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INSIDE HEALTH

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Programme 4.

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TX:听 22.09.15听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 FIONA HILL

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Porter

Coming up today:听 Flu jabs - last year鈥檚 vaccine didn鈥檛 work that well, so is this year鈥檚 going to be any better?

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Peer review - nothing to do with the Upper Chamber, but a key process in the publication of new research. But what does it actually mean? Margaret McCartney and Carl Heneghan continue their series demystifying the scientific language of medicine.

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And our guide to knock knees and bandy legs 鈥� what鈥檚 normal and what鈥檚 not.

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Clip

Pretty much all children are born slightly bow legged and the worst of the sort of bow leg appearance is around the age of 18 months.听 Then the next thing that happens is by the age of three to five years old the knee undergoes a sort of normal change in morphology and becomes knock-kneed.听 Then we get a spate of referrals that are more to do with knock-knees.

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Porter

More from that children鈥檚 orthopaedic surgeon later.

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But first controversial changes to the way the NHS funds some cancer treatments - changes that could mean an increasing number of patients will be denied access to the latest therapies.

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Five years ago media coverage about cancer invariably centred on reports that many people were missing out on expensive new drugs that could extend their lives - albeit often by not very much.

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The Cancer Drugs Fund was introduced in 2011 in England to address those concerns. It enables doctors to apply for special funding to offer individual patients new drugs that haven鈥檛 been approved by NICE and would not normally be available on the NHS.听 But the CDF has been a victim of its own success and demand has blown the budget with an overspend of nearly 拢140 million this year alone. As a result the number of drugs the CDF will pay for has been cut, and the whole scheme is being phased out in March next year and it is still unclear what will replace it.

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Vicky Rockingham was diagnosed with a rare form of cancer in her stomach - a gastrointestinal stromal tumour or GIST - in 2007. At the time of diagnosis there wasn鈥檛 much that could be done and the cancer spread. She has since tried various drugs but they only slowed the inevitable. 听But earlier this year her specialist applied to the CDF to pay for her to have a new treatment regorafenib, which costs around four and a half thousand pounds a month.

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Rockingham

This is the first drug I鈥檝e taken that鈥檚 actually done something to my tumours and it鈥檚 made them less dense and so it appears to be killing the cancer cells.听 So for me this was like an amazing thing.听 It鈥檚 a drug that I take orally, it still allows me to function 鈥� I鈥檓 a mother of two young boys, a wife and I also work full-time for the Environment Agency who I must admit are a very supportive organisation.听 I still exercise regularly as well and do five k runs at least twice a week, so it鈥檚 not changing my life dramatically by taking this drug but what is dramatic is it鈥檚 actually effectively giving me time.听 It鈥檚 not going to cure my cancer but it seems to be affecting it enough that it will give me a lot more time in my life.

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Porter

As someone who was already on the drug you鈥檙e supposedly guaranteed to keep getting it but how is the uncertainty over the future of the CDF affected you, I mean at one stage your drug was delisted wasn鈥檛 it?

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Rockingham

That鈥檚 right.听 It鈥檚 had a really big impact because as a group of patients we have a very rare cancer, so there鈥檚 not a lot of support for us apart from organisations such as GIST Support UK, which has been set up by patients.听 So we had to mount our own E-petition to try and get this drug put back on to the Cancer Drug Fund.听 So it was a very worrying time for us and when you鈥檙e living with a cancer that you know will 鈥� there isn鈥檛 any current cure that puts a lot of strain on families and people around you to then have to put lots of energy and effort into launching these campaigns at the same time.

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Porter

One of the issues with this debate Vicky is that the general perception is that the CDF is about drugs that are very expensive and that they don鈥檛 add much 鈥� maybe three or four months of life 鈥� to some people but what you鈥檙e saying in your case is this drug really has potentially transformed your life, I mean you鈥檙e still carrying on a perfectly normal life 鈥� you鈥檙e working?

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Rockingham

Absolutely.听 I recognise these drugs are expensive but in most cases, such as myself, I鈥檓 not on full dose, I鈥檓 on a three quarter dose, so the actual cost will be slightly less.听 I鈥檓 able to still work and contribute tax, I鈥檓 able to support my family with my husband and offer my children a lot of opportunities.听 It鈥檚 expected that this drug 鈥� it鈥檚 not been around for long, only since about 2013 鈥� it may give me a good few couple of years or work for a good few couple of years, it doesn鈥檛 mean at the end of those couple of years I will then die, it鈥檚 just that I will then be around for a couple more years while hopefully they will have found another drug that is just as effective or even perhaps a cure.听 If I鈥檇 been diagnosed in the year 2000 my consultant would have offered me a cup of tea and palliative care.听 The advances in technology in medicine since 2000 has been incredible and this drug is actually effectively killing my cancer cells.听 So who knows what鈥檚 round the corner in terms of trials etc. in the next few years whilst I鈥檓 on this drug.

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Porter

Vicky Rockingham talking to me from Salford.

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Jonathan Pearce is Chair of Cancer 52 - an alliance of organisations that represents people like Vicky with rarer cancers.听

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Pearce

It鈥檚 complicated and it鈥檚 confusing, it causes a lot of anxiety because people are uncertain about what鈥檚 going to happen. 听You hear stories in the media that these drugs are automatically going to be axed when the reality is there鈥檚 still a process of negotiation going on behind the scenes between the NHS and the pharmaceutical companies that produce the drugs.听 For people that are grappling with a cancer diagnosis, cancer treatment, that鈥檚 really difficult.

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Porter

We know that the Cancer Drug Fund鈥檚 going to come to an end at the end of March next year, there鈥檚 going to be something put in its place, I mean it鈥檚 likely that that鈥檚 going to have a lower budget, that鈥檚 one of the aims of ending the CDF isn鈥檛 it?

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Pearce

Yes and I think most people, certainly at Cancer 52, we do understand that you鈥檝e got to manage your budgets and you can鈥檛 have blank cheques for everything.听听 However, I suppose the way we see it is that there鈥檚 got to be a proper understand and listening to the patient perspective and getting priorities right because the Cancer Drugs Fund was set up originally, one of its objectives, was to help people with rare and less common cancers access new and innovative treatments.听 What鈥檚 happened in practice is that the majority of its treatments have gone to people with the more common forms of cancer and so they鈥檙e disadvantaged and people with rare and less common cancers are already disadvantaged in that you鈥檙e less likely to get a rare and less common cancer but if you do you鈥檙e more likely to die from it.听 So it鈥檚 vitally important that the CDF caters for that need.

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Porter

And so proportionately these new treatments are probably even more important for the sort of people that you represent?

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Pearce

They are and I don鈥檛 think there鈥檚 always an understanding that you鈥檝e got a whole bag of different forms and types of cancer in that sort of rare and less common cancer group that counts as nearly half of all cancers.听 And within that you鈥檝e got cancers where people are coming forward for treatments with curative intent 鈥� so they鈥檙e trying to get them cured 鈥� they may be at an end of life situation, they may also have chronic forms of cancer which aren鈥檛 going to be cured but people can live with for ages.听 So you鈥檝e got lots of different nuances around how you decide which treatments to give to which people.

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Porter

At the moment NICE uses a threshold which applies to basically everybody with cancer, it鈥檚 a one size fits all, and what you鈥檙e saying is that you should take into consideration the patient鈥檚 circumstances, their condition and their likely outcome.听 It might be a surprise to people that they don鈥檛 already do that.

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Pearce

No, no and there鈥檚 really only one set of assessments that鈥檚 used across all treatments, as you鈥檝e just highlighted, and particularly for treatments for cancers that are rare and less common there are scores where they can鈥檛 rate highly on them and there are things around the overall effectiveness and the progression through survival, so how these drugs impact on people.听 They can鈥檛 score at all on those measures because they don鈥檛 have the clinical data and they don鈥檛 have the clinical data because you鈥檙e talking about a small group of people, so you can only have a relatively small trial.听 And so there鈥檚 a distortion in favour, if you like 鈥� no one wants to deny anyone cancer treatments 鈥� but in favour of larger cancer groupings, common cancers, where you can get that critical mass of numbers to do the phase three clinical trials, even though there may be issues around some of that data as well but rare and less common cancers are disadvantaged from the very outset on many of these scoring systems.

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Porter

Jonathan Pearce, and listening to that in our Glasgow studio is Dr Margaret McCartney. Margaret, we have talked about the CDF in England, but this is a challenge across the whole UK isn鈥檛 it, so how鈥檚 it being managed elsewhere?

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McCartney

Well there are different arrangements in different parts of the UK.听 So in Scotland we have a patient access scheme who seek to make judgements about drugs that are not routinely available on the NHS.听 In Wales they decided not to create a Cancer Drugs Fund, even after a petition recently, and instead they have individual patient funding requests for drugs that are not routinely available.听 Northern Ireland, it鈥檚 a bit different, they have got an individual funding request system but they鈥檝e been consulting on whether or not to change this and there have been suggestions that this may be an appropriate time to reconsider the provision of free prescriptions in Northern Ireland so that there would be money from otherwise free prescriptions, so you would start charging for them instead, and use that cash to bolster a fund for access to cancer drugs not otherwise routinely available.

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Porter

This is such a difficult issue and I鈥檓 glad I鈥檓 not in a position where I have to make these sorts of decisions but if we spend a lot of money on new treatments that may or may not be very helpful for the patients that are receiving them that means we鈥檙e not spending the money elsewhere.

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McCartney

Yeah, that was the conclusion really from a report from the National Audit Office, who reported very recently on the 17th September, who looked into how good the Cancer Drugs Fund was and whether there should be something better instead.听 And they found that 51% of patients who got drugs from the Cancer Drugs Fund had got treatments NICE had previously appraised and found wanting and decided not to recommend, so there鈥檚 a really big issue.听 We鈥檝e got this system called NICE that鈥檚 meant to give us fair 鈥� transparent as it can be 鈥� evaluations of drugs and treatments and yet the Cancer Drugs Fund has been used to get around that and I think that has created a big problem in inequality.

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Porter

But we did hear 鈥� Jonathan made the point there that the NICE criteria and this quality of life and how much they鈥檙e prepared to pay for that is a sort of one size fits all and maybe we should have a parameter that can be adjusted to suit the individual case more?

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McCartney

So what you鈥檙e really looking for there is a bit of flexibility within the system, a system that鈥檚 flexible enough to say well actually in this case there are exceptional extenuating circumstances so we鈥檙e not going to apply the rules here.听 And that conflicts with the idea that you have this very fair system with rigid rules that everyone must follow, so everybody gets the same underneath it and there is an inherent conflict there, how to marry up a bit of flexibility that allows for a bit of manoeuvrability when people don鈥檛 fit into the rules but also having rules that apply to everyone and therefore appear fair.

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Porter

Well consultation on what should replace the CDF is due to start imminently - a process, I suspect, will be watched avidly across the UK. Thank you very much Margaret. As usual there are some links to more background information on the Inside Health page of the Radio 4 website.

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This year鈥檚 flu jabs have arrived at surgeries across the country but if my experience has been anything to go by, reports that last year鈥檚 vaccine didn鈥檛 work that well have left some people wondering whether it鈥檚 worth having.

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Every year flu vaccine manufacturers work with the World Health Organisation and others to predict what strains of virus are likely to cause outbreaks, so production can start early enough to beat the virus to our shores. Their track record is pretty good but last year was an exception with the vaccine only offering 30% protection - down from its usual 70-80%.

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So, has that dented confidence in this year鈥檚 campaign? Professor Andrew Pollard is Chair of the Joint Committee on Vaccination and Immunisation and I put the question to him on a line from Geneva.

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Pollard

Yes I mean I think that鈥檚 inevitable that it鈥檚 very difficult for all of us to understand that there鈥檚 this gestimate that has to go on.听 I think the importance of being vaccinated 鈥� it can鈥檛 be underestimated because it鈥檚 such an important cause of serious illness every winter, so even if 鈥� if it doesn鈥檛 work very well it will save some people鈥檚 lives.

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Porter

Looking forward now as to what鈥檚 going to be happening this flu season.听 First of all are we expecting a bad one and secondly are we anticipating that this year鈥檚 vaccine will be as good as the best ones have been in the past?

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Pollard

I mean I don鈥檛 think we鈥檙e going to be let off lightly this winter with a mild flu season but I have every confidence that the vaccine will have some impact and I鈥檓 hopeful that the selection this year will mean that we鈥檒l do extremely well.听 But to be honest we have to wait to see which virus turns up when our flu season starts and that鈥檚 the only time that we鈥檒l really know how well this year鈥檚 vaccine matches.

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Porter

The latest edition to the groups offered the vaccine is young children, why is it so important that they鈥檙e vaccinated?

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Pollard

Well the vaccine for young children is not really the same as the vaccine that we鈥檙e giving in the adult and the at risk programme.听 The vaccine given to children in fact doesn鈥檛 even have a needle, it鈥檚 a vaccine that is squirted up the nose and it鈥檚 a slightly different vaccine in that it鈥檚 a weakened strain of the virus and it鈥檚 alive, so it actually in very young children, as of primary school age and pre-school, makes fantastic immune responses and gives them huge protection which keeps them in school and keeps those who are in risk groups healthy.听 The added benefit of having a comprehensive childhood flu programme is that we know that children are very important in the spread of flu in the population and if you vaccinate school age children not only do you protect them from getting ill but you actually protect everyone else in the population, to the extent that that programme could prevent many of the cases that we see in adults and will potentially over the next few years have a huge impact on the winter pressures that the NHS faces.听 So that programme has started rolling out pre-school children were included over the last few years and we鈥檙e now moving in England for the first two years for primary school with the hope that within a few years from now all children will be vaccinated in primary school and that鈥檚 when I think we鈥檒l start to see a very big impact.听 Now there鈥檚 some very exciting data just released from last winter already shows that in some of the areas of the country where we鈥檝e been piloting a slightly wider flu programme for children we鈥檙e already seeing the suggestion of a big impact on the whole community.

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Porter

Professor Andrew Pollard talking to me from Geneva. And there is a link to the current recommendations on who should have a flu jab this year on our website.

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Now, if you are parent or grandparent, you will be all too aware of the different ways that young children develop, but that won鈥檛 stop you comparing your toddler with their friends - particularly when it comes to how they walk. Concerns about knock-knees and bandy legs are common in consulting rooms like mine and a significant proportion end up in specialist clinics for a definitive answer as to whether there is anything to worry about.听 Clinics like this one at the Royal London Hospital where a four year boy is seeing consultant children鈥檚 orthopaedic surgeon Manoj Ramachandran.

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Actuality

Ramachandran

So he wakes up at night crying?

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Mother

Wakes up at night.

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Ramachandran

And he鈥檚 always pointing to one鈥�

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Mother

Just only one knee鈥� he鈥檚 telling me it鈥檚 there.

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Ramachandran

And how often does it happen 鈥� every night?

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Mother

Not every night, it used to be like every three weeks, then it鈥檚 two weeks and then it鈥檚 every week鈥�

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Ramachandran

So when鈥檚 the last time it happened?

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Mother

Happened two days ago.

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Ramanchandran

Okay.听 And then you didn鈥檛 notice anything wrong with the shape of his legs but your GP noticed鈥�

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Mother

The GP noticed it yes.

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Ramanchandran

That one of his legs was turned inwards.

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Mother

Yes he did鈥�

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Ramanchandran

The right one.

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Mother

鈥�he checked it.听 Yes.

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Ramanchandran

Okay, can I have a look at him?听 Darling can you go for a walk for me, can you go and touch the wall there and come back, that鈥檚 it, that鈥檚 it.听 So both knees turn in slightly when he walks, I don鈥檛 know if you can see that.听 Do it one more time, have a look 鈥� if you look at his kneecap when he walks back towards us鈥� just come back now, yes good touching, his kneecap鈥檚 just turning slightly 鈥� just turning a little bit.

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Mother

Probably you can notice鈥�

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Ramanchandran

And then can you just sit him on your lap, that鈥檚 fine, I鈥檒l just examine him here, that鈥檚 fine.听 So first of all he鈥檚 got good turning in of his legs, good turning out, very flexible, in fact you鈥檙e quite flexible aren鈥檛 you, look at that.听 Are you very flexible?听 I鈥檓 not, I can鈥檛 do very much.

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Mother

I鈥檓 not, sorry I can鈥檛 do that.

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Ramanchandran

Well he can.

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Mother

Oh dear how did that happen?

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Ramanchandran

How did that happen?听 That鈥檚 how he鈥檚 born, so that鈥檚 normal for him.听 And his hips 鈥� move normally.听 So he actually can turn in a long way 鈥� in and out 鈥� so he tends to walk slightly turned in because that鈥檚 what most children do at this age, they tend to walk slightly in 鈥� and actually his knee shape altogether is completely fine.听 You can put his clothes back on.听 I鈥檝e had a look at his x-rays, his x-rays are completely normal.听 So this is a very common thing we see 鈥� sometimes it鈥檚 linked to having slightly low levels of Vitamin D but you鈥檝e had your supplements for that.听 But it鈥檚 mostly linked to growing pains and growing pains are slightly more common in children who are loose jointed, he鈥檚 quite loose jointed, he can get his鈥� yeah, it鈥檚 often not a daytime thing, they鈥檙e completely active during the day, they鈥檙e running around no problems at all, but it鈥檚 something that happens at night.听 It鈥檚 nothing to be concerned about and they鈥檙e usually related to periods of growth, so whenever he鈥檚 growing a little bit around his knee it will hurt more.听 Okay, so from our side of things we don鈥檛 need to do anything, we鈥檙e not worried about him, we鈥檙e discharging 鈥� you can take this to the front desk.

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Mother

Okay that鈥檚 good, I鈥檓 happy now, I鈥檓 happy to hear that he鈥檚 okay.

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Porter

And the outcome in that boy鈥檚 case - that both Mum and GP were worrying unnecessarily - is not that unusual.

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Ramachandran

In my clinics up to a quarter of the patients that we get sent tend to have essentially normal variances, nothing wrong, it鈥檚 often parents, extended family and sometimes the GP that鈥檚 stressed or worried about these conditions being something more pathological or abnormal but in fact they鈥檙e just normal developmental variance.

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Porter

Let鈥檚 talk about what鈥檚 normal then.听 What happens to children鈥檚 legs as they develop?

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Ramachandran

There鈥檚 two aspects.听 One is when you鈥檙e looking at them from the front and you鈥檙e looking at how their legs line up.听 So you can either be knock-kneed or bow legged.听 Now pretty much all children are born slightly bow legged and the worst of the sort of bow leg appearance is around the age of 18 months and you start walking, on average, somewhere between 12 and 18 months.听 Most children are naturally bow legged.听 So we tend to get a lot of referrals around that age, when they first start walking, because people are worried that this an abnormal when it isn鈥檛.听 Then the next thing that happens is by the age of three to five years old the knee undergoes a sort of normal change in morphology and becomes knock kneed, so then we get a spate of referrals that are more to do with knock knees.

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Porter

And this is in the pre-school child?

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Ramachandran

This is in the pre-school child.听 And by the age of seven you sort of reach your adult alignment which is slightly knock-kneed in most people but there鈥檚 a bit of variation and often bow legs can run in some families and knock knees can run in other families but overall you see bow legs and knock knees and then straight legs.听 So we get referrals at the times you鈥檇 expect.听 But if it鈥檚 your child and you鈥檙e watching your child walk and comparing that to other children around them at school you鈥檙e right to be concerned.

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Porter

Let鈥檚 talk about the way that they walk because I mean you鈥檝e talked about the way their knees look, the other thing that we get a lot of is people concerned about the position of the feet as they鈥檙e walking and pigeon toed probably is the most common that I would see in general practice, people come in, what鈥檚 happening there?

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Ramachandran

When people come to see me in clinic I show them that I actually have out toes, so my feet face outwards and I walk on my 鈥� dad鈥檚 foot faced outwards, my granddad鈥檚 foot faced outwards 鈥� so it鈥檚 something like a third of the population in the world tend to walk with their feet turned inwards, a third tend to walk with their feet turned outwards and a third walk feet pointing straight forward.听 Add to that that some children are more loose jointed, so they can get their feet into all sorts of extreme positions and they tend to become comfortable either in-toed or out-toed, these are all normal variants.听 And most of these just get better year on year, some of it is occasionally from the hips, some of it鈥檚 from the knees but that鈥檚 how your hip joint鈥檚 developing or knee joint鈥檚 developing and they will improve with time.

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Porter

So the difficult thing 鈥� I mean you鈥檙e an expert in this field 鈥� but the difficult thing for parents and for GPs like me is that we鈥檝e got to look at what could be a normal variant or could not be, what are the suspicious signs 鈥� going back to the knees, when would you start to worry that something wasn鈥檛 right?

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Ramachandran

So I like to talk about the Ss, so if someone鈥檚 symptomatic, so they鈥檝e got pain or stiffness 鈥� it鈥檚 another S 鈥� in and around any particular joint, particularly the knee or the hip, then we鈥檇 like to see them because there maybe something underlying that.听 If they鈥檙e asymmetrical 鈥� another S 鈥� so one side is more in-toed or out-toed than the other then we鈥檙e a bit more worried.听 If they鈥檙e shorter than you鈥檇 expect them to be for their age then they may have something underlying.听 I鈥檓 talking about extremes of height rather than just slightly shorter than their peer group.听 If they鈥檝e got any other sort of underlying condition such as syndromes or systemic problems such as hormonal problems, like thyroid issues, that can be an underlying cause.听 But most often it鈥檚 parents who are stressed 鈥� and that鈥檚 my final S 鈥� which is they鈥檙e worried about it and that鈥檚 transferred to the GP unfortunately and that鈥檚 difficult because we know that most of them will be okay but we end up seeing them.

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Porter

There鈥檚 been a lot of concern about the changing shape of our children 鈥� I鈥檓 talking about the obesity epidemic as it鈥檚 referred to 鈥� has that had an impact in clinics like yours, is that bad for people鈥檚 bones or gait?

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Ramachandran

Yeah I mean that鈥檚 been shown in our current literature too.听 So something like 10% of boys and girls at reception level at school are considered clinical obese, this was from back in the 1990s, a sort of national obesity survey鈥�

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Porter

Probably worse now.

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Ramachandran

Probably worse, exactly and it鈥檚 20% when you get to primary school leaving age, so year six.听 We know that if you carry more weight you tend to put more weight on your feet, so you tend to be more flat footed when you walk.听 You can walk with more of a knock-kneed or bow legged effect and you can get more pain in your joints, particularly the hip and the knee.听 At extreme levels, when you鈥檙e morbidly obese for example, so you鈥檙e carrying a lot of weight, you can put so much weight on your joints, particularly the hip and the knee, that you can end up with certain much rarer conditions that we don鈥檛 tend to see very often but we are seeing more and more of these conditions such as a slipped hip or a slipped epiphysis, where the ball of the ball and socket joint of the hip tends to fall out of the hip or something called Blount鈥檚 Disease where you have very severe bow-leggedness mainly because there鈥檚 so much pressure on the growth area of the knee.听 So those are extreme conditions but we鈥檙e seeing an increase in incidents globally and we think that鈥檚 related to obesity.

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Porter

But for the 鈥渘ormal鈥� (in inverted commas) overweight child just being the fact that they鈥檙e overweight may accentuate the traits at that particular age 鈥� so if they鈥檙e an overweight toddler they might be a little bit more bow-legged, if they鈥檙e an overweight pre-schooler they might be a little bit more knock-kneed.

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Ramachandran

And have more pain, so they鈥檙e more symptomatic as a result and that means that even their day-to-day activities, they鈥檙e taking part in sports they find it more difficult, they find it more difficult to even go to sleep at night sometimes because they have more night pains.听 There are all sorts of effects of carrying more weight around with you.

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Porter

Orthopaedic surgeon Manoj Ramachandran with some reassuring guidance for parents 鈥�. and their doctors.

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Now to the next instalment of our special series - Inside Language - where听 Dr Margaret McCartney and Carl Heneghan, Professor of Evidence Based Medicine at the University of Oxford, demystify the terms used by researchers and the journals that publish them. This week, what does peer review mean?

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Heneghan

Peer review is the process by which academic journals select publications that they want to put in their journals.听 And I鈥檒l just take you through the process of say the last journal publication that we sent a piece of research to a journal.听 You send the article in in an electronic system and then an editor looks at that and makes an initial internal review decision of should we send this out for peer review or not.听 If he decides yes, they sometimes say no because they say it鈥檚 not of interest or the question鈥檚 not important, but they then send it out to peer review.听 It goes out to a number of reviewers in the academic arena who are potentially experts in that area who will then look at that article and comment and critique that article and then send their comments and critiques back to you as the author.听 You then get an opportunity to respond to them, improve the article in some way and then they go back to the journal, look at all of that response, your response, and then make a decision to publish or not.听 And it really is a way of trying to say that actually we鈥檝e improved this article, it鈥檚 worthy of publication, and we鈥檝e ironed out the problems.听 However, there are substantial issues with peer review that do occur.

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Porter

Well let鈥檚 come back to those issues in a moment.听 First of all Margaret when you鈥檙e looking at something why is it important that it鈥檚 been peer reviewed from your perspective as a reader?

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McCartney

It鈥檚 very often used as a quality marker.听 So one of the things that we all look for in a journal article before we even begin is say is this published in a peer review journal or has this just been chucked on to someone鈥檚 website and there鈥檚 been no quality control whatsoever.听 But as Carl says there are big problems with peer review.

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Porter

So the advantage is that you would expect better quality, what can go wrong?

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Heneghan

The problem is people say well it鈥檚 been peer reviewed, that means this is a robust valid piece of research, which is actually nonsense.听 And we鈥檝e worked with a lady called Sara Schroter at the BMJ who did a study about 10 years ago that sent out an article with 14 deliberate flaws in it to about 600 reviewers, who were regular reviewers at the BMJ, and asked the reviewers to pick out the flaws and basically the reviewers were miserable, on average they could pick out three of about nine major flaws.听 And so that shows that peer review is actually a pretty flawed process.

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Porter

Well the quality of the process has got to be dependent on the quality of the peers hasn鈥檛 it?

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McCartney

You鈥檙e really asking an unpaid army who are kind of themselves unchecked, it鈥檚 a bit random about who gets selected for peer review, in fact sometimes authors are asked who they would like to peer review their work, have to suggest peer reviewers, so the whole system just seems 鈥� once you start to pick it apart 鈥� a bit more dodgy than one might expect.

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Heneghan

There鈥檚 actually even a website where you can go to, it鈥檚 called Retraction Watch, Retraction Watch has picked up people who have been putting spoof names in which are themselves to peer review their own articles.听 So that鈥檚 one major gaff you can see.听 But I think the issue is I get to peer review articles, I only have a very small amount of time and actually in that small amount of time I鈥檓 supposed to be able to look at an article that could be somebody鈥檚 two years鈥� work and try and complete a whole scientific critique.听 It鈥檚 practically impossible.听 So what we say to people is okay it鈥檚 in a journal, it鈥檚 gone through some preliminary process, but you should still have your own skills to assess is this robust, is this an important valid piece of information.

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Porter

And that鈥檚 the take home message then Margaret, that peer review is good but it鈥檚 not infallible, don鈥檛 take it as a guarantee of quality.

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McCartney

Absolutely and certainly when something鈥檚 not been peer reviewed I suppose you鈥檙e going to be a bit more concerned about it.听 But the bottom line is this is why I go and look at big powerful reviews where someone else has already done the peer - post-publication peer review for me, someone else has already looked at the data like Cochrane reviews or systematic reviews, where people went through the data, that went and said look what are the flaws in the study, can we trust this study or not, just because something has been printed in a medical journal does not mean that it鈥檚 any good.

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Porter

Carl Heneghan and Margaret McCartney who will be back for more next week, when we will also be investigating the link between some types of commonly prescribed medicines and falls - and discovering how repeated falls are a red flag for underlying health issues, and one that shouldn鈥檛 be ignored.

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Join me then to find out why?

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ENDS