How Old Is Your Heart?

Public Health England (PHE) in collaboration with the British Heart Foundation (BHF) has launched a heart check-up to identify ‘your heart age compared to your real age’.  Is it a valuable public health intervention or a waste of time and money?

It begins by asking age, gender, ethnicity and postcode.

Then: Do you have cardiovascular disease? No.

Do you smoke? No.

But I did. I quit two years, three months and thirteen days ago. Not that I’m still counting. But this does make a big difference. My heart is ‘older’ than it would be if I’d never smoked, I know that. It can take up to ten years for risk levels to return to those of a non-smoker.

Next it asks for height, weight and a few questions on medical history. Pretty standard.

Then it asks what your cholesterol level and blood pressure are. How many people know that?

And that’s it, end of test. It tells me that my heart age is four years older than my real age and says this:

 Your risk of having a heart attack or stroke within the next 10 years is 5.8%

Your heart age is an estimate because you don't know all your numbers. We've based your result on the national average.

If you have high cholesterol and blood pressure, your heart age could be as high as 69.

Make an appointment with your doctor, nurse or pharmacist to get your blood pressure and cholesterol tested.

There are no questions about alcohol and drug consumption, diet and exercise, all things which the NHS and PHE normally tell us make a big difference to heart health. I’ve lived in central London all my adult life and we keep being told how damaging pollution is to health and longevity so it might be a good idea to include a question on that.

The NHS is already struggling, does it really need a few million people making appointments to get their BP and cholesterol checked? Or do they expect people to rush out and buy self-testing kits? And then going to the GP when they get a high result. GPs have not surprisingly expressed concern about this test adding to their already extreme workload.

Is it good public health policy to frighten people with an unrealistic heart age? Who is the mythical ‘average’ person the figures are based on? I’m considerably taller, lighter and fitter than the average woman, for example (and an ex-smoker, yes, I know) so they can't use her to scare me like some sort of Baba Yaga.

There’s also the question of efficacy. NICE has already rejected the use of lifetime risk scores because of a lack of evidence, which means they will scare people, overload GPs - and not have any effect. It’s not even a case of the end justifying the means.

The people behind the project are defending it in various parts of the media by saying it will raise awareness and start a conversation. As an awareness raiser it fails because all it will do is frighten people into going to the GP, or frighten them and then they’ll carry on as normal, or make them think about making some changes and then give up after a few weeks because that’s how we operate. No imminent threat, no motivation.  Will there be any follow-up to see if people have taken action? Doubtful.

If it’s a way of collecting information about the population, then the holes in it make that information of very limited value – unless all PHE wants to know is how many of us don’t know our BP and cholesterol. This is not a compulsory test. The people doing it are self-selecting, opting in, and the reasons they do this could skew the results. Is it idle curiosity, concern, fear or some other reason? Is it mostly the group known as the ‘worried well’? People on very low incomes and many old people will be excluded because of lack of online access.

Heart disease is a serious and growing problem that takes long-term investment and lifestyle management to tackle.  According to the British Heart Foundation:

Heart and circulatory diseases cause more than a quarter (26%) of all deaths in the UK - over 150,000 deaths each year, an average of 420 people each day or one death every three minutes.

But hang on a minute… it also says:

Since the BHF was established the annual number of deaths from heart and circulatory diseases in the UK has fallen by more than half.

In 1961, more than half of all deaths in the UK were attributed to CVD (320,000 deaths).

Since 1961 the UK death rate from heart and circulatory diseases has declined by more than three quarters.

Would it not perhaps be worth looking at why rates have fallen, what else people are dying of, what interventions have worked in the past, where limited resources could be most usefully targeted? For example, obesity has risen since 1961, smoking rates have fallen and life expectancy has risen so people are more likely to have multiple comorbidities that accumulate with age – more than one potentially life-limiting condition at once.

As it happens, I did have my BP checked this week as part of an ongoing treatment for something not heart-related. I didn’t put it in the test because I wanted to see what results came up. The nursing assistant who checked it said he’d tried to take the test but it didn’t work because he was too young. He agreed with me about the flaws in the design. (My BP is great, thanks for asking).

If you do want to know about the state of your heart and its future, you’d be better off doing this:

Save Our Souls - on the NHS

Should the National Health Service be tending to our spiritual health and if so, how far should it go?

This week, during a debate about an amendment to the Health and Social Care Bill, tabled by psychiatrist and crossbench peer Baroness Hollins, the Archbishop of York called for the words ‘spiritual health’ to be inserted into a clause about the duty of the secretary of state, the NHS Commissioning Board and clinical commissioning groups to improve the quality of services.

Spirituality is already covered in healthcare guidelines even though there is no evidence-base for it and even though its use is so broad as to be almost meaningless as I wrote about here. For example, going to football matches is considered a spiritual act by some healthcare providers, including the Royal College of Psychiatrists. Guidelines often assume that everyone is spiritual and has spiritual needs that the NHS must cater to. NHS Scotland’s past guidelines stated: ‘We are not human beings seeking spiritual experience. We are spiritual beings seeking what it means to be human’.

The NHS already forks out £29 million a year for hospital chaplains and again there is no evidence that they improve the patient care. In fact, many of the country’s best hospitals spent the lowest proportion of their expenditure on chaplaincy services.

The debate around the amendment wasn't just about some sort of wooly feel-good spirituality. The Archbishop of York’s idea of treating the spirit goes beyond what most people would consider the domain of doctors and nurses. During the debate, Dr John Sentamu told peers: "I am one of those who believe that human beings are psychosomatic spiritual entities."

He then explained how he freed the spirit of a girl who was terrified after seeing a goat sacrificed. Visits from a GP, psychiatrist and psychologist did little to help, he said, but then he said a prayer, anointed the girl and lit a candle on his visit. Shortly after, he received a phone call saying the girl was no longer terrified and was talking again. "That was not mental or physical illness; there was something in her spirit that needed to be set free," he told his peers.

This is a very particular interpretation of the word ‘spiritual’. A spokesman for the Archbishop said the case of the young girl just involved a standard prayer of healing. With candles and anointing to set her spirit free? Although Sentamu did not directly describe his actions as exorcism, they were very close to standard exorcist practice. He is not, by the way, a medical doctor. He is, however, someone who determines the laws and policy of this country along with all the other bishops in the Lords. Even so, as a lawyer he should know that one anecdote does not constitute evidence.

However, his statement isn't that outrageous when you know that the NHS has already been quietly working with exorcists to treat patients for at least 40 years.

Dr Rob Waller, a consultant psychiatrist and an honorary clinical lecturer at the University of Edinburgh was formerly part of a medical support group for the local Catholic exorcist at Bradford District Care Trust. It met monthly to discuss cases and whether they should be dealt with by the church or by a doctor. He said: “There was a similar set-up with local imams, and the Church of Scotland has links with psychiatrists and considers exorcism.” He also said that every consultant psychiatrist will see a “handful of patients” in their career requiring “some kind of deliverance ministry”.

It sounds so much more innocuous when you call it deliverance - although maybe not if you've seen the film of that name.

Professor Robin M. Murray, head of Psychiatric Research at Kings College’s Institute of Psychiatry, who this year was awarded a knighthood for his services to medicine, said: “Not all psychiatric problems respond to conventional treatments. So while I don’t know of any scientific evidence that exorcism works, I would have thought it reasonable for a [hospital] chaplain to carry this out.”

This is a scientist saying that a procedure with no evidence is reasonable.

However, Dr James Woolley, consultant psychiatrist at the Springfield Hospital in southwest London, doesn't believe in demonic possession or exorcism. There are many psychiatric syndromes characterised by a patient believing they are possessed and, for that reason alone, Woolley says, it would be “reckless and unprofessional” to recommend exorcism as an avenue of treatment. “The psychosis could get worse, and being in a highly paranoid state is associated with the risk of harm primarily to yourself and potentially to other people.”

Reckless and unprofessional. There is a possible placebo effect but the ethics of placebos are complex and still need evidence to justify their use.

In the mid-1970s, Archbishop of Canterbury Dr Donald Coggan laid down strict guidelines on exorcisms (deliverance) which were to be carried out only by an appointed diocesan exorcist after consultation with a doctor. The Church of England has 44 exorcists, one for every diocese, appointed by the Archbishop of Canterbury. Next time Rowan Williams is sounding off in the media, bear in mind that he is in charge of these men. The interview for appointment must be interesting.

There's a story in the Mail today about a nurse who asked Jesus to help when a baby was dying of a heart attack. While this is an extreme case, and she was struck off (and it is the Mail) the dangers of introducing any level of non-evidence-based behaviour into healthcare should not be treated lightly. The current trend for 'holistic' treatment opens the door to worse care, not better. At a time when the NHS is facing severe cuts, surely the most important thing is to treat patients and keep them alive long enough to worry about the state of their souls?

Homeopathy and the NHS - update

In May, the British Medical Association's annual conference of junior doctors declared that homeopathy is witchcraft and now the BMA’s conference in Brighton has voted overwhelmingly against commissioning or funding for homeopathic remedies or homeopathic hospitals in the health service. They also want training posts in homeopathic hospitals scrapped.

What’s more, pharmacists should remove homeopathic remedies from their shelves because this strongly suggests to the public they are medicines. Instead they should be put in a section marked ‘placebos’.

This may well be a step too far because, as we know, Boots doesn’t sell homeopathy because it works, they sell it because people like to buy it. In case you’ve forgotten - a spokesman for Boots said: "I have no evidence to suggest that [homeopathic remedies] are efficacious. It's about consumer choice and a large number of our customers think they work."

Dr Mary McCarthy, a GP at the conference, said: ‘We are not asking for homeopathy to be stopped and it will allow those who want to do it to continue to use it. What we are asking is that it’s not funded by the scarce NHS resources.’

OK, so it’s not witchcraft

BMA junior doctors’ committee vice-chair Tom Dolphin, who first proposed banning homeopathy at the BMA annual junior doctors conference in May, said: ‘I got into trouble for saying at the juniors conference that homeopathy is witchcraft.

'I take that back and apologise to the witches I apparently offended by association. Homeopathy isn’t witchcraft — it is nonsense on stilts. It is pernicious nonsense that feeds into a rising wave of irrationality that threatens the hard won gains of the enlightenment, and the scientific method.’

He warned that society risked ‘sinking back into a state of magical thinking, where made-up science passes for rational discourse, and wishing for something to be true counts as proof’.

Tell it like it is, Tom.

There were, of course, supporters of homeopathy at the conference and protesting outside.

Dr David Shipstone, a urologist, said it would be unfair to pick on homeopathy as there were plenty of other treatments which were used by doctors despite a lack of categorical evidence they worked. He said: "What is valid scientific evidence? Academics can argue about it all day."

It’s not about valid evidence in this case, but about the total lack of evidence even after 200 or so trials. Unless by ‘valid’ he means ‘imaginary’ – or possibly homeopathic evidence is so dilute that it contains no evidence at all.

BMA board of science chair-elect Averil Mansfield said: ‘What we want to be supporting and promoting is things that have scientific evidence. The resources are small in the NHS and that I think has to be our central priority.’

The Department of Health said it was looking into the issue:
"The department is considering issues to do with homeopathic remedies and hospitals as part of the government's response to the Science and Technology Committee's report on homeopathy. The response will be issued soon."