The connections between the biology of obesity and the mechanisms of the surgery we use is really a new science established in the last three to five years," said Dr. Robin Blackstone, president of the American Society for Metabolic and Bariatric Surgery, who was not involved in the study. "Now that we understand more about how these procedures are working, it makes sense that the bypass patients would have more control. The band would not produce those same effects."

"Bypass results in more weight loss than the band and it is a more sustainable weight loss," Blackstone added. "Now we begin to understand why that is, because it has these kinds of effects."

It's not possible yet to say that one type of surgery or another is better for a certain type of patient, noted Blackstone, who is also the medical director at Scottsdale Healthcare Bariatric Center in Arizona.

"A lot of people are working to figure out which procedure is best for which patients," she said.

"People that are motivated to use the band generally don't have much weight to lose, or they're attracted by the safety profile -- the lower mortality rates -- and that it's reversible," Blackstone said.

"The more we begin to understand about patients individually, including the genetic components of their obesity, we'll be able to match a procedure really well for them. We just don't know how to select people out for each procedure," she said.

Goldstone said his next step will be determining whether the reduced response to fattening foods seen in gastric bypass patients actually translates into their making healthier, low-calorie food choices.

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Why Are So Many Seniors Getting End-of-Life Surgery?

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One in three people on Medicare have surgery in the final year of their lives, and many have surgery in their last month, according to a new study published in The Lancet.

Of the 1.8 million Medicare patients over age 65 who died in 2008, researchers found that a third had undergone surgery in the year before death and that 18% of those surgeries had occurred in the month before death. Nearly 1 in 10 had surgery in their final week. The numbers were surprisingly high, researchers said.

To some extent, the finding makes sense: sick people have surgery and sick people also die. But while the researchers did not examine whether individual surgeries were necessary or whether they improved patients' quality of life — many surely did — the data suggested they did not improve outcomes overall. Areas of the country that had high rates of surgery also had high rates of death.

MORE: Anesthesia May Put Kids at Risk for Learning Disabilities

Geography had a lot to do with a Medicare patient's likelihood of having surgery in the last year of life. Muncie, Ind., had the highest rate, at 34%, while Honolulu had the lowest, at 12%. Why that's so isn't clear, but the authors suggested several possible contributing factors, including population health, patterns of medical practice, culture and availability of end-of-life services such as hospice care.

Rates of surgery also differed by age. About 38% of 65-year-old Medicare patients had surgery in the year they died, compared with 35% of 80-year-olds — not a very vast difference. But rates of surgery dropped off more sharply in patients older than 80, with fewer than 24% of patients between 80 and 90 having surgery, suggesting that surgeons had greater concerns about the risk of complications in this age group.

Given the patterns in surgery rates across the country, the authors suggest that medical need is not the only factor driving doctors' desire to operate. Many surgeries may be done to avoid difficult discussions about patients' prognosis, or to fix problems that wouldn't necessarily prolong life or improve its quality, the authors said. Doctors are also failing to figure out exactly how dying patients wish to spend their final days.

MORE: Breaking a Hip More Than Doubles Women's Risk of Death

"In a lot of places, we're doing a lot of these surgeries I think unnecessarily," lead author Ashish Jha, a professor of health policy and management at the Harvard School of Public Health, told Bloomberg. "We're not having the kinds of conversations with patients that we need to have, about what they want out of their last few days and how we help them achieve those goals."

Reported Bloomberg:

Doctors and hospitals may have a financial incentive to operate on dying seniors "regardless of the patient's preferences or goals," because Medicare is guaranteed to pay for the procedures, said Amy Kelley, an assistant professor of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine in New York.

In an accompanying comment in The Lancet, Kelley wrote that doctors', insurance companies' and hospitals' incentives must be aligned with the wishes of the patient. She also suggested that another to way to increase the likelihood that patients get the care they want is to ensure that all medical and nursing school students receive basic education in end-of-life care

The study is not without its limitations, however. For example, researchers looked only at surgery patients who died; it's not known how many patients who had the same procedure survived.

MORE: Deep Fear of Childbirth Drives Some C-Sections

Meredith Melnick is a reporter at TIME. Find her on Twitter at @MeredithCM. You can also continue the discussion on TIME's Facebook page and on Twitter at @TIME.

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Analysis: The debate over closing child heart surgery units

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27 September 2011 Last updated at 11:17 GMT By Jane Hughes Health correspondent, BBC News Nicolas Tompkins had surgery at 2.5 weeks Nicolas Tompkins' parents believe he wouldn't be with them if it wasn't for the doctors and nurses at the Royal Brompton Hospital in central London.

At just four weeks old, he's recovering from a 15-hour operation to correct a complicated and rare defect in his heart.

Surgeons effectively had to re-wire it, after discovering that his lungs weren't properly connected, and he wasn't getting enough oxygen.

He was lucky to be treated by a world expert in his condition.

His parents are incredulous at the thought that the team which saved his life could be about to be broken up.

"Everybody we meet here, every doctor, every nurse, is clearly at the top of their game," said his father, Andrew Tompkins. "There's nowhere like this in the world. How could they want to close it?"

Continue reading the main story

If we get centres of excellence, we can save money and still get better care”

End Quote Mike Farrar NHS Confederation Chief Executive The reason is that children's heart surgery across England is being reorganised. And, as one of three hospitals in London carrying out this kind of specialised paediatric treatment, the Royal Brompton was told it would have to scale down its children's heart unit and stop doing all operations.

Other units in Leeds, Southampton, Newcastle and Leicester are still waiting for a decision as to whether they will also stop doing operations. Ultimately, at least four will close across England.

The review does not affect patients in Scotland, who are all treated in Glasgow. Welsh patients are treated in England, while patients in Northern Ireland travel to Dublin for treatment.

Bristol scandal

The review of children's heart surgery came about as a result of the inquiry into the Bristol heart babies scandal in the 1990s, when a number of babies died needlessly during operations by surgeons with insufficient experience. It concluded that children would get better, safer care if there were fewer, larger, more specialised units.

"We know the best results can only be achieved by surgeons and units treating a lot of patients," said Professor Norman Williams, President of the Royal College of Surgeons. "And we also know that patients benefit from units with enough surgeons to give a round-the-clock service."

Yet, as the Royal Brompton's experience shows, reorganising services is not straightforward.

Without cardiac patients, it says its paediatric intensive care unit would no longer be viable. And without intensive care, it would no longer be able to offer its specialist children's lung services - treating children with cystic fibrosis and other conditions. It says its respiratory unit is second to none in the country, and many, many patients will lose out.

And so one part of the NHS is going head-to-head against another in the High Court. Watching around the country are not just the other units under threat, but NHS hospital trusts which know they must reorganise other hospital services to remain viable and provide the best possible patient care.

Tough challenge

The NHS Confederation has said the reconfiguration process will become increasingly necessary; not just because of a tougher financial climate, but also to improve care.

"At the moment, we're not getting the best outcomes we can because some services are distributed across too many sites," said NHS Confederation Chief Executive, Mike Farrar. "If we get centres of excellence, we can save money and still get better care."

Reorganising services is one of the hardest things the health service has to do, said Chris Ham, head of the health thinktank, the Kings Fund.

"But it is absolutely necessary at the present time," he said. "Not first and foremost because of the financial pressures but because we will only deliver world class standards of care if we grasp this nettle and take decisions that are long overdue by concentrating some of those services in fewer hospitals."

The fight over the future of the Royal Brompton may well be one of many more to come.

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