An article in the Student Edition of the BMJ has prompted this article in today's Independent
Female doctors who have laid siege to the male bastion of the medical profession are poised to overtake their male counterparts in what a medical journal describes as a "giant leap for womankind". Women have outnumbered men in medical schools for a decade and are set to become a majority of the medical workforce by 2017. They already dominate in people-friendly areas such as general practice, paediatrics and palliative care, while still struggling in the chauvinistic disciplines of cardiology and surgery.
But the progressive feminisation of medicine carries dangers, experts warn. There is a still a gender pay gap and a reluctance by women to put in the time and effort needed to attain the most senior posts and maintain medicine's influence in the corridors of power. Maham Khan, from Imperial College, London, writing in the student edition of British Medical Journal, says more women doctors could lead to safer practice. Women are less likely to be hauled before the General Medical Council on disciplinary charges or investigated for failures in performance. Over eight years 490 male doctors were banned from seeing patients following performance reviews by the National Clinical Assessment Service, compared with 79 women.
Problems remain, however. Women are under-represented at the top of the profession, according to Professor Jane Dacre, medical school director of University College London, because they are "not investing in the time and effort it takes to get the top jobs". Parveen Kumar, president of the Royal Society of Medicine, told the BMJ: "Women don't like to be seen as putting themselves forward." In 2004, Dame Carol Black, then president of the Royal College of Physicians, triggered a debate about the influence of women in an interview with The Independent in which she warned that the growing numbers could reduce the influence of the medical profession at the highest level. This was not about women's capacity to perform, but about their willingness to devote the time and effort, beyond their medical responsibilities, to furthering the interests of the profession. Men were happy to give up their evenings, sit on committees and eat dinners for a chance to walk the corridors of power. It was not clear, Lady Black suggested, whether women would have the same appetite for networking.
A report by the Royal College of Physicians warned in 2009 that the gender balance of the profession was changing so fast it threatened the care of patients. Women were more likely to work part time and to break their careers to have families, and competition for less female-friendly disciplines such as surgery would be reduced.
Despite the challenges, medicine is ahead of other professions in terms of gender equality, Maham Khan writes. Women will take 55 years to reach equality with men amongst senior judges and 73 years amongst directors of FTSE 100 companies. "In terms of numbers, female doctors have made giant leaps," she says.
Men fare better than women in almost all areas of life – except when it comes to their health. They are twice as likely as women to die before 65. Now a doctors' study is calling for policies to tackle problems caused by men's macho attitude to health – rejecting advice and not seeing GPs soon enough. Alan White, professor of men's health at Leeds Metropolitan University – who led the study published in the British Medical Journal – said intervention should start in schools to give boys "skills to make healthier decisions throughout their lives". Bosses should collaborate with unions to promote men's health in the workplace, while pubs, clubs and sports centres should also be targeted, the study urges.
I got into trouble for predicting this in 1984. Here is my comment today:
More female doctors means more part-time posts, more juggling between home and work commitments, more hand-overs that are not completed, more overlapping double shifts that are paid for twice, less continuity, more patients falling through the cracks, less working late to paper over the cracks.
Worst off will be those unmarried female doctors, especially those without children who will be expected to work extra long hours (unpaid) to compensate for their sisters who 'must get off to see to the kids'.
Take a look at what is actually happening on the ground rather than in some idealized image of how the 'equalities industry' would like it to be.
Showing posts with label healthcare. Show all posts
Showing posts with label healthcare. Show all posts
Wednesday, November 30, 2011
Monday, November 28, 2011
Danger at night and weekends
The annual hospital guide published by Dr Foster Intelligence using official figures shows that one in eight trusts has higher than expected death rates on Saturdays and Sundays, suggesting they are only working to a five-day week. Many hospitals have far fewer senior consultants on site outside of normal office hours, the data show, and rely on junior doctors and nurses to treat critically ill patients.
In a handful of trusts, the mortality rate rises by 20 per cent or more between weekdays and weekends. Low staffing levels in A&E have been identified as one of the long-standing problems at Stafford Hospital, where hundreds of patients died after receiving “appalling” care, and the unit will close overnight for three months starting this week.
Although I do not take much notice of Dr Foster reports, since they use crude data which is often modified when the CQC produces a more comprehensive view. (Stafford was only one of 6 Trusts identified by Dr Foster - the other 5 were exonerated). Nevertheless, out of hours care has been one of the problems identified by the NHS as one of its deficiencies. As a result there have been major changes to the provision of care. Vascular surgery has been confined to small groups of expert vascular surgeons, who are ready with their teams to appear where the problem is. No junior doctor ever gets to lead on emergency vascular surgery. It is true of almost all elective surgery, which is now conducted between 9 and 5.
When I was young it was quite commonplace for major colorectal surgery to take place in the evening for an elective list arranged by the Senior Registrar from 7pm to 11pm. But we had different types of junior doctors then.
When I was a resident in Bristol there were 6 Senior Registrars in Surgery, aged between 38 and 44. These were very senior and experienced doctors who were just waiting consultant jobs. One of those was John Trapnell, whose obituary I posted recently. Among the others I remember were Colin Davidson, Roger Celestin and Harry Espiner. All have long since retired with great success in their careers. Today, Senior Registrars have all gone and instead we have registrars. These young men have many fewer hours of experience and their training is arranged so that they will get fewer yet. At the age of 35 they expect to get consultant jobs, but although they may get expert in microspecialties (just doing breasts or stomachs or pancreases) they will never become the General Surgeons that their predecessors were.
Physicians were always younger than surgeons when they became consultants, and I was particularly young at the age of 30, but 33-35 would be average. I was always on an on-call rota of at least 1 in 3 throughout my whole career, but we trained a mixed junior doctor/ senior nurse cadre who were competent to deal with the medical emergencies that we would have to deal with urgently (mainly neutropenic sepsis) and more complicated problems (mainly transfusion and coagulation difficulties) could be dealt with from the confines of a warm bed.
General Physicians have largely disappeared from the NHS. Elective work is done in daytime by Gastroenterologists, Chest Physicians, Neurologists, Endocinologists, Cardiologists, Rheumatologists, and Rehabilitation Specialists. We and others have set up Acute Medical Units, attached to Accident and Emergency Units where an on-call Senior Doctor is responsible for the first 24-48 hours of an admission only, although referral to an intensive cardiac unit or stroke unit may be required earlier. Expert endoscopy, CT scanning, MRI and ultrasonography is also available within the first 24 hours.
Changes in junior doctor training have forced more senior involvement at nights and at weekends and have in the best hospitals rethinking on how things should be done. There is one major deficiency that I have identified, though. The European Union forced through its European Working Time Directive, with the consent of the last Labour Government and against protests of the British Medical Establishment. This meant that not only were junior doctors not allowed to work for more than 48 hours a week, but included in that time would be on-call time, when the doctors would be sleeping, not working. This has meant a total revision of doctors' rotas that has neither helped the service they provide nor their training. Now even the Germans think it was a mistake and have conceded that this may be one of the things that the UK can have back to its own control if there have to be renegotiation of the EU charter because of fiscal rearrangements.
In a handful of trusts, the mortality rate rises by 20 per cent or more between weekdays and weekends. Low staffing levels in A&E have been identified as one of the long-standing problems at Stafford Hospital, where hundreds of patients died after receiving “appalling” care, and the unit will close overnight for three months starting this week.
Although I do not take much notice of Dr Foster reports, since they use crude data which is often modified when the CQC produces a more comprehensive view. (Stafford was only one of 6 Trusts identified by Dr Foster - the other 5 were exonerated). Nevertheless, out of hours care has been one of the problems identified by the NHS as one of its deficiencies. As a result there have been major changes to the provision of care. Vascular surgery has been confined to small groups of expert vascular surgeons, who are ready with their teams to appear where the problem is. No junior doctor ever gets to lead on emergency vascular surgery. It is true of almost all elective surgery, which is now conducted between 9 and 5.
When I was young it was quite commonplace for major colorectal surgery to take place in the evening for an elective list arranged by the Senior Registrar from 7pm to 11pm. But we had different types of junior doctors then.
When I was a resident in Bristol there were 6 Senior Registrars in Surgery, aged between 38 and 44. These were very senior and experienced doctors who were just waiting consultant jobs. One of those was John Trapnell, whose obituary I posted recently. Among the others I remember were Colin Davidson, Roger Celestin and Harry Espiner. All have long since retired with great success in their careers. Today, Senior Registrars have all gone and instead we have registrars. These young men have many fewer hours of experience and their training is arranged so that they will get fewer yet. At the age of 35 they expect to get consultant jobs, but although they may get expert in microspecialties (just doing breasts or stomachs or pancreases) they will never become the General Surgeons that their predecessors were.
Physicians were always younger than surgeons when they became consultants, and I was particularly young at the age of 30, but 33-35 would be average. I was always on an on-call rota of at least 1 in 3 throughout my whole career, but we trained a mixed junior doctor/ senior nurse cadre who were competent to deal with the medical emergencies that we would have to deal with urgently (mainly neutropenic sepsis) and more complicated problems (mainly transfusion and coagulation difficulties) could be dealt with from the confines of a warm bed.
General Physicians have largely disappeared from the NHS. Elective work is done in daytime by Gastroenterologists, Chest Physicians, Neurologists, Endocinologists, Cardiologists, Rheumatologists, and Rehabilitation Specialists. We and others have set up Acute Medical Units, attached to Accident and Emergency Units where an on-call Senior Doctor is responsible for the first 24-48 hours of an admission only, although referral to an intensive cardiac unit or stroke unit may be required earlier. Expert endoscopy, CT scanning, MRI and ultrasonography is also available within the first 24 hours.
Changes in junior doctor training have forced more senior involvement at nights and at weekends and have in the best hospitals rethinking on how things should be done. There is one major deficiency that I have identified, though. The European Union forced through its European Working Time Directive, with the consent of the last Labour Government and against protests of the British Medical Establishment. This meant that not only were junior doctors not allowed to work for more than 48 hours a week, but included in that time would be on-call time, when the doctors would be sleeping, not working. This has meant a total revision of doctors' rotas that has neither helped the service they provide nor their training. Now even the Germans think it was a mistake and have conceded that this may be one of the things that the UK can have back to its own control if there have to be renegotiation of the EU charter because of fiscal rearrangements.
Friday, October 28, 2011
Point of contact testing
In today's Lancet there is an article on point of Care (POC) testing in the context of HIV in Africa.
New durable, simple, and affordable cytometric CD4 testing devices aim to decrease the time to beginning antiretroviral therapy and loss to follow-up. Rapid testing with microfluidics meets the criteria for true POC testing, providing immediate results without needing laboratory personnel or infrastructure. These tests will conserve diagnostic resources and provide convenience and savings for patients. Whether the availability of such technology will help to overcome the many obstacles to successful delivery and scale-up of antiretroviral therapy in resource-limited settings is still to be shown.
CD4 staging establishes eligibility for antiretroviral therapy after HIV diagnosis. To obtain a CD4 cell count in resource-limited settings presents many challenges, and the scale of these challenges is often underestimated. The required two minimum clinic visits often span a month or longer, and associated transport costs can deter access to care. Pre-analysis infrastructure includes blood collection apparatus, a trained phlebotomist, and quick, reliable, and accountable transport and tracking of samples. Laboratories need functioning and calibrated instruments, trained and disciplined personnel, and quality assurance programmes. Finally, the return of CD4 results to a distant clinic is fraught with the difficulties of handwritten medical records and unique identifiers. POC testing offers a solution to many of these difficulties by dispensing with these multiple steps without compromising the accuracy of the result. But many of these difficulties are specific to rural Africa and cannot be extrapolated to downtown New York of even Cape Town.
The clinical settings in which POC CD4 testing might be most effective in treatment and retention have not been identified. Based on an observational study carried out in primary health clinics in Mozambique, Jani and colleagues report varied effects of POC CD4 testing on loss to follow-up at different points between enrolment and initiation of antiretroviral treatment. Decreased loss to follow-up was reported between enrolment and CD4 staging but not between CD4 staging and initiation of antiretroviral therapy in treatment-eligible patients. Time from enrolment to CD4 testing also decreased with POC testing, but this finding did not result in a difference in time to initiation of antiretroviral therapy after treatment eligibility was established. The largest loss, noted in many studies from Africa, occurs between rapid POC diagnosis of HIV infection and referral to a programme including CD4 testing. Efficiency could be improved through linkage of POC CD4 counts with HIV testing so that people who are HIV positive immediately receive CD4 testing, and targeted post-test counselling about risk of disease progression, transmission, and treatment eligibility. This approach might be particularly germane to programmes for the prevention of mother-to-child transmission of HIV, in which the time to initiation of antiretroviral therapy needs to be short for maximum benefit. In resource-limited settings, where late attendance to antenatal clinics is common, the need for urgent initiation of antiretroviral therapy in treatment-eligible pregnant women is even greater.
POC CD4 testing may not be ideal for every situation. In cities in Africa with well developed transportation and laboratory infrastructure, centralised, high-throughput flow-cytometry might be most efficient. At 20 min per sample, POC CD4 testing could rapidly overwhelm a busy clinic's capacity for patient throughput and service delivery. Conversely, POC capacity in rural clinics and mobile diagnostic services depends on sufficient demand to justify the expense of services in dispersed communities. The cost-effectiveness of placement of these units in voluntary counselling and testing for adults and antenatal clinics for prevention of mother-to-child transmission has not yet been tested, although the urgency of rapid initiation of antiretroviral treatment in eligible pregnant women is clearly of high importance for maternal health and transmission prevention. Feasibility and sustainability depend on the long-term durability of instruments; ease of maintenance, repairs, and replacements; availability of an adequate supply chain; and reasonable costs.
POC testing is a promising advance in efficient service delivery and monitoring in resource-limited settings. However, persistent, albeit lower, loss to follow-up occurs despite the introduction of this technology, which emphasises the complexity of health-seeking behaviour especially for HIV and acceptance of lifelong antiretroviral therapy. Successful HIV programmes should efficiently identify people with HIV by rapid testing, engage HIV-positive patients in care with rapid provision of CD4 staging, provide appropriate counselling, and assess readiness, then initiate antiretroviral therapy and retain individuals in care and treatment with appropriate monitoring. Although technology such as POC CD4 testing might improve service efficiency, such advances must be accompanied by increased knowledge about the barriers to retention, and implementation of solutions to prevent loss to follow-up, and to realise the full potential of HIV treatment, care, and prevention.
The AIDS epidemic has been the beneficiary of vast amounts of cash, no doubt driven by the homosexual lobby. Undoubtedly, the sciences of virology, immunology, gene therapy and molecular medicine have benefited from the attention paid to HIV. Point of Care testing has been an important issue in hematology. Anticoagulant control, diabetic control, pre-chemotherapy blood tests and even chemotherapy trough levels have been areas where POC testing might be thought to be beneficial. The drawback have always been expense and reliability. Reliable POC machines are very expensive and each individual measurement is slow. No doubt patients like them for their convenience, but money spent on them is money not spent elsewhere.
New durable, simple, and affordable cytometric CD4 testing devices aim to decrease the time to beginning antiretroviral therapy and loss to follow-up. Rapid testing with microfluidics meets the criteria for true POC testing, providing immediate results without needing laboratory personnel or infrastructure. These tests will conserve diagnostic resources and provide convenience and savings for patients. Whether the availability of such technology will help to overcome the many obstacles to successful delivery and scale-up of antiretroviral therapy in resource-limited settings is still to be shown.
CD4 staging establishes eligibility for antiretroviral therapy after HIV diagnosis. To obtain a CD4 cell count in resource-limited settings presents many challenges, and the scale of these challenges is often underestimated. The required two minimum clinic visits often span a month or longer, and associated transport costs can deter access to care. Pre-analysis infrastructure includes blood collection apparatus, a trained phlebotomist, and quick, reliable, and accountable transport and tracking of samples. Laboratories need functioning and calibrated instruments, trained and disciplined personnel, and quality assurance programmes. Finally, the return of CD4 results to a distant clinic is fraught with the difficulties of handwritten medical records and unique identifiers. POC testing offers a solution to many of these difficulties by dispensing with these multiple steps without compromising the accuracy of the result. But many of these difficulties are specific to rural Africa and cannot be extrapolated to downtown New York of even Cape Town.
The clinical settings in which POC CD4 testing might be most effective in treatment and retention have not been identified. Based on an observational study carried out in primary health clinics in Mozambique, Jani and colleagues report varied effects of POC CD4 testing on loss to follow-up at different points between enrolment and initiation of antiretroviral treatment. Decreased loss to follow-up was reported between enrolment and CD4 staging but not between CD4 staging and initiation of antiretroviral therapy in treatment-eligible patients. Time from enrolment to CD4 testing also decreased with POC testing, but this finding did not result in a difference in time to initiation of antiretroviral therapy after treatment eligibility was established. The largest loss, noted in many studies from Africa, occurs between rapid POC diagnosis of HIV infection and referral to a programme including CD4 testing. Efficiency could be improved through linkage of POC CD4 counts with HIV testing so that people who are HIV positive immediately receive CD4 testing, and targeted post-test counselling about risk of disease progression, transmission, and treatment eligibility. This approach might be particularly germane to programmes for the prevention of mother-to-child transmission of HIV, in which the time to initiation of antiretroviral therapy needs to be short for maximum benefit. In resource-limited settings, where late attendance to antenatal clinics is common, the need for urgent initiation of antiretroviral therapy in treatment-eligible pregnant women is even greater.
POC CD4 testing may not be ideal for every situation. In cities in Africa with well developed transportation and laboratory infrastructure, centralised, high-throughput flow-cytometry might be most efficient. At 20 min per sample, POC CD4 testing could rapidly overwhelm a busy clinic's capacity for patient throughput and service delivery. Conversely, POC capacity in rural clinics and mobile diagnostic services depends on sufficient demand to justify the expense of services in dispersed communities. The cost-effectiveness of placement of these units in voluntary counselling and testing for adults and antenatal clinics for prevention of mother-to-child transmission has not yet been tested, although the urgency of rapid initiation of antiretroviral treatment in eligible pregnant women is clearly of high importance for maternal health and transmission prevention. Feasibility and sustainability depend on the long-term durability of instruments; ease of maintenance, repairs, and replacements; availability of an adequate supply chain; and reasonable costs.
POC testing is a promising advance in efficient service delivery and monitoring in resource-limited settings. However, persistent, albeit lower, loss to follow-up occurs despite the introduction of this technology, which emphasises the complexity of health-seeking behaviour especially for HIV and acceptance of lifelong antiretroviral therapy. Successful HIV programmes should efficiently identify people with HIV by rapid testing, engage HIV-positive patients in care with rapid provision of CD4 staging, provide appropriate counselling, and assess readiness, then initiate antiretroviral therapy and retain individuals in care and treatment with appropriate monitoring. Although technology such as POC CD4 testing might improve service efficiency, such advances must be accompanied by increased knowledge about the barriers to retention, and implementation of solutions to prevent loss to follow-up, and to realise the full potential of HIV treatment, care, and prevention.
The AIDS epidemic has been the beneficiary of vast amounts of cash, no doubt driven by the homosexual lobby. Undoubtedly, the sciences of virology, immunology, gene therapy and molecular medicine have benefited from the attention paid to HIV. Point of Care testing has been an important issue in hematology. Anticoagulant control, diabetic control, pre-chemotherapy blood tests and even chemotherapy trough levels have been areas where POC testing might be thought to be beneficial. The drawback have always been expense and reliability. Reliable POC machines are very expensive and each individual measurement is slow. No doubt patients like them for their convenience, but money spent on them is money not spent elsewhere.
Monday, October 24, 2011
Screening for cancer
To most people it seems sensible that if we can screen for occult disease then we ought to. Strangely, the figures don't add up that way. If it were the case that every occult case of disease would eventually turn up and need to be treated, and if it were the case that there were no false positives picked up by the screening test and if it were the case that none of those false positives came to any harm for being detected, then, no matter the cost, it would be worthwhile to screen for occult disease.
The two areas where the value of screening tests is disputed are breast cancer and prostate cancer.
The problem with mammography for breast cancer is first that the premeonpausal breast is too dense to see cancer in and second that nobody advocates screening for the over-70s when breast cancer is at its most prevalent. Third, many of the precancerous lesions found will never require any treatment during the lady's lifespan. Fourth, there are many false positives. Fifth, managing those false positives cause harm to the patient who at very least has a period of unjustified anxiety but may need a biopsy and in extreme cases a mastectomy.
Time and again the figures have shown that mammography for this population is not wise. It is true that life expectancy for breast cancer has increased since mammography was introduced, but this is also true for the under-50s and over-70s who were not screened. It is most likely due to the introduction of Nolvadex for treatment.
Now the US Preventative Services Task Force has ruled that the PSA blood test should not be used to screen for prostate cancer on the grounds that it does not save lives and can lead to harm. The review concludes, "The widespread US practice of annual PSA-based screening for prostate cancer in men aged 50 years and older is not supported by results from randomized controled trials. PSA-based screening may modestly reduce prostate cancer mortality; but this absolute benefit is small relative to other causes of death in this age group and is associated with substantial harm. The vast majority of men treated for PSA-detected prostate cancer will not have death from prostate cancer prevented but there is convincing evidence that treatment of prostate cancer detected through PSA screening causes at least moderate harm such as erectile dysfunction, urinary incontinence, bowel dysfunction and death.
The two areas where the value of screening tests is disputed are breast cancer and prostate cancer.
The problem with mammography for breast cancer is first that the premeonpausal breast is too dense to see cancer in and second that nobody advocates screening for the over-70s when breast cancer is at its most prevalent. Third, many of the precancerous lesions found will never require any treatment during the lady's lifespan. Fourth, there are many false positives. Fifth, managing those false positives cause harm to the patient who at very least has a period of unjustified anxiety but may need a biopsy and in extreme cases a mastectomy.
Time and again the figures have shown that mammography for this population is not wise. It is true that life expectancy for breast cancer has increased since mammography was introduced, but this is also true for the under-50s and over-70s who were not screened. It is most likely due to the introduction of Nolvadex for treatment.
Now the US Preventative Services Task Force has ruled that the PSA blood test should not be used to screen for prostate cancer on the grounds that it does not save lives and can lead to harm. The review concludes, "The widespread US practice of annual PSA-based screening for prostate cancer in men aged 50 years and older is not supported by results from randomized controled trials. PSA-based screening may modestly reduce prostate cancer mortality; but this absolute benefit is small relative to other causes of death in this age group and is associated with substantial harm. The vast majority of men treated for PSA-detected prostate cancer will not have death from prostate cancer prevented but there is convincing evidence that treatment of prostate cancer detected through PSA screening causes at least moderate harm such as erectile dysfunction, urinary incontinence, bowel dysfunction and death.
Tuesday, October 18, 2011
Blowing our own trumpet
I had my first dose of my second course of my third line of chemotherapy this morning. Once again I was impressed by the set-up at the Royal Bournemouth Hospital. I learned today that it received the accolade of NHS Hospital of the Year in 2009. And in 2010 it was awarded Safe Hospital of the Year status. It is now 21 months since there has been a case of hospital acquired MRSA.
To continue blowing our own trumpet may I direct you to our new website set up by our new colleague, Dr Renata Walewska. http://www.rbch.nhs.uk/index.php?id=616 Please browse. You will see that we have had nearly 800 scientific publications over the past 30 years.
To continue blowing our own trumpet may I direct you to our new website set up by our new colleague, Dr Renata Walewska. http://www.rbch.nhs.uk/index.php?id=616 Please browse. You will see that we have had nearly 800 scientific publications over the past 30 years.
Saturday, October 15, 2011
Which is the best hospital in America?
Which are the best hospitals in America? Most people who make a judgement would pick on the famous ones like: MD Anderson, Duke, Mass General, Stanford, Mount Sinai, Cleveland Clinic, Vanderbilt, the Mayo, University of Michigan, Brigham and Womens, University of Washington, Johns Hopkins etc. There are 17 that make the US News and World Report. These hospitals publish the best research and are most in the news for their innovative work.
But there is another way of looking at things. The Joint Commision for accrediting hospitals in America has released a list of the 450 best performing hospitals in America and none of the 17 makes the cut. This is because the Joint Commission focuses on everyday diagnoses such as the routine care of surgical cases, and people with pneumonia or myocardial infarction. It uses only wellattested process measures such a giving aspirin to people with chest pain and prophylactic antibiotics to patients undergoing surgery. Hospitals had to score 95% or better on all the 22 tested process measures.
The 405 hospitals included many small community hospitals and very few major urban and famous institutions. Some hospitals use their complex case mix as an excuse though it is hard to see how this would make a difference to drawing blood cultures before giving iv antibiotics or giving chemotherapy on time according to the prescribed schedule.
I do not think this is a purely American problem. In my role of inspecting pathology departments in most of teh big teaching hospitals in teh UK, I noticed remarkable carelessness in attention to detail. In looking at the glamorous aspects of a research institution they often took their eye off the ball. My son at teh CQC and my daughter as a junior doctor would concur, and most of the medicao-legal cases that I have been involved with involve large teaching hospitals.
I think at Bournemouth we had the best of both worlds. We were undoubtedly the District General Hospital with the best record for research and innovation, but we were also consistantly one of the best in teh country interms of achieving the highest standards in patient care and financial management.
But there is another way of looking at things. The Joint Commision for accrediting hospitals in America has released a list of the 450 best performing hospitals in America and none of the 17 makes the cut. This is because the Joint Commission focuses on everyday diagnoses such as the routine care of surgical cases, and people with pneumonia or myocardial infarction. It uses only wellattested process measures such a giving aspirin to people with chest pain and prophylactic antibiotics to patients undergoing surgery. Hospitals had to score 95% or better on all the 22 tested process measures.
The 405 hospitals included many small community hospitals and very few major urban and famous institutions. Some hospitals use their complex case mix as an excuse though it is hard to see how this would make a difference to drawing blood cultures before giving iv antibiotics or giving chemotherapy on time according to the prescribed schedule.
I do not think this is a purely American problem. In my role of inspecting pathology departments in most of teh big teaching hospitals in teh UK, I noticed remarkable carelessness in attention to detail. In looking at the glamorous aspects of a research institution they often took their eye off the ball. My son at teh CQC and my daughter as a junior doctor would concur, and most of the medicao-legal cases that I have been involved with involve large teaching hospitals.
I think at Bournemouth we had the best of both worlds. We were undoubtedly the District General Hospital with the best record for research and innovation, but we were also consistantly one of the best in teh country interms of achieving the highest standards in patient care and financial management.
Friday, June 10, 2011
How to care for the elderly?
How to care for the elderly?
A story is told of a community of Native Americans. Grandfather was becoming very old and forgetful and was really a lot of trouble to the tribe. One day, son says to grandson, “It’s time to take grandfather to meet the ancestors.”
Grandson replied, “Is he dying?”
Son says, “No, but it’s his time.”
Son and grandson put grandfather on a litter and carry him up to the high place where there were many wooden constructions decorated with feathers. There were tepees and strange bundles wrapped in animal skins, but no people. Son showed grandson how to sit grandfather up in one of the tepees. Grandson asked son, “Where are the ancestors?”
Son replied, “They are all around. They will come for grandfather shortly.”
Son and grandson began to make their way down the mountain.
Grandson says to son, “I’m really glad that you brought me with you today, Dad, because when it is your time I shall know where to take you.”
Son says to grandson, “You know what? Perhaps it isn’t grandfather’s time quite yet. Let’s go back and fetch him home to the village.”
Euthanasia is one way of dealing with Alzheimer’s disease, but most physicians do not support this as a way out, and despite the Assisted Suicide Bill regularly appearing before Parliament, it is always soundly defeated.
Although we see old age as one of the most difficult problems faced by any health care system, it is really a sign of the success of modern medicine. People used to die of infection, heart disease, pneumonia and the rest with an average longevity when I was young of 68 years; now they go on living into their 90s. They go on living until their brain breaks.
How do you deal with a broken brain living in a healthy body?
Might there be a medical solution? If there is we are probably a decade away from discovering it. About 10% of patients with dementia have a remediable condition – vitamin B12 deficiency and thyroid deficiency are the commonest causes but there are others. Perhaps another 10% have incurable dementia but also have a remediable condition such as pneumonia or heart failure that has recently made them worse. These problems should be looked for and treated. However, it is very important that these investigations are done by the primary care physicians while the patient is in his or her own home. The worst possible thing that can be done for patients with Alzheimer’s disease is to admit them to a ward of a general hospital.
When I was younger and inspecting a London teaching hospital, I was astonished to hear that 30% of the acute beds of the hospital were filled with what they called ‘bed-blockers’. These were patients for whom the hospital had done all it could and now wanted to discharge. Many of these patients had dementia and the relatives quite correctly determined that they could not cope at home. The only sensible alternative was a nursing home and to pay for this would involve selling the family home. But this was the kid’s inheritance and they were resisting the sale. They were doubly incensed because prior to the admission to hospital, Mum was managing at home reasonably well.
It is quite clear that when an elderly mildly demented patient is admitted to hospital, the disorientation involved frequently leads to an exacerbation of the dementia.
Apart from the factors I have mentioned, dementia is not really a medical problem and doesn’t have a medical solution, yet it is one of the reasons that the government gives for requiring 20% efficiency savings from the NHS in the next four years.
It is hard to credit it now, but when I was young, one woman in seven became a nurse. Of course, they didn’t all become State Registered Nurses (SRNs, what RGNs used to be called) with qualifications, but the type of nurse that we train now is a specialized creature, able to administer complicated drug regimens, to do ‘procedures’ like erecting a drip and passing a nasogastric tube. Most nurses didn’t do that and still don’t. They may be called ‘Health Care Assistants’, but the public knows them as nurses and they do the sort of tasks that nurses have always done. They wash and feed patients, they make beds, they wipe their bottoms, they take temperatures, pulses and blood pressures, they take blood samples, they dress wounds, they help patients out of bed and back into bed, and they generally make life a lot more pleasant than it would otherwise be. Many of them are also male. Quite a lot of what a demented patient needs is included in the above list. They seldom need an RGN but they do need the aid of health care assistants.
My sister works for a private company that provides these services in a person’s own home. It is funded mainly by the taxpayer and includes among its ministrations some element of entertainment like trips out and attendance at day-centers. My sister has no nursing training but she has been a mother and she has run her own small business. She knows how to organize things and is able to manage the other ‘home-helps’ as they used to be called. The point is that most people with mild dementia, or indeed mild failure of other bits of their bodies, can and ought to be helped to remain living in their own home. It is not costly to do so and it is worth the public investing in this resource. Of course, there is a place for family and church to contribute to this enterprise and there really is a ‘Big Society’ out there already doing it.
My mother is 91 and although she has all her marbles, she is inevitably slowing down and a little off her legs. My siblings do her shopping, tend her garden and clean her house. We do our part as much as we can, living much further away. A lady from her church lives around the corner and, although in her 80s, is a great help. Other people from her church provide transport to three church meetings every week. For Mum, life is worth living because of the support she gets.
Unfortunately, however good the support, dementia patients cannot always be kept in their own home. Often the main carer is a spouse of the same age and when the spouse gets ill someone must take over. If the children have the responsibility of caring, the care is often shared out unequally. High flying sons are too busy and their trophy wives don’t see why they should be involved. They may provide some money, but often this lifestyle is only maintained on tick. Other children may live too far away to get involved. On many occasions it is the youngest daughter who happens to live locally who has to give up her job or neglect her own family. Resentment is easily engendered.
For many the answer is a nursing home. But how to pay for it? In Scotland and Denmark the governments have decided that the general taxpayer should pay. Scotland has the advantage of a generous subsidy from England and Denmark has a basic tax rate of 53%. Joan Bakewell, who was advisor on old people to the last Labour government thought that the old person should sell his or her large house to pay for it.
The Dilman report has suggested that there should be a cap of about £50,000 on how much old people should pay towards their nursing home care. If they have total assets of less than £23,000 they are currently not expected to pay anything. £50,000 barely pays for 2 years in a nursing home – the average stay for a demented patient is about 18 months. Down south and in London £50,000 can often be found from income alone. Up north £50,000 often represents a person’s total assets, house and all. However, since the taxpayer picks up the rest of the tab and the biggest taxpayers are down south, there is a sort of equality about it.
Southern Cross, the largest provider of nursing home care in the UK is in financial difficulty. It sounds as though it has made an unwise investment, but it looks as though 32,000 individuals in Southern Cross Care Homes are going to find that their nursing homes are no longer secure. Nursing Homes are usually large houses that have been converted, Sometimes several houses are knocked into one. However they could be converted into flats of be used for other purposes. This very flexibility is a danger since it is price-sensitive. With the house sale market static there is a great demand for rented properties and some landlords have felt that nursing homes are not as profitable as flats.
There does not seem to be an easy answer to the conundrum, which is perhaps why the Labour Party has cried, "No contest" and has offered to work together with the government on a joint approach. For me the lesson to be learnt is that more people are going to have to work as carers and that the qualities that these people are going to need are patience, kindness and faithfulness. Rare qualities indeed!
A story is told of a community of Native Americans. Grandfather was becoming very old and forgetful and was really a lot of trouble to the tribe. One day, son says to grandson, “It’s time to take grandfather to meet the ancestors.”
Grandson replied, “Is he dying?”
Son says, “No, but it’s his time.”
Son and grandson put grandfather on a litter and carry him up to the high place where there were many wooden constructions decorated with feathers. There were tepees and strange bundles wrapped in animal skins, but no people. Son showed grandson how to sit grandfather up in one of the tepees. Grandson asked son, “Where are the ancestors?”
Son replied, “They are all around. They will come for grandfather shortly.”
Son and grandson began to make their way down the mountain.
Grandson says to son, “I’m really glad that you brought me with you today, Dad, because when it is your time I shall know where to take you.”
Son says to grandson, “You know what? Perhaps it isn’t grandfather’s time quite yet. Let’s go back and fetch him home to the village.”
Euthanasia is one way of dealing with Alzheimer’s disease, but most physicians do not support this as a way out, and despite the Assisted Suicide Bill regularly appearing before Parliament, it is always soundly defeated.
Although we see old age as one of the most difficult problems faced by any health care system, it is really a sign of the success of modern medicine. People used to die of infection, heart disease, pneumonia and the rest with an average longevity when I was young of 68 years; now they go on living into their 90s. They go on living until their brain breaks.
How do you deal with a broken brain living in a healthy body?
Might there be a medical solution? If there is we are probably a decade away from discovering it. About 10% of patients with dementia have a remediable condition – vitamin B12 deficiency and thyroid deficiency are the commonest causes but there are others. Perhaps another 10% have incurable dementia but also have a remediable condition such as pneumonia or heart failure that has recently made them worse. These problems should be looked for and treated. However, it is very important that these investigations are done by the primary care physicians while the patient is in his or her own home. The worst possible thing that can be done for patients with Alzheimer’s disease is to admit them to a ward of a general hospital.
When I was younger and inspecting a London teaching hospital, I was astonished to hear that 30% of the acute beds of the hospital were filled with what they called ‘bed-blockers’. These were patients for whom the hospital had done all it could and now wanted to discharge. Many of these patients had dementia and the relatives quite correctly determined that they could not cope at home. The only sensible alternative was a nursing home and to pay for this would involve selling the family home. But this was the kid’s inheritance and they were resisting the sale. They were doubly incensed because prior to the admission to hospital, Mum was managing at home reasonably well.
It is quite clear that when an elderly mildly demented patient is admitted to hospital, the disorientation involved frequently leads to an exacerbation of the dementia.
Apart from the factors I have mentioned, dementia is not really a medical problem and doesn’t have a medical solution, yet it is one of the reasons that the government gives for requiring 20% efficiency savings from the NHS in the next four years.
It is hard to credit it now, but when I was young, one woman in seven became a nurse. Of course, they didn’t all become State Registered Nurses (SRNs, what RGNs used to be called) with qualifications, but the type of nurse that we train now is a specialized creature, able to administer complicated drug regimens, to do ‘procedures’ like erecting a drip and passing a nasogastric tube. Most nurses didn’t do that and still don’t. They may be called ‘Health Care Assistants’, but the public knows them as nurses and they do the sort of tasks that nurses have always done. They wash and feed patients, they make beds, they wipe their bottoms, they take temperatures, pulses and blood pressures, they take blood samples, they dress wounds, they help patients out of bed and back into bed, and they generally make life a lot more pleasant than it would otherwise be. Many of them are also male. Quite a lot of what a demented patient needs is included in the above list. They seldom need an RGN but they do need the aid of health care assistants.
My sister works for a private company that provides these services in a person’s own home. It is funded mainly by the taxpayer and includes among its ministrations some element of entertainment like trips out and attendance at day-centers. My sister has no nursing training but she has been a mother and she has run her own small business. She knows how to organize things and is able to manage the other ‘home-helps’ as they used to be called. The point is that most people with mild dementia, or indeed mild failure of other bits of their bodies, can and ought to be helped to remain living in their own home. It is not costly to do so and it is worth the public investing in this resource. Of course, there is a place for family and church to contribute to this enterprise and there really is a ‘Big Society’ out there already doing it.
My mother is 91 and although she has all her marbles, she is inevitably slowing down and a little off her legs. My siblings do her shopping, tend her garden and clean her house. We do our part as much as we can, living much further away. A lady from her church lives around the corner and, although in her 80s, is a great help. Other people from her church provide transport to three church meetings every week. For Mum, life is worth living because of the support she gets.
Unfortunately, however good the support, dementia patients cannot always be kept in their own home. Often the main carer is a spouse of the same age and when the spouse gets ill someone must take over. If the children have the responsibility of caring, the care is often shared out unequally. High flying sons are too busy and their trophy wives don’t see why they should be involved. They may provide some money, but often this lifestyle is only maintained on tick. Other children may live too far away to get involved. On many occasions it is the youngest daughter who happens to live locally who has to give up her job or neglect her own family. Resentment is easily engendered.
For many the answer is a nursing home. But how to pay for it? In Scotland and Denmark the governments have decided that the general taxpayer should pay. Scotland has the advantage of a generous subsidy from England and Denmark has a basic tax rate of 53%. Joan Bakewell, who was advisor on old people to the last Labour government thought that the old person should sell his or her large house to pay for it.
The Dilman report has suggested that there should be a cap of about £50,000 on how much old people should pay towards their nursing home care. If they have total assets of less than £23,000 they are currently not expected to pay anything. £50,000 barely pays for 2 years in a nursing home – the average stay for a demented patient is about 18 months. Down south and in London £50,000 can often be found from income alone. Up north £50,000 often represents a person’s total assets, house and all. However, since the taxpayer picks up the rest of the tab and the biggest taxpayers are down south, there is a sort of equality about it.
Southern Cross, the largest provider of nursing home care in the UK is in financial difficulty. It sounds as though it has made an unwise investment, but it looks as though 32,000 individuals in Southern Cross Care Homes are going to find that their nursing homes are no longer secure. Nursing Homes are usually large houses that have been converted, Sometimes several houses are knocked into one. However they could be converted into flats of be used for other purposes. This very flexibility is a danger since it is price-sensitive. With the house sale market static there is a great demand for rented properties and some landlords have felt that nursing homes are not as profitable as flats.
There does not seem to be an easy answer to the conundrum, which is perhaps why the Labour Party has cried, "No contest" and has offered to work together with the government on a joint approach. For me the lesson to be learnt is that more people are going to have to work as carers and that the qualities that these people are going to need are patience, kindness and faithfulness. Rare qualities indeed!
Friday, May 27, 2011
Leaks about the NHS Bill
One of the back-bench Tory MPs who sits on the Health committee in Parliament has released this helpful e-mail about how the Tories are thinking about the NHS.
Colleagues,
As you are no doubt aware, there has been widespread media coverage during the 'pause' about the Government's NHS reforms. Coverage has suggested rather concerning change, coming not from within our own ranks but from amongst our coalition partners. I have been closely involved with the Bill at Committee stage and in public, and many colleagues have shared with me their concern that their views need to be counted.
The recent 1922 meeting demonstrated widespread support for the Bill. It is absolutely vital that Conservative backbenchers are able to input into this process, and that our views are not ignored. Thus far, critics of this Bill have made their voices the loudest, but we still have an opportunity to set out clearly Conservative backbenchers' 'red lines' on NHS reform, the principles on which we will not budge.
1. Core 'red lines'
The Conservative Party manifesto – on which we were all elected – does the job of setting out some key red lines from which we should not retreat. These are:
• We must nail the myth about so-called 'privatisation' of the NHS. Our commitment is that the NHS must continue to be free at the point of use, available to all, funded from general taxation, and based on need and not ability to pay. We have always supported this fundamental principle of the NHS and we will not yield on this principle.
• Patients should be able to be treated at any qualified provider. Patients should have every right to be treated at the best possible service, free of charge, on the NHS, if that service meets NHS standards and NHS costs. If a provider is qualified to deliver NHS standards at NHS costs – and a patient, together with their doctor, wants them to be treated there – the Government should do nothing that stands in their way.
• Patients, together with their doctors, should have a choice over where to be treated. Without such a choice, there can never be an incentive to drive up standards in the NHS. However, vested interests will fight to restrict patients' right to choose. Therefore, Monitor must be retained as a regulator to ensure that patients' choices are not being restricted and ensure that their interests are not being harmed.
• There must be no top-down bureaucracy and political micromanagement of the NHS. Making clear that responsibility lies with doctors and nurses on the frontline in itself makes clear that responsibility does not lie with the top-down NHS bureaucracy or with Whitehall. Without the clear division of responsibility, the top-down hierarchy will remain empowered and more money will continue to be spent on bureaucracy rather than on patient care. We have been clear about the date – April 2013 – when statutory responsibility must transfer from the top-down bureaucracy to GP consortia. Contrary to what is being said in public by others, this is a very reasonable period of time. Not to proceed with this division of responsibility puts at risk our aim of releasing £5 billion from NHS administration savings during this Parliament and being able to reinvest it all back into patient care.
• There must be no two-tier NHS. GPs should take charge of commissioning budgets, through consortia, everywhere in the country. To do otherwise would repeat the mistake of GP fundholding – where some areas of the country benefitted from GP commissioning but other areas fell behind. GPs must be given support where they are unable to commission the full range of services, but the network of GP commissioning consortia must be in place by April 2013. The statutory responsibility for ensuring that NHS services are delivered to patients is too important to be fudged.
2. Next Steps
I am keen that our views are heard at the top of government so that the debate is not monopolised by others and would be grateful for your feedback on the red lines and invite you also to share your views on the following if you wish:
• Are there any other red lines which have been omitted from the list?
• What could be included in the Health and Social Care Bill to make sure that future governments cannot undermine the principle of a universal, tax payer-funded NHS without consulting Parliament first?
• Do we need to strengthen mechanisms to ensure that unfair subsidies paid to providers – such as Labour's Independent Sector Treatment Centre programme – cannot be allowed?
• How can we ensure patients have the information they need to make an informed choice?
• What measures can be developed to ensure GPs are fully supported following the transfer of commissioning responsibility in April 2013?
I apologise for the length of this email, but I am determined that we reclaim the debate over the future of the National Health Service from those who seek to use the Bill as a political tool. I intend to share these views as part of the current listening exercise and I look forward to your input.
Kind regards,
Nick de Bois
Colleagues,
As you are no doubt aware, there has been widespread media coverage during the 'pause' about the Government's NHS reforms. Coverage has suggested rather concerning change, coming not from within our own ranks but from amongst our coalition partners. I have been closely involved with the Bill at Committee stage and in public, and many colleagues have shared with me their concern that their views need to be counted.
The recent 1922 meeting demonstrated widespread support for the Bill. It is absolutely vital that Conservative backbenchers are able to input into this process, and that our views are not ignored. Thus far, critics of this Bill have made their voices the loudest, but we still have an opportunity to set out clearly Conservative backbenchers' 'red lines' on NHS reform, the principles on which we will not budge.
1. Core 'red lines'
The Conservative Party manifesto – on which we were all elected – does the job of setting out some key red lines from which we should not retreat. These are:
• We must nail the myth about so-called 'privatisation' of the NHS. Our commitment is that the NHS must continue to be free at the point of use, available to all, funded from general taxation, and based on need and not ability to pay. We have always supported this fundamental principle of the NHS and we will not yield on this principle.
• Patients should be able to be treated at any qualified provider. Patients should have every right to be treated at the best possible service, free of charge, on the NHS, if that service meets NHS standards and NHS costs. If a provider is qualified to deliver NHS standards at NHS costs – and a patient, together with their doctor, wants them to be treated there – the Government should do nothing that stands in their way.
• Patients, together with their doctors, should have a choice over where to be treated. Without such a choice, there can never be an incentive to drive up standards in the NHS. However, vested interests will fight to restrict patients' right to choose. Therefore, Monitor must be retained as a regulator to ensure that patients' choices are not being restricted and ensure that their interests are not being harmed.
• There must be no top-down bureaucracy and political micromanagement of the NHS. Making clear that responsibility lies with doctors and nurses on the frontline in itself makes clear that responsibility does not lie with the top-down NHS bureaucracy or with Whitehall. Without the clear division of responsibility, the top-down hierarchy will remain empowered and more money will continue to be spent on bureaucracy rather than on patient care. We have been clear about the date – April 2013 – when statutory responsibility must transfer from the top-down bureaucracy to GP consortia. Contrary to what is being said in public by others, this is a very reasonable period of time. Not to proceed with this division of responsibility puts at risk our aim of releasing £5 billion from NHS administration savings during this Parliament and being able to reinvest it all back into patient care.
• There must be no two-tier NHS. GPs should take charge of commissioning budgets, through consortia, everywhere in the country. To do otherwise would repeat the mistake of GP fundholding – where some areas of the country benefitted from GP commissioning but other areas fell behind. GPs must be given support where they are unable to commission the full range of services, but the network of GP commissioning consortia must be in place by April 2013. The statutory responsibility for ensuring that NHS services are delivered to patients is too important to be fudged.
2. Next Steps
I am keen that our views are heard at the top of government so that the debate is not monopolised by others and would be grateful for your feedback on the red lines and invite you also to share your views on the following if you wish:
• Are there any other red lines which have been omitted from the list?
• What could be included in the Health and Social Care Bill to make sure that future governments cannot undermine the principle of a universal, tax payer-funded NHS without consulting Parliament first?
• Do we need to strengthen mechanisms to ensure that unfair subsidies paid to providers – such as Labour's Independent Sector Treatment Centre programme – cannot be allowed?
• How can we ensure patients have the information they need to make an informed choice?
• What measures can be developed to ensure GPs are fully supported following the transfer of commissioning responsibility in April 2013?
I apologise for the length of this email, but I am determined that we reclaim the debate over the future of the National Health Service from those who seek to use the Bill as a political tool. I intend to share these views as part of the current listening exercise and I look forward to your input.
Kind regards,
Nick de Bois
Sunday, May 22, 2011
Where now for the NHS?
When the NHS began it used to give away free hot water bottles. Things have changed. As people live longer they make more demands on health care. As technology improves health care becomes more expensive. This would not matter if growth of GDP was buoyant, but growth is sluggish. The NHS is being asked to make do within its existing budget, but to take account of demographic changes and health-specific inflation it has to make major savings elsewhere.
The last government threw huge amounts of money at the NHS, but productivity reduced. This means that doctors and nurses each saw relatively fewer patients. Part of this was the result of the European Working Time Directive which stopped junior doctors from working more than 48 hours a week, but more than that was a change from a professional contract, whereby doctors and nurses stayed working until the work was done, to a sessional contract whereby they engaged in a certain number of 3.5 hour sessions a week. Since their sessions included periods for administration, continued professional development, research and perhaps other non-clinical time, less time was spent at the coal face. The consequence was more doctors and nurses had to be employed to complete the work.
The option of throwing yet more money at the problem is not available. The new government has agreed to ring-fence the NHS budget, sparing it from the austerity package, but even with a standstill budget it has to make savings. Are there things that it is doing that it could stop doing?
One way of reducing the work in the NHS would be to encourage private practice. After all in many countries patients find that when people pay for services directly they get better results. There is no way that the NHS with its intrinsic rationing will be able to pay for the hotel services and promptness that middle class people are going to demand. These are not medical but social standards and there is no reason that they should not be paid for. Some ways that this could be done would be to give tax breaks for private health insurance, and to allow waiting lists for elective surgery on the NHS to drift. far from diminishing the NHS this would allow the national service to do what it is best at.
There are undoubtedly some health services that are best provided by the community. Even the United States recognizes this. No-one would suggest that the CDC was run as a private firm. Or the Walter Reed. There is no call to privatize the VA. I am content to let the British Public Health Service be run by the NHS. The epidemiology is best done by someone with statutory access to the data. In the UK family doctors are all independent contractors. They work for the NHS and are paid for out of general taxation, but they are effectively small businessmen. Not so the hospitals which are owned and paid for by the government and all employ thousands of health workers. But even here they have been separated into independent Trusts and are no longer one great monolith.
Still, I would have the NHS doing less. What I would concentrate on are the things that people cannot do for themselves. Lots of medical time is taken up with the trivial that does not need expensive time spent on it. Most virus infections cannot be treated (herpes is the exception) so there is no point going to the doctors with colds and flu. Many medical interventions are of unproven value. I see no reason why patients should not be allowed to purchase these as long as they don't use my money to do so. I am thinking of homeopathy especially, but there are many other 'treatments'.
A few years ago it was estimated that ten times as much money was paid by the NHS on indigestion remedies than on the whole of cancer chemotherapy. Surely this cannot be the correct priority. It is expensive treatments like cancer chemotherapy and cardiac surgery that we need help to pay for, not the provision of statins in the hope that they may prolong life. I think that NICE has things the wrong way round. Rather than setting a threshold for treatments yielding less than 1 QALY per £30,000, they should be seeking out the cheap treatments and recommending that people pay for them themselves.
The other area I find odd is to use the NHS budget for social engineering. Many illnesses are self inflicted. They are caused by smoking, drinking, eating unsuitable foods, not taking exercise, taking class A and class B drugs. Much mental illness is so engendered and much is simply unhappiness. To cram this degree of social problem into a medical model seems to me to be unwarranted. The remedy for many of these ills is not a medical one. Better housing, schooling, conditions of employment and environment may all have a part to play. Antidepressants are not the answer.
What is mainly wrong about the NHS is not poor quality medicine but its being used to answer questions it wasn’t designed to answer.
The last government threw huge amounts of money at the NHS, but productivity reduced. This means that doctors and nurses each saw relatively fewer patients. Part of this was the result of the European Working Time Directive which stopped junior doctors from working more than 48 hours a week, but more than that was a change from a professional contract, whereby doctors and nurses stayed working until the work was done, to a sessional contract whereby they engaged in a certain number of 3.5 hour sessions a week. Since their sessions included periods for administration, continued professional development, research and perhaps other non-clinical time, less time was spent at the coal face. The consequence was more doctors and nurses had to be employed to complete the work.
The option of throwing yet more money at the problem is not available. The new government has agreed to ring-fence the NHS budget, sparing it from the austerity package, but even with a standstill budget it has to make savings. Are there things that it is doing that it could stop doing?
One way of reducing the work in the NHS would be to encourage private practice. After all in many countries patients find that when people pay for services directly they get better results. There is no way that the NHS with its intrinsic rationing will be able to pay for the hotel services and promptness that middle class people are going to demand. These are not medical but social standards and there is no reason that they should not be paid for. Some ways that this could be done would be to give tax breaks for private health insurance, and to allow waiting lists for elective surgery on the NHS to drift. far from diminishing the NHS this would allow the national service to do what it is best at.
There are undoubtedly some health services that are best provided by the community. Even the United States recognizes this. No-one would suggest that the CDC was run as a private firm. Or the Walter Reed. There is no call to privatize the VA. I am content to let the British Public Health Service be run by the NHS. The epidemiology is best done by someone with statutory access to the data. In the UK family doctors are all independent contractors. They work for the NHS and are paid for out of general taxation, but they are effectively small businessmen. Not so the hospitals which are owned and paid for by the government and all employ thousands of health workers. But even here they have been separated into independent Trusts and are no longer one great monolith.
Still, I would have the NHS doing less. What I would concentrate on are the things that people cannot do for themselves. Lots of medical time is taken up with the trivial that does not need expensive time spent on it. Most virus infections cannot be treated (herpes is the exception) so there is no point going to the doctors with colds and flu. Many medical interventions are of unproven value. I see no reason why patients should not be allowed to purchase these as long as they don't use my money to do so. I am thinking of homeopathy especially, but there are many other 'treatments'.
A few years ago it was estimated that ten times as much money was paid by the NHS on indigestion remedies than on the whole of cancer chemotherapy. Surely this cannot be the correct priority. It is expensive treatments like cancer chemotherapy and cardiac surgery that we need help to pay for, not the provision of statins in the hope that they may prolong life. I think that NICE has things the wrong way round. Rather than setting a threshold for treatments yielding less than 1 QALY per £30,000, they should be seeking out the cheap treatments and recommending that people pay for them themselves.
The other area I find odd is to use the NHS budget for social engineering. Many illnesses are self inflicted. They are caused by smoking, drinking, eating unsuitable foods, not taking exercise, taking class A and class B drugs. Much mental illness is so engendered and much is simply unhappiness. To cram this degree of social problem into a medical model seems to me to be unwarranted. The remedy for many of these ills is not a medical one. Better housing, schooling, conditions of employment and environment may all have a part to play. Antidepressants are not the answer.
What is mainly wrong about the NHS is not poor quality medicine but its being used to answer questions it wasn’t designed to answer.
Wednesday, May 11, 2011
What is wrong with the NHS
The NHS is being reorganized again - or is it. In the wake of the Liberal Democrats defeat at the polls they are stiffening up their opposition to Andrew Lansley's Health Bill in the hope that they will be seen by the electorate as still having some backbone.
The Health Bill was an attempt to make the NHS more accountable to its users by giving control of the budgets to consortia of local family doctors instead of administrators. The government has ring fenced the budget of the NHS, but since there is a built-in inflation in health spending due to demographic drift and scientific development, even a stand-still budget seems like cuts.
So what is wrong with the NHS and what needs fixing?
The last Labour government threw a lot of money at the NHS and brought average spending up to where it was in most of Europe - but of course during the same period Europe also increased its spending so that the NHS still lags behind Germany, Spain and France in its spending. The criticism was made that much of the money was wasted because productivity actually fell while the spending increased. I contend that this was because the government did not believe how hard doctors and nurses were working. The contracts were made more watertight so that people were actually paid for their work and discouraged from doing unpaid overtime by the European Working Time Directive. So it appeared that people were doing less for more. More jobs were created to fill in the gaps.
Another criticism of the NHS was that priorities for treatment had become distorted. Waiting lists had been shortened to no more than 18 weeks anywhere, but this had sometimes meant that things like cosmetic surgery were given priority over mental health services or even cancer surgery. Cancer referrals was supposed to take no more than 2 weeks, but there were built in delays waiting for scans and follow-up appointments. Again every breast lump was placed at the head of the queue even though many of them would be benign cysts.
By giving GPs the budget the idea would be that they could better decide on priorities and not make the same basic errors that administrators would make. On the other hand GPs are themselves providers to the NHS and might find it profitable to favor their own services at the expense of other providers. Near-patient testing or the use of 'factory laboratories' without pathologist's supervision, might be preferred to our conventional model. GPs certainly favored themselves when abandoning night duties to private services for a very small cut in income. The private night services have scored some spectacular own-goals.
One possible drive behind the Conservative reforms has been the possibility of private providers supplying some of the services. I have no problem with this as long as they are professionally scrutinized. We have private catering and waste disposal, and why not. The attempt by Blair's government to introduce private treatment centers for orthopedic operations was disastrous. They cherry-picked the easy options and left their complications to be picked up by the NHS.
The other drawback of private treatment centers is their lack of commitment to training and research which are an essential element of the NHS. One remedy for this would be to ensure that hospital specialists had a say in the purchasing of services, but Lansley is resisting this. Lansley has family members who are family doctors and his might not be an unjaundiced eye.
It seems to me that there some elements of health that have to be provided by the public sector. This is recognized even in America where the CDC and VA are both provided at public expense.
Another question is whether it is possible to restrain the costs of drugs. In any market any product can price itself out of contention. The very rich, like Steve Jobs, will be able to buy anything to keep himself alive; the indigenous poor will not. An insurance system, however provided, evens out the difference, but it will not be attractive to everybody. Attempts to arbitrarily control what is spent will fall foul of individual unfair exceptions. The UK government has set up a cancer fund to deal with these exceptions when NICE seems harsh. It has not been universally acceptable.
I suppose what is wrong with the NHS is what is wrong with modern medicine. It is not universally successful.
The Health Bill was an attempt to make the NHS more accountable to its users by giving control of the budgets to consortia of local family doctors instead of administrators. The government has ring fenced the budget of the NHS, but since there is a built-in inflation in health spending due to demographic drift and scientific development, even a stand-still budget seems like cuts.
So what is wrong with the NHS and what needs fixing?
The last Labour government threw a lot of money at the NHS and brought average spending up to where it was in most of Europe - but of course during the same period Europe also increased its spending so that the NHS still lags behind Germany, Spain and France in its spending. The criticism was made that much of the money was wasted because productivity actually fell while the spending increased. I contend that this was because the government did not believe how hard doctors and nurses were working. The contracts were made more watertight so that people were actually paid for their work and discouraged from doing unpaid overtime by the European Working Time Directive. So it appeared that people were doing less for more. More jobs were created to fill in the gaps.
Another criticism of the NHS was that priorities for treatment had become distorted. Waiting lists had been shortened to no more than 18 weeks anywhere, but this had sometimes meant that things like cosmetic surgery were given priority over mental health services or even cancer surgery. Cancer referrals was supposed to take no more than 2 weeks, but there were built in delays waiting for scans and follow-up appointments. Again every breast lump was placed at the head of the queue even though many of them would be benign cysts.
By giving GPs the budget the idea would be that they could better decide on priorities and not make the same basic errors that administrators would make. On the other hand GPs are themselves providers to the NHS and might find it profitable to favor their own services at the expense of other providers. Near-patient testing or the use of 'factory laboratories' without pathologist's supervision, might be preferred to our conventional model. GPs certainly favored themselves when abandoning night duties to private services for a very small cut in income. The private night services have scored some spectacular own-goals.
One possible drive behind the Conservative reforms has been the possibility of private providers supplying some of the services. I have no problem with this as long as they are professionally scrutinized. We have private catering and waste disposal, and why not. The attempt by Blair's government to introduce private treatment centers for orthopedic operations was disastrous. They cherry-picked the easy options and left their complications to be picked up by the NHS.
The other drawback of private treatment centers is their lack of commitment to training and research which are an essential element of the NHS. One remedy for this would be to ensure that hospital specialists had a say in the purchasing of services, but Lansley is resisting this. Lansley has family members who are family doctors and his might not be an unjaundiced eye.
It seems to me that there some elements of health that have to be provided by the public sector. This is recognized even in America where the CDC and VA are both provided at public expense.
Another question is whether it is possible to restrain the costs of drugs. In any market any product can price itself out of contention. The very rich, like Steve Jobs, will be able to buy anything to keep himself alive; the indigenous poor will not. An insurance system, however provided, evens out the difference, but it will not be attractive to everybody. Attempts to arbitrarily control what is spent will fall foul of individual unfair exceptions. The UK government has set up a cancer fund to deal with these exceptions when NICE seems harsh. It has not been universally acceptable.
I suppose what is wrong with the NHS is what is wrong with modern medicine. It is not universally successful.
Tuesday, April 19, 2011
NICE changes
There are considerable differences between the British and American health services, although the differences are not so great as is sometimes made out. In both countries the greater proportion of care is paid for by the taxpayer (surprisingly the American taxpayer pays out a greater proportion of GDP than the British taxpayer). In both countries there is a system whereby a third party insurer is left with the bill. The proportion paid for by the private insurer and the taxpayer certainly varies in both countries, but not by as much as you would think. In both countries a regulator decides whether or not a particular treatment is licensed (the FDA in America; the MHRA in the UK). What is different among other things is the organization known as the National Institute for Health and Clinical Excellence or NICE which has a regulatory role in the UK.
NICE has been a matter of particular ire for some of my American correspondents who have warned that should such an organization be part of Obama's plans, it would be tantamount to the introduction of 'death committees'.
This is to misunderstand how NICE works. Before NICE it was left to local conglomerates to decide whether the taxpayer would pay for a new drug that had been licensed by the MHRA (which generally makes very similar decisions to the FDA). The local conglomerates were very arbitrary about how they chose one drug over another - the cancer doctor might shout louder than the dementia doctor or vice versa. This resulted in what became known as 'postcode prescribing'. If you lived in one district you might get the drug but a mile up the street you might not.
NICE was introduced to counter this unfairness. If a drug was regarded as cost-effective for a particular condition, then a local health authority was obliged to provide it, however, short their budget might be and no matter how loudly a particular specialist shouted. NICE had no power to say a particular drug should not be prescribed, but if the budget was tight, market forces would prevail. Health authorities limited their prescribing to what they must provide and pay for. If the drug was not NICE approved, it was always possible to get it paid for through a private insurance company, but they would not let you join a scheme just when the need became apparent. The point about insurance is that it is take out before your house catches fire. Unfortunately, only about 20% of the population has private insurance. A third option is to put the money that could have bought a health insurance policy into a savings scheme and pay for your drugs yourself.
In the current austerity governments are bound to look at what they spend on healthcare to see whether they get value for money. For this reason among many American authorities are looking at NICE to see whether the template can be adapted for American use. An article in last week's New England Journal of Medicine from experts at John Hopkins explores the subject.
NICE finds itself changing its nature as the government moves to what it calls 'value-based pricing' of pharmaceuticals in 2014. Currently, NICE's decision-making process uses a cost-effectiveness threshold, based on the number of quality-adjusted life-years (QALYs) gained with a particular drug for a given cost (between 20 and 30,000 pounds, ($32,000-$48,000)- the goal being to secure as much public health benefit as possible within a specified budget determined every 2 years. Other social values are not formally reflected in this threshold, but NICE's decision-making committees are expected to consider them in their deliberations, and in practice they do affect outcomes. I wonder what would be the result if there were a disease that only affected university professors or CEOs of large companies; would the threshold be different.
This strictly utilitarian approach does not fit easily with people's ideas of fairness and to circumvent this, the government have introduced a special cancer fund to help sufferers who might fall foul of the £30,000 maximum. Value-based pricing offers a new approach to incorporating values. It would begin with a basic price threshold, expressed as cost per QALY and retain NICE's central role “both in undertaking pharmacoeconomic assessments and in providing advice to the NHS on the relative clinical and cost effectiveness of treatments.” But the new approach, says the Department of Health, will better reflect “all the components that contribute to a treatment's impact on health and quality of life,” including “important factors that patients and society value.Under the new system, the Health Ministry would negotiate prices for new drugs with manufacturers, but prescribing decisions would be left to individual doctors who are given a capitation-based budget by the government and need not follow particular decision-making processes. And although NICE would continue to provide advice on the optimal use of new drugs, that advice is unlikely to translate as now into a constitutional right to access.I'm not completely clear how these changes would operate in practice. I suspect that they are merely there to allow more flexibility into the system that will allow the middle classes with 'sharp elbows' to get things that other people will be denied. In other words it will keep the Daily Mail off our back.
Although the British and U.S. health care systems differ, some policy experts in both countries see improving health care value propositions as one solution to the conundrum of sky-rocketing costs and limited resources. The U.S. Affordable Care Act explicitly rejects Britain's National Health Service model, with its global budgeting and public acceptance of prioritization and consideration of costs. Nevertheless, the British experience may carry important implications for U.S. health care reform.NICE's history and the British government's new turn demonstrate that, as a political if not a moral matter, the value of health care cannot be defined solely in terms of comparative clinical effectiveness or health outcomes. But clearly it is hard, politically and technically, to define value, even for an organization that has pioneered approaches to expanding the meaning of value in healthcare.
NICE has been a matter of particular ire for some of my American correspondents who have warned that should such an organization be part of Obama's plans, it would be tantamount to the introduction of 'death committees'.
This is to misunderstand how NICE works. Before NICE it was left to local conglomerates to decide whether the taxpayer would pay for a new drug that had been licensed by the MHRA (which generally makes very similar decisions to the FDA). The local conglomerates were very arbitrary about how they chose one drug over another - the cancer doctor might shout louder than the dementia doctor or vice versa. This resulted in what became known as 'postcode prescribing'. If you lived in one district you might get the drug but a mile up the street you might not.
NICE was introduced to counter this unfairness. If a drug was regarded as cost-effective for a particular condition, then a local health authority was obliged to provide it, however, short their budget might be and no matter how loudly a particular specialist shouted. NICE had no power to say a particular drug should not be prescribed, but if the budget was tight, market forces would prevail. Health authorities limited their prescribing to what they must provide and pay for. If the drug was not NICE approved, it was always possible to get it paid for through a private insurance company, but they would not let you join a scheme just when the need became apparent. The point about insurance is that it is take out before your house catches fire. Unfortunately, only about 20% of the population has private insurance. A third option is to put the money that could have bought a health insurance policy into a savings scheme and pay for your drugs yourself.
In the current austerity governments are bound to look at what they spend on healthcare to see whether they get value for money. For this reason among many American authorities are looking at NICE to see whether the template can be adapted for American use. An article in last week's New England Journal of Medicine from experts at John Hopkins explores the subject.
NICE finds itself changing its nature as the government moves to what it calls 'value-based pricing' of pharmaceuticals in 2014. Currently, NICE's decision-making process uses a cost-effectiveness threshold, based on the number of quality-adjusted life-years (QALYs) gained with a particular drug for a given cost (between 20 and 30,000 pounds, ($32,000-$48,000)- the goal being to secure as much public health benefit as possible within a specified budget determined every 2 years. Other social values are not formally reflected in this threshold, but NICE's decision-making committees are expected to consider them in their deliberations, and in practice they do affect outcomes. I wonder what would be the result if there were a disease that only affected university professors or CEOs of large companies; would the threshold be different.
This strictly utilitarian approach does not fit easily with people's ideas of fairness and to circumvent this, the government have introduced a special cancer fund to help sufferers who might fall foul of the £30,000 maximum. Value-based pricing offers a new approach to incorporating values. It would begin with a basic price threshold, expressed as cost per QALY and retain NICE's central role “both in undertaking pharmacoeconomic assessments and in providing advice to the NHS on the relative clinical and cost effectiveness of treatments.” But the new approach, says the Department of Health, will better reflect “all the components that contribute to a treatment's impact on health and quality of life,” including “important factors that patients and society value.Under the new system, the Health Ministry would negotiate prices for new drugs with manufacturers, but prescribing decisions would be left to individual doctors who are given a capitation-based budget by the government and need not follow particular decision-making processes. And although NICE would continue to provide advice on the optimal use of new drugs, that advice is unlikely to translate as now into a constitutional right to access.I'm not completely clear how these changes would operate in practice. I suspect that they are merely there to allow more flexibility into the system that will allow the middle classes with 'sharp elbows' to get things that other people will be denied. In other words it will keep the Daily Mail off our back.
Although the British and U.S. health care systems differ, some policy experts in both countries see improving health care value propositions as one solution to the conundrum of sky-rocketing costs and limited resources. The U.S. Affordable Care Act explicitly rejects Britain's National Health Service model, with its global budgeting and public acceptance of prioritization and consideration of costs. Nevertheless, the British experience may carry important implications for U.S. health care reform.NICE's history and the British government's new turn demonstrate that, as a political if not a moral matter, the value of health care cannot be defined solely in terms of comparative clinical effectiveness or health outcomes. But clearly it is hard, politically and technically, to define value, even for an organization that has pioneered approaches to expanding the meaning of value in healthcare.
Friday, April 08, 2011
Malpractice
The British government has changed the law on no-win/no-fee medical negligence cases. Under legislation drawn up by New Labour, claimant's lawyers could claim double their normal costs if they win a case. (Tony Blair was a lawyer). They can claim their usual fee plus a success fee of 100%. The whole package is payable by the losing defendant. The defendant is also liable to pay an insurance premium that the claimant takes out to insure against the possibility of losing. This system leaves the losing defendant paying out more in legal costs than they do in damages so that defensible cases are often settled rather than incur high legal expenses. In 2008-9 the NHS paid £312m in damages and £465m in lawyer's fees.
Under the new system losing claimants will no longer have to pay the winning defendant's costs so there will no longer be a need for insurance against losing. A losing defendant will pay the claimant's costs, but not a success fee, which will become the responsibility of the winning claimant, who will pay it out of damages won. The success fee will be capped at 25% of general damages.
The new regulations were welcomed by the Medical Defence Union which recently reported a case where the damages were £8000 and the lawyer's fees, £62,000.
Under the new system losing claimants will no longer have to pay the winning defendant's costs so there will no longer be a need for insurance against losing. A losing defendant will pay the claimant's costs, but not a success fee, which will become the responsibility of the winning claimant, who will pay it out of damages won. The success fee will be capped at 25% of general damages.
The new regulations were welcomed by the Medical Defence Union which recently reported a case where the damages were £8000 and the lawyer's fees, £62,000.
Monday, January 31, 2011
NHS reforms
The NHS is undergoing yet another reorganization. The split between purchaser and provider is being maintained, but rather than the purchaser being a medical manager led Primary Care Trust, in future Consortia of General Practitioners will determine which services are purchased and there will be more open competition among providers. The role of NICE will be diminished to merely offering advice.
There is a good deal of trepidation about the changes. Hospital doctors fear that GPs will not understand what secondary care providers might be offering; that they might go for a cheaper option without understanding why it is so cheap (ie it doesn't work); that they might repatriate services to GP practices inappropriately (eg near patient blood testing which is much more expensive than testing in laboratories with large machines and it is poorly quality controled, though superficially it does offer some attractive qualities like instant access, it is like comparing a Polaroid picture with a professional photographer).
I came across a good example of how things can go wrong. A Primary Care Trust decided to purchase GP blood tests from a different hospital from the one that patients were likely to be referred to for treatment. One result was that patients arrived for treatment with no blood test results on the hospital computer so that everything had to be repeated, but worse than this, the GPs would ring up the lab where the patient was registered to ask for advice on the recent blood test. Of course the hematologist had not seen the recent blood test an could not give an opinion. On the other hand, the haematologist at the hospital where the blood test was performed, could not help; he did not know the patient and in any case the contract was for blood tests, not their interpretation - that's why they were cheaper.
GP's are worried that they have no management training and may not be up to the job, but undoubtedly they will employ some of the displaced managers from the PCTs. Patients are worried that we will be back to post code prescribing. am worried that GPs will purchase complimentary medicine rather than cancer chemotherapy.
In the BMJ of January 29th, Des Spence, a left wing GP and regular columnist, voices his opinion on the changes. He admits that the previous government pushed up labor costs and reduced productivity, but he fears that the private sector will find this an easy way in to the NHS. The private sector, he says is not based on competition, but greed. He is scathing about the effect of competition in the USA. Healthcare costs are twice as expensive as in the UK and 50 million citizens have restricted access to care. Medicare and Medicaid together spend almost as great a proportion of a much larger GDP as the whole of the NHS does of the smaller British GDP, and when you add in the VA and CDC the proportion is greater. He also claims that the US system is more bureaucratic and that 'competition' has produced the world's most expensive drugs. He says that the US system is defined by overinvestigation, overdiagnosis and overtreatment. Mere activity is no measure of quality.
There is a good deal of trepidation about the changes. Hospital doctors fear that GPs will not understand what secondary care providers might be offering; that they might go for a cheaper option without understanding why it is so cheap (ie it doesn't work); that they might repatriate services to GP practices inappropriately (eg near patient blood testing which is much more expensive than testing in laboratories with large machines and it is poorly quality controled, though superficially it does offer some attractive qualities like instant access, it is like comparing a Polaroid picture with a professional photographer).
I came across a good example of how things can go wrong. A Primary Care Trust decided to purchase GP blood tests from a different hospital from the one that patients were likely to be referred to for treatment. One result was that patients arrived for treatment with no blood test results on the hospital computer so that everything had to be repeated, but worse than this, the GPs would ring up the lab where the patient was registered to ask for advice on the recent blood test. Of course the hematologist had not seen the recent blood test an could not give an opinion. On the other hand, the haematologist at the hospital where the blood test was performed, could not help; he did not know the patient and in any case the contract was for blood tests, not their interpretation - that's why they were cheaper.
GP's are worried that they have no management training and may not be up to the job, but undoubtedly they will employ some of the displaced managers from the PCTs. Patients are worried that we will be back to post code prescribing. am worried that GPs will purchase complimentary medicine rather than cancer chemotherapy.
In the BMJ of January 29th, Des Spence, a left wing GP and regular columnist, voices his opinion on the changes. He admits that the previous government pushed up labor costs and reduced productivity, but he fears that the private sector will find this an easy way in to the NHS. The private sector, he says is not based on competition, but greed. He is scathing about the effect of competition in the USA. Healthcare costs are twice as expensive as in the UK and 50 million citizens have restricted access to care. Medicare and Medicaid together spend almost as great a proportion of a much larger GDP as the whole of the NHS does of the smaller British GDP, and when you add in the VA and CDC the proportion is greater. He also claims that the US system is more bureaucratic and that 'competition' has produced the world's most expensive drugs. He says that the US system is defined by overinvestigation, overdiagnosis and overtreatment. Mere activity is no measure of quality.
Thursday, November 04, 2010
The evisceration of NICE
Polly Toynbee says, "NICE is one of Labour's best inventions". Proof if ever it was needed that NICE has to go. It is is a truth self-evident to all Guardian readers that whatever Polly Toynbee says is automatically antithetical to all right-thinking people. When Polly pontificates we know what side to take.
I don't suppose Polly has ever sat in on a NICE appraisal so as usual she is talking about something of which she has only theoretical knowledge. I have sat in as an expert witness on five occasions. On almost all occasions NICE has got it wrong at first, though sometimes they have managed to correct their view on appeal.
There are several things wrong with the way NICE goes about their work. First: certain members (though not all) of their committees have an extreme prejudice against pharmaceutical companies. They naturally assume that the company is dishonest. I have even seen committee members accuse expert witnesses of being in the pay of Big Pharma and being made to withdraw the assertion under the threat of legal action.
Second: the choice of their own 'expert witnesses' is sometimes bizarre - eschewing people who have researched and written about the problem in favour of local generalists who have no reputation in the field.
Third: their research is done by health economists and 'teenage scribblers' - young graduates who just review the literature without any experience of treating patients or of the great variety of clinical situations that present themselves. These people have no 'feel' for either the disease or its treatment.
Fourth: despite the assertion that 'post-code prescribing' is a great sin, it is actually extremely sensible. For example, there National Guidelines on sickle cell screening for mothers. This is extremely sensible in Camberwell where there is a very high incidence of people of Afro-Caribbean descent, but very stupid in Bournemouth where almost everybody is 'oppressively' white. In Bournemouth, the major health problem is care for the elderly - especially of Alzheimer's disease. The denial of drugs for early cases was much more unfair in Bournemouth than, say, somewhere like Derby, where the geriatricians have so few old people to look after that they look after people in their 50s.
This new government is committed to localism and I thoroughly approve. Having sat through endless reorganisations I am certain the the NHS was best managed in the period prior to 1974 when local authorities could still influence decisions about the provision of services. If you believe in getting the best health service you can in your local area (which is what most people want - they couldn't care a fig for the problems of people in Glasgow who smoke, drink and feast on deep-fried Mars bars - unless they are Glaswegians), then these new moves to disempower NICE can only he welcomed.
I don't suppose Polly has ever sat in on a NICE appraisal so as usual she is talking about something of which she has only theoretical knowledge. I have sat in as an expert witness on five occasions. On almost all occasions NICE has got it wrong at first, though sometimes they have managed to correct their view on appeal.
There are several things wrong with the way NICE goes about their work. First: certain members (though not all) of their committees have an extreme prejudice against pharmaceutical companies. They naturally assume that the company is dishonest. I have even seen committee members accuse expert witnesses of being in the pay of Big Pharma and being made to withdraw the assertion under the threat of legal action.
Second: the choice of their own 'expert witnesses' is sometimes bizarre - eschewing people who have researched and written about the problem in favour of local generalists who have no reputation in the field.
Third: their research is done by health economists and 'teenage scribblers' - young graduates who just review the literature without any experience of treating patients or of the great variety of clinical situations that present themselves. These people have no 'feel' for either the disease or its treatment.
Fourth: despite the assertion that 'post-code prescribing' is a great sin, it is actually extremely sensible. For example, there National Guidelines on sickle cell screening for mothers. This is extremely sensible in Camberwell where there is a very high incidence of people of Afro-Caribbean descent, but very stupid in Bournemouth where almost everybody is 'oppressively' white. In Bournemouth, the major health problem is care for the elderly - especially of Alzheimer's disease. The denial of drugs for early cases was much more unfair in Bournemouth than, say, somewhere like Derby, where the geriatricians have so few old people to look after that they look after people in their 50s.
This new government is committed to localism and I thoroughly approve. Having sat through endless reorganisations I am certain the the NHS was best managed in the period prior to 1974 when local authorities could still influence decisions about the provision of services. If you believe in getting the best health service you can in your local area (which is what most people want - they couldn't care a fig for the problems of people in Glasgow who smoke, drink and feast on deep-fried Mars bars - unless they are Glaswegians), then these new moves to disempower NICE can only he welcomed.
Sicker Americans rescued by expensive healthcare
Are Americans healthier than English people? Certainly not, but they do live slightly longer.
This paradoxical situation is described in a new report in the journal Demography and reported in today's Daily Telegraph. People in the US are twice as likely to contract diabetes and a third more likely to develop cancer than those among similar aged people in England.
The study, co-authored by the Institute for Fiscal Studies in London, involved analysing information from two comparable surveys of people aged 50 and over in the United States and England – 20,000 people in the US Health and Retirement Survey and 12,000 people in the English Longitudinal Survey of Ageing.
They found that on average American people aged 55 to 64 were between a third and a half more likely to suffer from one or more of the following chronic diseases: diabetes, high-blood pressure, heart disease, heart attack, stroke, chronic lung diseases and cancer. Diabetes rates were more than twice as high in the United States as in England (12.07 per cent versus 5.88 per cent) and cancer prevalence was more than third as high in the United States (9.57 per cent compared to 5.48 per cent) for people aged 55 to 64. Despite this, both sets of pensioners had a similar life expectancy (82 for men, 85 for women) with Americans actually living on average a few months longer.
It appears that at least in terms of survival at older ages with chronic disease, the medical system in the United States may be better than the system in England. Why is this? it is a case of throwing more money at a problem. Official figures from the OECD show that America spends 16 per cent of its GDP on health care compared with 8.7 per cent in England. As a result, the American system is much more likely to aggressively screen and treat diseases, no matter how much it costs. Americans are much sicker but they make up for it with much more aggressive and expensive health care.
This paradoxical situation is described in a new report in the journal Demography and reported in today's Daily Telegraph. People in the US are twice as likely to contract diabetes and a third more likely to develop cancer than those among similar aged people in England.
The study, co-authored by the Institute for Fiscal Studies in London, involved analysing information from two comparable surveys of people aged 50 and over in the United States and England – 20,000 people in the US Health and Retirement Survey and 12,000 people in the English Longitudinal Survey of Ageing.
They found that on average American people aged 55 to 64 were between a third and a half more likely to suffer from one or more of the following chronic diseases: diabetes, high-blood pressure, heart disease, heart attack, stroke, chronic lung diseases and cancer. Diabetes rates were more than twice as high in the United States as in England (12.07 per cent versus 5.88 per cent) and cancer prevalence was more than third as high in the United States (9.57 per cent compared to 5.48 per cent) for people aged 55 to 64. Despite this, both sets of pensioners had a similar life expectancy (82 for men, 85 for women) with Americans actually living on average a few months longer.
It appears that at least in terms of survival at older ages with chronic disease, the medical system in the United States may be better than the system in England. Why is this? it is a case of throwing more money at a problem. Official figures from the OECD show that America spends 16 per cent of its GDP on health care compared with 8.7 per cent in England. As a result, the American system is much more likely to aggressively screen and treat diseases, no matter how much it costs. Americans are much sicker but they make up for it with much more aggressive and expensive health care.
Thursday, October 28, 2010
More good news
My old hospital had an iron lung on the ward 2 balcony. We never had to use it, but in 1956 children from my school died from polio and others were in leg irons. That was why we seldom went swimming.
26 October 2010 -- This week, Africa has the unprecedented chance to drive out polio when 15 countries across the continent launch a synchronized mass immunization campaign to reach 72 million children. Some 290 000 vaccinators will go door-to-door to deliver two drops of oral polio vaccine (OPV) to every child under five in "highest risk" areas for polio transmission.
It seems that one of the serotypes of wild poliovirus (type 2) has already been eradicated so the immunisation campaign is now concentrating on Types 1 and 3.
Attempts to control polio in Nigeria suffered a setback in 2003 when a group of Muslim clerics claimed that the conventional vaccine was tainted as part of a U.S. plot to make women there infertile.
There is now a new vaccine that is claimed to be four times more effective than the previous one. Although eradicated from most of the globe, polio can still be found in northern Nigeria, northern India and along the Pakistan-Afghanistan border. In 2007, 1,310 cases were reported worldwide, according the U.S. Centers for Disease Control and Prevention.
But this news item might yet prevent success: PESHAWAR, Oct 19: More than 26,000 families have refused to administer anti-polio drops to their children in Khyber Pakhtunkhwa. "These families refused administering oral vaccine to their children because the parents thought it turned the recipients infertile and impotent," they said. Two campaigns carried out from September 27 to 29 and October 11 to 13 showed that those parents flatly refused to get their children immunised on religious grounds. The Khyber Pakhtunkhwa and Fata together have reported 57 cases of polio this year so far.
Pakistan has become one of the poorly performing countries in the history of polio eradication programme,” they said. Other polio-endemic countries have shown tremendous progress in polio eradication as Nigeria reported 400 cases in 2009 but number of cases this year is only 8. India had brought down the cases to 31 compared to 385 last year while Afghanistan reported 75 cases in 2009 and this year only 18.
Pakistan had recorded 82 cases this year so far and it could easily surpass the 87 cases, which it reported last year.
26 October 2010 -- This week, Africa has the unprecedented chance to drive out polio when 15 countries across the continent launch a synchronized mass immunization campaign to reach 72 million children. Some 290 000 vaccinators will go door-to-door to deliver two drops of oral polio vaccine (OPV) to every child under five in "highest risk" areas for polio transmission.
It seems that one of the serotypes of wild poliovirus (type 2) has already been eradicated so the immunisation campaign is now concentrating on Types 1 and 3.
Attempts to control polio in Nigeria suffered a setback in 2003 when a group of Muslim clerics claimed that the conventional vaccine was tainted as part of a U.S. plot to make women there infertile.
There is now a new vaccine that is claimed to be four times more effective than the previous one. Although eradicated from most of the globe, polio can still be found in northern Nigeria, northern India and along the Pakistan-Afghanistan border. In 2007, 1,310 cases were reported worldwide, according the U.S. Centers for Disease Control and Prevention.
But this news item might yet prevent success: PESHAWAR, Oct 19: More than 26,000 families have refused to administer anti-polio drops to their children in Khyber Pakhtunkhwa. "These families refused administering oral vaccine to their children because the parents thought it turned the recipients infertile and impotent," they said. Two campaigns carried out from September 27 to 29 and October 11 to 13 showed that those parents flatly refused to get their children immunised on religious grounds. The Khyber Pakhtunkhwa and Fata together have reported 57 cases of polio this year so far.
Pakistan has become one of the poorly performing countries in the history of polio eradication programme,” they said. Other polio-endemic countries have shown tremendous progress in polio eradication as Nigeria reported 400 cases in 2009 but number of cases this year is only 8. India had brought down the cases to 31 compared to 385 last year while Afghanistan reported 75 cases in 2009 and this year only 18.
Pakistan had recorded 82 cases this year so far and it could easily surpass the 87 cases, which it reported last year.
Wednesday, October 27, 2010
Life expectancy
Last year there were 491,348 deaths in Britain - a 3.5 per cent drop from 2008. The number dying from coronary heart disease fell by 28 per cent in men and 32 per cent in women between 2004 and 2009.
The improvement is being attributed to the use of statins which have cut deaths from coronary thrombosis. However, it could as easily be attributed to fewer people smoking. I am told that heart attacks end in death in only 8% of incidents now and that this occurs almost entirely in smokers.
Infant mortality rate was also at its lowest point in 2009. There is no getting away from it: people are living longer.
At the same time there is news that Swine flu hit young children disproportionately and especially children from a Pakistani and Bangladeshi backgrounds. There were 457 reported and confirmed swine flu-related deaths across the UK between April last year and March this year. The highest death rate of 14 per million was for children aged less than a year old. Mortality rates were much higher for Bangladeshi children (47 deaths per million population) and Pakistani children (36 deaths per million) than for white English children (four deaths per million). Those with pre-existing conditions - especially neurological diseases such as cerebral palsy - were hardest hit.
The elephant in the room is the high incidence of inherited disease in families from the Indian sub-continent - especially in the Muslim community - because of consanguineous marriage. The impact on the health service is immense. Where the genetic defect is identified the cost of remedying it is huge, and where it is unidentified it brings unknown and expensive medical problems.
I am not one who would turn sick immigrants away - though I have been told that the assumptions made by patients' relatives that the NHS should provide a service that hasn't been paid for to anyone who turns up from anywhere in the world appears to the young doctors who must do the work as breathtakingly rude. I believe that the rich nations do have a responsibility to the needy of poor nations, but prevention is part of the remedy. There are no religious reasons for marrying your cousins. The motive is greed - to keep the family fortune from passing into the hands of strangers. It was the same thing that was practised in Britain before the 1st World War, when estates were entailed to the eldest son of a family. Try watching the new Julian Fellowes' country house drama, Downton Abbey.
My own particular objection to the inclusion of Bangladeshi and Pakistani statistics is that these have the effect of lowering the reputation of the NHS, which generally performs very well. It is the same effect that tells us that 41 million Americans carry no medical insurance. Many of them are illegal immigrants. We do not need across the board changes in the name of political correctness, to solve a problem that is very specific and particular. Resources must be directed at problems, not laid on with a trowel.
The improvement is being attributed to the use of statins which have cut deaths from coronary thrombosis. However, it could as easily be attributed to fewer people smoking. I am told that heart attacks end in death in only 8% of incidents now and that this occurs almost entirely in smokers.
Infant mortality rate was also at its lowest point in 2009. There is no getting away from it: people are living longer.
At the same time there is news that Swine flu hit young children disproportionately and especially children from a Pakistani and Bangladeshi backgrounds. There were 457 reported and confirmed swine flu-related deaths across the UK between April last year and March this year. The highest death rate of 14 per million was for children aged less than a year old. Mortality rates were much higher for Bangladeshi children (47 deaths per million population) and Pakistani children (36 deaths per million) than for white English children (four deaths per million). Those with pre-existing conditions - especially neurological diseases such as cerebral palsy - were hardest hit.
The elephant in the room is the high incidence of inherited disease in families from the Indian sub-continent - especially in the Muslim community - because of consanguineous marriage. The impact on the health service is immense. Where the genetic defect is identified the cost of remedying it is huge, and where it is unidentified it brings unknown and expensive medical problems.
I am not one who would turn sick immigrants away - though I have been told that the assumptions made by patients' relatives that the NHS should provide a service that hasn't been paid for to anyone who turns up from anywhere in the world appears to the young doctors who must do the work as breathtakingly rude. I believe that the rich nations do have a responsibility to the needy of poor nations, but prevention is part of the remedy. There are no religious reasons for marrying your cousins. The motive is greed - to keep the family fortune from passing into the hands of strangers. It was the same thing that was practised in Britain before the 1st World War, when estates were entailed to the eldest son of a family. Try watching the new Julian Fellowes' country house drama, Downton Abbey.
My own particular objection to the inclusion of Bangladeshi and Pakistani statistics is that these have the effect of lowering the reputation of the NHS, which generally performs very well. It is the same effect that tells us that 41 million Americans carry no medical insurance. Many of them are illegal immigrants. We do not need across the board changes in the name of political correctness, to solve a problem that is very specific and particular. Resources must be directed at problems, not laid on with a trowel.
Saturday, October 16, 2010
How to make new drugs available earlier and cheaper.
In today's BMJ there is an open letter to the Secretary of State for Health from Professor Peter Lachmann, the retired professor of immunology from Cambridge University and past-president of the Academy of Medical Sciences. In it he makes this interesting suggestion:
About 60% if drug development is taken up by late stage, Phase III trials. Phase I trials ensure safety and phase II trials demonstrate efficacy. Both require small numbers of patients and are relatively cheap to run. Phase III trials are expensive to run and require large numbers of patients, but still cannot detect side effects that occur in fewer than one in a thousand patients.
He says that the population now believes that drugs have to be absolutely safe ans that if anybody comes to harm from them they should be able seek compensation from the courts, and that this has led to drugs being hugely expensive and very slow to bring into use. It is now estimated that to develop a novel drug costs several hundreds of millions of dollars and takes at least 10 years.
In his opinion there is a strong case for making drugs available after phase II trials have shown that they work and to rely on post-marketing surveillance for detecting rare side effects. This would make new drugs much cheaper and available much earlier. It is arguable that phase III trials save fewer lives from avoided side effects than they cause by delaying their availability.
Initially patients should be able to get these new drugs by signing a waiver indemnifying the manufacturer from damages should there be any harm from the drug.
In any case the practice of suing drug companies for adverse effects is pointless. It does the company no financial harm, since the cost is passed on to the consumer. Only lawyers benefit. Legal redress should be reserved for negligence of other malfeasance.
It is probable that many useful drugs are never developed because the potential market is too small and the financial risks too great.
I can see merit in this approach, but Lachmann misses out on the benefits of phase III trials. Phase II trials will show you that a drug has activity in a particular disease and by doing randomized phase II trials (which are a bit more expensive) you can even see if it is more active than the best available alternative, but without phase III trials you will never know whether the new drug gives you a better lifestyle or a longer life than what went before. And you certainly won't know whether it is worth buying.
About 60% if drug development is taken up by late stage, Phase III trials. Phase I trials ensure safety and phase II trials demonstrate efficacy. Both require small numbers of patients and are relatively cheap to run. Phase III trials are expensive to run and require large numbers of patients, but still cannot detect side effects that occur in fewer than one in a thousand patients.
He says that the population now believes that drugs have to be absolutely safe ans that if anybody comes to harm from them they should be able seek compensation from the courts, and that this has led to drugs being hugely expensive and very slow to bring into use. It is now estimated that to develop a novel drug costs several hundreds of millions of dollars and takes at least 10 years.
In his opinion there is a strong case for making drugs available after phase II trials have shown that they work and to rely on post-marketing surveillance for detecting rare side effects. This would make new drugs much cheaper and available much earlier. It is arguable that phase III trials save fewer lives from avoided side effects than they cause by delaying their availability.
Initially patients should be able to get these new drugs by signing a waiver indemnifying the manufacturer from damages should there be any harm from the drug.
In any case the practice of suing drug companies for adverse effects is pointless. It does the company no financial harm, since the cost is passed on to the consumer. Only lawyers benefit. Legal redress should be reserved for negligence of other malfeasance.
It is probable that many useful drugs are never developed because the potential market is too small and the financial risks too great.
I can see merit in this approach, but Lachmann misses out on the benefits of phase III trials. Phase II trials will show you that a drug has activity in a particular disease and by doing randomized phase II trials (which are a bit more expensive) you can even see if it is more active than the best available alternative, but without phase III trials you will never know whether the new drug gives you a better lifestyle or a longer life than what went before. And you certainly won't know whether it is worth buying.
Tuesday, September 28, 2010
Bribing patients
Yesterday, Sir Michael Rawlins, the head of NICE (what they call a death committee in America) was on the radio talking about whether to bribe people to stay healthy.
Once the public exchequer assumes responsibility for people's healthcare it has a financial interest in limiting its costs. Much healthcare expenditure is related to lifestyle choices - smoking, drinking, lack of exercise and doing drugs. True freedom would allow people do make these choices, though they can make the payment if they choose badly. But I don't want them doing it on my dollar. Even without government healthcare, I pick up some of the cost - spousal beatings, road traffic accidents, environmental health hazards, police, the courts, abandoned children etc.
There are studies that show that free gym membership, free self-help groups and the like can change bad habits and reduce later expenditure on treatment of coronary heart disease, diabetes and the like. So should government engage in a sort of libertarian paternalism to change people's habits?
There is a moral question. Should the honest, worthy poor pay for the feckless? And if we admit a carrot, when should we admit a stick?
Thaler and Sunstein would suggest a 'nudge' rather than money. One suggestion: a would-be non smoker opens a checking account. For every day the cost of her cigarettes goes in the bank. On any day there is no deposit, the bank empties the account into that of her least favorite charity - (Free Palestinians for example).
Once the public exchequer assumes responsibility for people's healthcare it has a financial interest in limiting its costs. Much healthcare expenditure is related to lifestyle choices - smoking, drinking, lack of exercise and doing drugs. True freedom would allow people do make these choices, though they can make the payment if they choose badly. But I don't want them doing it on my dollar. Even without government healthcare, I pick up some of the cost - spousal beatings, road traffic accidents, environmental health hazards, police, the courts, abandoned children etc.
There are studies that show that free gym membership, free self-help groups and the like can change bad habits and reduce later expenditure on treatment of coronary heart disease, diabetes and the like. So should government engage in a sort of libertarian paternalism to change people's habits?
There is a moral question. Should the honest, worthy poor pay for the feckless? And if we admit a carrot, when should we admit a stick?
Thaler and Sunstein would suggest a 'nudge' rather than money. One suggestion: a would-be non smoker opens a checking account. For every day the cost of her cigarettes goes in the bank. On any day there is no deposit, the bank empties the account into that of her least favorite charity - (Free Palestinians for example).
Friday, September 24, 2010
GTAC to go
I see in this morning's Telegraph that the QUANGO that I am a member of, GTAC, is to go. We had already lost our right to a first class ticket on the train to travel to the meetings, but now the whole thing is to disappear. Actually, it will simply revert to being an ordinary ethical committee for gene therapy trials and this will mean that the experts who have been recruited to study the trials will no longer be paid to do so. I suspect that they will find their time too much in demand to be able to volunteer it. For around 20 hours work per meeting, the fee was £150 - not much more than the minimum wage.
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