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28 February, 2007

Legal appeal forces the NHS into the modern world

A cancer sufferer who spent 70,000 pounds on a drug that he believed would prolong his life has been told it can now be prescribed on the NHS. Keith Ditchfield, 53, a businessman who lives in Stonyhurst, Lancashire, is terminally ill. He learnt of Nexavar while receiving treatment in Germany. When he asked for the medication to be prescribed on the health service last year, he was turned down.

Since then Mr Ditchfield, has been buying the drug and believes that it has prolonged his life and left him, at least temporarily, in remission.

He has now been told that his appeal against the decision by East Lancashire Primary Care Trust has been successful. Nexavar was approved by the US Food and Drug Administration in 2005 and is widely prescribed in Europe for advanced cancers.

Source



HAVING GOOD CONTACTS STILL MATTERS IN BRITISH MEDICAL CARE

Exactly what the NHS was designed to obviate

Peter Ashley was told that he had dementia seven years ago, after enduring three years of treatment for a series of wrongly diagnosed conditions that culminated in electric shock therapy.

The retired company director from Warrington recalls very well the day he and his wife were given the diagnosis of Lewy bodies dementia, a rarer form of the disease with characteristics of Parkinson's. "We literally fell apart. It was the summer, and I remember we sat on the patio for days just crying - and we are not really that sort of couple. I just did not know what it meant for my retirement plans, our plans for more holidays and, most importantly, what it would mean for my three daughters and my wife," he said.

However Mr Ashley, 71, has been fortunate, receiving excellent medical and psychiatric treatment, and he continues to live a fulfilling life. Fortunately, a neighbour held a senior post in the local mental health care trust, so he was given prompt and up-to-date advice on treatment. Unusually for early-stage dementia, he was approved for drug therapy, although only on the basis of a trial. He takes Exelon, which helps to retain cognitive function.

"I also adopted a `use it or lose it' strategy and began to lecture on dementia and sat on the NICE Guideline Development Group, which came up with recommendations for treatment. I have very bad short-term memory problems and I cannot get around very well. My spatial awareness is very poor. But I am convinced that the drugs have been a key element in helping me to retain a great deal of my mental capability," he said.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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27 February, 2007

STATE GOVERNORS WANT FEDERAL HANDOUT FOR BACKDOOR SOCIALIZATION OF MEDICINE

U.S. state governors appealed Sunday for President George W. Bush and Congress to provide more money for a health-care program that insures millions of children. At stake is coverage for six million people, overwhelmingly children, as well as the hopes of many governors of tackling the larger challenge of the uninsured. All governors rely on the program, intended to aid uninsured working families. "We can come to a consensus that children should be the first priority," said Georgia Gov. Sonny Perdue.

State leaders met privately to discuss the State Children's Health Insurance Program at their annual winter meeting of the National Governors Association. "This is one area where I think people stand entirely together," said New Jersey Gov. Jon Corzine. Georgia and New Jersey are two of 14 states that are expected to run out of money for the program before the next budget year begins in October; in Georgia, it could be as soon as March. The governors want two things: enough money to keep the program afloat through October and changes to Bush's budget.

Analysts say his spending plan would shortchange the health program, even if the number of people served did not grow. The figure is put at US$10 billion to $15 billion over the next five years. U.S. Health and Human Services Secretary Mike Leavitt said he met privately with governors and would keep talking. But he offered little hope the administration would accept governors' demands.

The program, approved in 1997, covers uninsured children whose families earn too much to fall under Medicaid, the joint state-federal health care service for the poor. More than a dozen states have expanded the SCHIP program, with consent of the U.S. government, to cover adults in those families. The program now insures an estimated 639,000 adults among its six million.

Many governors said the administration's efforts to scale back the program would undermine state efforts to craft universal health care plans. Many of these have started with a target of insuring all children. "Many, many states seek to expand it as a step on the way to universal health care," said Arizona Gov. Janet Napolitano. "Governors are doing more on health care than anyone else."

California, Massachusetts and Pennsylvania have developed some of the most ambitious proposals to try for universal health-care coverage. Most states have just tried to strengthen their health-care system to cover more people. At their private session Sunday, governors said there is bipartisan support for help on the immediate needs and a long-term commitment to the current program.

Leavitt said Sunday there is enough money among states to cover short-term shortfalls, if states with surpluses share with those with deficits, an idea that has little support among governors. And Bush wants the SCHIP program to remain focused on poor children, not all children and not adults, beyond those states where it's already allowed, Leavitt said.

Napolitano, who heads the NGA, said the issue would come up Monday when governors meet with members of Bush's cabinet. A bipartisan group of 13 governors has written congressional leaders asking them to cover the money shortfall before the budget year ends. "We built all that up. We don't want to pull the rug out," said Rhode Island Gov. Don Carcieri. With aggressive enrolment, his state had enrolled 94 per cent of children before administrative hurdles and other problems lowered that number, he said.

Maryland Gov. Martin O'Malley said in their private lunch, many governors were "visibly frustrated" at the administration's approach. In public, several governors said they were confident they could work out a compromise. Pennsylvania Gov. Ed Rendell unrolled a plan this year to extend coverage to nearly all his state's citizens. He said the administration had been helpful to his efforts and just last week approved a waiver allowing the state to raise its eligibility for the program to 350 per cent of federal poverty levels. "This covers about our last 180,000 children who aren't covered," Rendell said. "I want to give the administration high praise."

Amid all the discussion about dollars and percentages, the real cost is being ignored, some governors said. "I think more about what it means to be a parent, a parent who can't go to sleep at night without worrying that if my kid gets ill tomorrow or gets in an accident, he won't have adequate coverage," said Virginia Gov. Tim Kaine. "I can't imagine more anxiety."

Source



Sick elderly left starving in Australian public hospitals

As many as four in every 10 elderly patients in Queensland hospitals could be slowly starving in their beds. Health staff are failing to notice the signs of malnutrition and are too busy to check whether patients are eating properly, The Courier-Mail can reveal. Malnutrition can delay recovery times and in severe cases quicken a patient's death.

Merrilyn Banks, director of nutrition at the Royal Brisbane and Women's Hospital, said: "We think malnutrition only happens in Third World countries, but it is a problem in aged care and hospitals here. "We have found that 30 to 40 per cent of elderly patients are affected. There's generally not enough awareness of the issue because we are used to treating disease and are just not looking for under-nutrition."

Malnutrition can cause the condition of a patient admitted to hospital with a minor illness to rapidly deteriorate. "When people get ill they have trouble with their appetite and it becomes more difficult for them to eat," Ms Banks said. "Malnutrition can actually increase the rate of infection and may slow rehabilitation." She said medical staff were not necessarily to blame for patients failing to eat. "In a lot of cases malnutrition is just not obvious," she said. "Everybody in the health system is very busy."

Anthony Power, a Brisbane private practice nutritionist, said he saw up to 10 elderly patients each week suffering from malnutrition after being discharged from hospital. In one case, a woman in her 60s had lost almost 20kg after she developed a post-operative infection. "It can happen very quickly. They may be recovering from an illness and don't have the energy to eat and then develop vitamin and mineral deficiencies which further impair their digestion. "The system needs to do more to tackle this."

Ms Banks has received funding from the hospital's Research Foundation to assess how much the problem is costing Queensland Health through longer hospital stays and the treatment of associated complications. One solution might be the appointment of dedicated care assistants to ensure elderly people eat properly while on the wards.

Val French, president of Queensland pressure group Older People Speak Out, said: "Older people are the least likely to ever complain." Gay Hawksworth, secretary of the Queensland Nurses Union, added: "There is a shortage of nurses . . . but nurses are well aware of the need to make sure patients are eating and drinking." [The notoriously low attractiveness of public hospital food surely does not help. And the recent move to make it "healthy" has almost certainly reduced its attractiveness even further. People are not rabbits and elderly people in particular are most unlikely to change lifetime dietary habits]

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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26 February, 2007

The bugs the NHS can’t beat

Last week’s horrifying statistics reveal hospitals are no nearer to killing off super bugs, says Sian Griffiths

How would you feel if a relative was about to go into hospital? A friend told me recently that when she heard her mother had to have an operation her first thought was: “Oh no, she’ll get MRSA.” Certainly the headlines in the papers last week seemed to justify her fears. Deadly hospital superbugs killed a record 5,400 people during 2004-05, according to figures released on Thursday by the Office for National Statistics (ONS).

And now as well as MRSA there’s an even more lethal infection stalking the wards. Deaths involving clostridium difficile rose 69% — up from 2,247 to 3,807 — while deaths from MRSA climbed 39% from 1,168 to 1,629. In other words, clostridium difficile (commonly known as C diff) was a cause of mortality on two in every 500 death certificates and MRSA a cause of death on one in every 500.

Hugh Pennington, a microbiologist, says that C diff, which can thrive when the balance of bacteria in the gut is disturbed after antibiotic treatment, causing diarrhoea and vomiting, produces a “toxic poison and is very often the last straw”.

The ONS figures are worrying enough, but campaigners warn that the real statistics could be even higher because of underreporting on death certificates. Nor do they take account of victims who survive such as the actress Leslie Ash, who announced last month that she is suing the Chelsea and Westminster hospital in London for £1m compensation after being struck down by a superbug during treatment there. Three years on, she is unable to walk unaided. Papers lodged at the High Court say her career is all but over.

No one is more furious about last week’s ONS report than agony aunt Claire Rayner. Not only did she contract MRSA after a routine stay at a National Health Service hospital six years ago, she has now been infected once again. Last week Rayner, 76, told The Sunday Times she is being treated for MRSA, which she believes she caught recently at her local hospital while waiting for treatment to a wound to her knee. “I think I got MRSA from sitting for four hours with an open wound in a busy A and E department,” she says. “But I am glad it is not C diff. Things are simply not being done properly. Hospitals should smell of carbolic and antiseptic and soap, not lavatories and vomit.”

Rayner is president of a campaign for better NHS care. Thousands of families have contacted the Patients Association helpline to share their stories of filthy wards, unclean toilets, sticky floors and serious, sometimes fatal, illnesses caused by the superbugs — strains that are resistant to many antibiotics.

Katherine Murphy of the association says it took one call last week from a woman who had lost a close relative to C diff, probably contracted at the local hospital. “She went to the coroner’s office early on a Monday morning and he said to her, ‘You are the first this week, but last week I had four deaths from C difficile caught at that hospital’.”

According to Kerry Walker, 31, who is considering legal action against the Southern general hospital in Glasgow, where she believes she contracted an almost fatal bout of C diff during a caesarean, the bug will be even more infamous than MRSA.

It is three years since the then health secretary John Reid called for MRSA infection rates in hospitals to be halved by 2008. That same year Rayner nursed her husband Des at home with a private nurse rather than risk him entering hospital. With last week’s figures soaring to such terrifying heights, many families must feel tempted to make similar decisions.

The problem for hospitals is that the superbugs are highly infectious and easily transmitted, particularly to patients with open wounds. And as hospital trusts struggle with funding deficits, cleaning contracts are high on the list of things to be shaved back.

“Fighting hospital-acquired infections is simply not a priority for ministers who are more preoccupied with cutting operation waiting times,” says Murphy. Pennington partly agrees: “More and more patients is a reason why staff just don’t have the time to do things such as basic hygiene.” The government insists its target of halving MRSA infections (as opposed to death rates) will be met by 2008 and that they have already fallen by 11% in two years. “We are not losing the battle on MRSA,” says a spokesman. “The challenge is for trusts to go further faster.”

Rayner, however, advocates that patients take charge of their own hygiene: showering before an operation and carrying antiseptic wipes. Somehow I don’t think that will reassure my friend. It sounds like the boy trying to stick his fist in the dyke — too little, too late.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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25 February, 2007

BRITISH AMBULANCE MESS

Two thirds of the ambulance trusts in England are missing targets to attend life-threatening emergencies quickly because of a shortage of funding, The Times has learnt. Millions of pounds needed to fund extra vehicles and crews are instead being withheld as local health authorities struggle to balance their books before the end of the financial year, ambulance leaders say.

The number of 999 ambulance calls has more than doubled in a decade and has risen even this year as patients have become concerned about access to out-of-hours GP services, the Ambulance Service Association (ASA) said. But despite a streamlining of the service last year designed to improve performance, the latest figures obtained by The Times reveal that 8 of the 12 mainland ambulance services are failing to achieve a 75 per cent success rate for attending serious emergency calls within eight minutes.

The current situation, using year-to-date figures, compares with the end of the previous financial year when three quarters of the 31 ambulance trusts in England were hitting the target for 75 per cent of ambulances to attend priority calls within eight minutes.

Richard Diment, chief executive of the ASA, said that the reorganisation of the service, an increase in demand and a lack of funding had all contributed to a fall in performance since July. “The number of category A calls has risen by about 10 per cent week-on-week compared with last year, and the total number of calls by 6 to 8 per cent,” he said. “The public and the Department of Health expect ambulance trusts to perform to national standards, yet PCTs are saying, ‘We know these are the targets but we just do not have the resources to help you meet them’.”

Mr Diment criticised local NHS primary care trusts (PCTs), which fund the ambulance service, for letting emergency response times slip while they struggled to balance their books and meet the 18-week maximum waiting times target for hospital referrals.

Ambulance trusts in North West, West Country, South East Coast and London are among the trusts currently missing the category A target. Some say that they hope to catch up by the end of the financial year. Other trusts have recorded huge variations in the different patches they cover, suggesting that high-performing areas could be masking low achievement elsewhere. For example, in South Western Ambulance Service, Dorset hits the target consistently , while Somerset and Cornwall have failed every month since last July.

Ken Wenman, chief executive of the South Western Ambulance Service, said: “It is historically more difficult to achieve these exacting performance targets in more rural areas. However, this has been recognised by our commissioners, and work is being undertaken to assess the financial implications of meeting them.”

Targets for the ambulance service are due to be toughened from next year, when the response time clock will start from the moment a call was made rather than when all a caller’s details had been taken. Trusts will also be expected to meet a new target to answer 95 per cent of all calls within five seconds. The total number of emergency calls rose from 5.6 million calls in 2004-05 to nearly six million last year

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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24 February, 2007

FINANCIAL FIDDLING IN THE NHS

The NHS is set to break even this year, redeeming the promise made by Patricia Hewitt, the Health Secretary. But figures released yesterday covering the third quarter of the 2006-07 financial year paint a mixed picture. The most deficit-ridden of the NHS organisations appear to have got even further into trouble, but their deficits should be balanced by surpluses made elsewhere to create a small overall surplus of 13 million.

Last year, the gross deficit (the figure resulting from adding up the deficits of all NHS organisations that were in deficit) was 1,312 million. This year it is forecast to be 1,318 million. There are also more organisations forecasting a deficit (35 per cent) this year than there were last (33 per cent).

But the figures are misleading because the income of these organisations was “top-sliced” to create a reserve at the beginning of the year. This reduced their income, plunging more into deficit. The top-slicing removed 1.14 billion from primary care trust [PCT] budgets, and another 450 million was saved from training and public health budgets. An official said yesterday that up to 300 million might be restored to the trusts before the end of the financial year, which would enable many to present a better picture.

The economies have been made by delaying operations, not replacing staff and by deferring orders for supplies wherever possible until the next financial year. There will also be 1,446 compulsory redundancies in 2006-07, compared with 200-300 in a typical year.

Niall Dickson, chief executive of the King’s Fund health think-tank, said what had been done smacked of “a short-term fix for a long-standing problem”. He said: “The goal this year has been to ensure that the NHS as a whole makes a net surplus — turning around last year’s net deficit of 547 million. By holding back around 1.6 billion from PCT and other budgets this year the NHS will achieve this goal. “But financial performance across NHS organisations remains variable; in part as a result of these tactics, nearly half of all PCTs and a third of trusts forecast a deficit by the end of this year — an increase on last year. “Today’s figures once again highlight that if the NHS is going to survive and prosper it will need to get to grips with the underlying causes of the financial deficits.

“There is a need now to tackle low productivity, and deal with the widespread and often unexplained variations in performance. For some organisations this will demand a very different approach to delivery.” The report said that the NHS budget grew to 75 billion in 2006/07, an increase of 5.4 billion. But almost 700 million of that cash was used to pay off deficits from previous years.

Norman Lamb, the Liberal Democrat health spoksman, said: “The Government is employing all sorts of tricks by shifting debts from one organisation to another. These accounting rules would make Del Boy proud but won’t make the problem disappear.”

Andrew Lansley, the Shadow Health Secretary, said: “Labour are able to claim that the NHS will finish this year in surplus, but the surplus they have generated is a sham. “There are more NHS organisations, saddled with worse deficits, than there were last year. “Patricia Hewitt’s skin is being saved only by savage cuts to centrally held budgets, which will all need to be restored in the years to come.”

Peter Carter, general secretary of the Royal College of Nursing, said: “Ministers today might try to claim a small NHS surplus but this figure has only been achieved by raiding essential NHS training budgets, freezing posts, shedding jobs and cutting patient services.”

Source



BUREAUCRATIC INDIFFERENCE KILLING AUSTRALIAN PUBLIC HOSPITAL PATIENTS

Inaction allows superbugs to spread in NSW hospitals

PATIENTS may be getting potentially fatal infections in hospitals because the State Government has yet to allocate any of the $1.6 million it promised to combat drug-resistant superbugs. Professor Lyn Gilbert, who heads an expert panel looking at the problem, said she was surprised more people were not taking legal action. "People are dying of diseases that should have been prevented," she said. "What surprises me is how infrequently people sue hospitals."

Professor Gilbert, who chairs the NSW expert group on multiresistant organisms and the director of Westmead Hospital's Centre for Infectious Diseases and Microbiology, said hospital managers recognised the importance of infection control, "but they are limited by resources". "None have enough [money] to do surveillance work. They put out fires, really," she said.

The NSW Government has long accepted that patients at highest risk of developing potentially lethal bacterial infections - those having joint replacements, heart or vascular surgery and those in intensive care - should be screened before their treatment to check whether the bugs are present on their skin. This is because usually harmless bacterial "colonisation" can cause serious illness if it enters a surgical wound. But hospitals cannot proceed with planned improvements because they have still received none of the funding, promised a year ago to carry out screening and other recommendations of an expert committee convened in the wake of disease outbreaks.

In the western Sydney area alone, said Professor Gilbert, it would cost about $220,000 a year to screen all patients using pathology tests. But hospitals would incur even greater costs if they isolated patients who had been infected or colonised by the virulent organisms. Associate Professor Peter Collignon, director of microbiology and infectious diseases at Canberra Hospital, said up to 5000 Australians developed septicemia from golden staph bacteria while in hospital. "One-third of those will die," he said. "These cause more deaths than the road toll. My firm belief is half of these infections at least are preventable." He said surveillance for pathogens was essential, because hospitals could not act unless they knew they had a problem.

Dr Tom Gottlieb, the vice-president of the Australasian Society for Infectious Diseases, said there was "a kind of nihilism" in the response of health authorities to hospital infections as neither challenged high rates of preventable illness. Dr Gottlieb, a Sydney specialist, said surveillance was expensive and inevitably would identify only a small number of colonised patients compared with the total screened. But it was worth screening for antibiotic-resistant golden staph, in particular, because of its high death rate, he said. If the bacteria affected an artificial joint, it could require three years or longer of antibiotic treatment and repeat surgery.

In a statement to the Herald, a Department of Health spokeswoman blamed "consultation to finalise an equitable split of the funds" and the need to put in place "performance indicators" for the long delay.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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23 February, 2007

Healthcare reform: Some unclear on the concept

The backlash against President Bush's healthcare reform proposal, as expressed in his State of the Union speech last month, has been swift and widespread. From the progressive left comes the very real challenge that the plan calls for no real restraints on insurance premiums, but merely hopes to offset those steadily rising numbers by offering everyone a tax credit, so that those skyrocketing rates continue, being paid for with pre-tax dollars. From the conservative side, there is concern that the Bush plan may penalize those who already have good insurance coverage through their employers.

But perhaps the most ludicrous criticism stems from the claims by the American Association for Retired People and other advocacy groups, that the Bush plan might endanger Social Security funding. According to a McClatchy Newspapers column by Dave Helling, entitled Benefit Dilemma, the question being raised is, "Would you trade health insurance today for tomorrow's check?" He quotes AARP legislative policy director David Certner as saying, "We don't think there should be a trade-off between a health benefit today and a pension benefit tomorrow."

The concern they are raising is that since the tax deduction ($7,500 for individuals, or $15,000 for a family) applies not only to the withholding taken out in weekly paychecks, but to the FICA payroll tax as well. The reason for this, as the article notes, is that if FICA were excluded from the deduction, about a third of all taxpayers would get no benefit at all from the tax-break.

This has AARP and other "elderly advocacy" groups up in arms, since it appears to put working folks in an iimediate bind: choosing between good health today and comfortable retirement later on. The argument goes as follows: If you pay less in payroll taxes along the way, your eventual benefits from Social Security will be smaller. Even supporters of the Bush plan, from such pro-liberty thinktanks as the Cato Institute and the National Center for Policy Analysis, admit that this is "possible" as a result of the proposed system. http://www.cato.org/pub_display.php?pub_id=7171 Michael Cannon, Cato's director of health policy studies, reportedly admits the problem could exist, although he notes that ""Social Security benefits don't help you if you're dead."

And this is where the argument fails, actually. Although AARP is vested in the continuation of Social Security as we know it, the reality is, those current benefits are funded by the ongoing "contributions" of today's working folks,. There is no "lockbox" . and there's no guarantee that twenty years down the road the money will be there for those wishing to "retire" under today's requirements. The "trust fund" is a figment of politicians' imaginations, not a true sequestered funding-source, either now or in the future.

However, there is a much larger question involved here, one the AARP seems to overlook. "Retirement" today has very little to do with ending productive behavior in the world. For most of the Baby Boomer generation, all this means is a shifting from conventional employment to something the heart always wanted to do; more often than not, this means embarking on a whole new career-path, not sitting back in the rocking chairs and waiting for death, as has been presented as the model for retiring in the past.

And the most important factor, or at least one of them, for someone making a decision to continue as a producer in society, is continued health and wellness. Without a sound body and mind, one is hard-pressed to become that writer, artist or whatever that has been crying to be unleashed from within; if illness or frailty is holding you back, the chances are that creative spark will have a hard time reaching the surface. Even for those who do not feel that special creative bent, retirement life in the future is well enhanced by good health, and if not dealing with a roster of physical ailments allows one a much greater chance to keep doing something of value to the world. (In other words, the only people truly affected by this choice are those whose retirement plans consist of "doin' nuthin' the rest of my life"; as studies show, those people won't live very long, without something they truly care about doing to keep the life-spark alive.)

The AARP is of course irate about this, since their existence depends on keeping the "elderly" convinced that they need someone to look out for their interests. Like any other political pressure group, this requires a docile herd of sheep, rather than a hale and hearty assortment of strong and vital individuals, who just happen to be advanced chronologically. As an alternative to the Bush prescription, they are pushing for replacing the proposed tax deduction with a direct tax-credit for healthcare, one which would not touch FICA payments, thereby leaving the retirement issue out of the picture. His expectation is that younger workers at lower pay-rates might apply the credits to paying taxes and then use the extra money for healthcare.

However, this model still promotes the idea that working hard now is the road to leisure and stagnation later on. If the intention is to produce healthier and happier people today, there seems little point in promoting that sedentary life of payback in our later years. For those who truly intend to remain at least somewhat productive, despite advancing years, this diversion of funding to deal with today's issues seems only a logical outcome of that shifting paradigm.

Bottom-line, solving the healthcare mess now, and then focusing our energies on having longer, healthier lives down the road, seems a far better course to take, than continuing to walk the same weathered pathways that have given us the current crisis in healthcare. Although the Bush plan is far from perfect, it does at least in this aspect have the right goals in mind: helping people pay for their own health and wellness, by reducing their tax-burdens otherwise.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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22 February, 2007

Tangle of NHS red tape brings on thoughts of early retirement

Working for the NHS may once have been a decision that lasted the length of a doctor's career but many of today's medics are now considering early retirement or work abroad, The Times/Doctors.net poll reveals. While few are openly contemplating a move to the private sector, almost half of respondents said they were planning early retirement or taking up positions outside Britain. Just over a third said they expected to work for the NHS until normal retirement age.

Many said they still felt that the NHS was one of the best health services in the world but their loyalty was being sorely tested by what they viewed as excessive bureaucracy. Only a minority believed the Government's reform agenda would maintain or improve standards of care. These are not doctors disillusioned with the NHS per se (although a minority are) but with the direction it has taken under Labour.

Nowhere is this shown more clearly than in the answers to questions about the National Programme for IT, a 20 billion plan to put every patient's medical record on line and provide doctors with access to it. Asked if they were optimistic that it would change the way the health service is run, 91 per cent said no, and only 9 per cent yes. More than three quarters (76 per cent) agreed that "overall it has been a frustrating project", but only 14 per cent believed it should be abandoned.

However, few favoured pouring more money into the scheme to ensure success. A massive majority (93 per cent) opposed that idea, with a mere 7 per cent in favour.

Asked what they would like to see changed, doctors voted for less bureaucracy (49 per cent) and less administration (13 per cent). No other changes, including more doctors or more funding, claimed more than 7 per cent support.

Individual comments spelt out the frustrations. While some asked for the sky - "better politicians" - many more backed the idea of keeping politicians out of the NHS altogether, and running it with a nonpolitical governing body like the one that sets interest rates for the Bank of England. Once even suggested that Richard Branson should be recruited to run the NHS. Depoliticisation was a recurrent theme, while many doctors called for greater medical involvement in decision-making, and fewer changes from the top, or for political ends. "Devise a plan and stick to it" one doctor said.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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21 February, 2007

Don't get ill late at night in Britain

Because I have a perversely nocturnal brain I often write late into the night. So I had only just gone to bed last Thursday when the phone rang. My bedside clock said 3.11am. I answered with a sense of foreboding. Aside from the odd wrong number, any call we get between three and seven in the morning usually means that someone we know well is in some sort of trouble.

So it proved. We had been called by a service called Lifeline. If you are old, infirm or housebound and live by yourself, you wear an electronic device like a pendant round your neck. Should you take a tumble and can't get up, you press it to speak to a central operator who has the phone numbers of your nearest and dearest. It's a reasonable system, though I can't help thinking guiltily that if we - we as individuals, and we as society - really cared about our elderly we wouldn't leave them quite so much to fend for themselves.

Anyway, we flung on pullovers and whizzed two miles up the road to see what had happened to the lady concerned: a close relative, aged 86. The sight that greeted us was shocking. She had fallen on her way to the loo, opened up an ulcer, was shivering and half-conscious. Her skin was a ghastly blue. Worst of all, she was crumpled into a pool of her own blood. To my untutored eye, she seemed to have lost pints.

It was just after 3.30am. I dialled 999. When I described the old lady's condition the operator gave clear, concise first-aid instructions and said an ambulance was on its way. We found blankets, made her as comfortable as we could, and prayed that help wouldn't arrive too late.

Alas, this is Britain, 2007. At around 3.45am the phone rang. It was the London Ambulance Service. The essence of the call was: we're a bit busy tonight, sorry; can you cope? We said we would do our best. Seven minutes later our patient lost consciousness. Panicking, we called 999 again. Hang on in there, we were told. More agonising minutes passed. There is no helplessness worse than watching someone's life slip away for lack of prompt medical care in the middle of one of the richest, most sophisticated cities on the planet.

At 4.05am we heard a noise outside and glimpsed a flashing blue light coming along the road. I raced down the stairs to guide the ambulance to the flat. But the surreal sight that greeted me almost made me keel over with amazement. It was a fire engine.

The crew were already running towards me, breathing-gear and hoses at the ready. "Where's the incident?" one shouted. "What incident?" I replied. "The incident at this address," he said. "Someone phoned 999 for the fire service." "We called for an ambulance," I said. "An old lady's had a bad fall."

The firemen looked bemused but undaunted. They leapt up the stairs with every bit of medical clobber they could find. But I sensed that the spectacle in the flat alarmed them almost as much as it terrified us. By now the pool of blood stretched a couple of feet in every direction from where the woman lay. It was 4.10am - 40 minutes after we had made the 999 call. Luckily, skilled help was soon on hand. A paramedic turned up in a car. She administered oxygen and issued an urgent request for an ambulance on her radio. Only then did it transpire that there were no ambulances available in our area: a huge swath of northwest London. One would have to be despatched from Islington. "Eight minutes max, this time of night," said one of the firemen, trying to be reassuring.

It took 25. At 4.35am, about 65 minutes after we had made the first call, the ambulance arrived. The old lady finally got to hospital more than two hours after she had pressed her alarm.

Interestingly, A&E was virtually empty. There had been - surprise, surprise - no horrific incident tying up all the ambulances in North London in the early hours of last Thursday morning. The truth, it seemed, was that there was only one manned ambulance covering the entire area that night. Why? Because (we were informally told) the authority concerned had suspended ambulance crews' overtime, presumably in an attempt to alleviate its well-publicised financial problems.

Once again, as so often in Blair's Britain, we had encountered a colossal gap between what the politicians tell us is right with the country, and what our own eyes and brains tell us is wrong. More than 92 billion of our taxes is poured into the health service annually. That's around 1,800 pounds a year for every man, woman and child in England and Wales. We are assured that things are getting better all the time. The NHS certainly boasts more bureaucrats and fancy computer programs than ever before. Yet a semiconscious 86-year-old lies in a pool of her blood for 65 minutes waiting for an ambulance. In what sense is that progress? What are the NHS's priorities, if not for dealing with that?

The old lady, you will be pleased to know, is slowly recovering. Those Blitz-generation Londoners are as tough as nails. I'm the one who's still in shock. Where on earth did that fire engine come from?

Source



Australia: Lawyers squealing about damages cap

Insurance premiums will be reviewed to ensure that they have fallen in the wake of reforms to personal injury laws which capped compensation payouts, the State Government says. Premier Peter Beattie yesterday stopped short of endorsing Attorney-General Kerry Shine's claim that the laws were unfair, but said the Government was willing to check whether the changes made in 2002 were still working.

However, he warned lawyers they should not expect the laws to be significantly relaxed. "I just want to be really clear that ambulance chasers shouldn't get too excited," Mr Beattie said. "We are not going to go back to the bad old days when we couldn't get insurance to cover our doctors. "(But) the insurance industry had an obligation to reduce their premiums. I don't think it's unreasonable that we should actually have a look at that too, to make sure they have done that."

In an earlier interview with The Courier-Mail, Mr Shine had criticised the laws, saying they had unfairly blocked people with minor injuries claiming compensation, because their court costs could not be covered. He accused insurance companies of profiting from the crackdown, which was aimed at addressing the public liability insurance crisis when soaring premiums were sending community groups and charities to the wall. Under the changes, general damages were capped at $250,000 and court costs limited on payouts of less than $50,000.

Australian Lawyers Alliance state president Ian Brown welcomed the Attorney-General's comments and called for an immediate overhaul. "It is now widely accepted that the so-called insurance crisis was not the result of an increase in claims, but rather inherent problems within the insurance industry and external global financial factors," Mr Brown said. "Of course insurance companies must remain profitable, but not at the price now being paid by Queenslanders - and particularly our most vulnerable, the elderly and children, who have almost completely lost the right to fair compensation for injury caused by the wrongdoing of another."

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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20 February, 2007

Disillusioned doctors say Labour decade of reform has failed NHS

Most doctors believe that Labour has failed to reform the NHS and that funding by taxation alone will not improve the quality of care. An online poll of more than 3,000 doctors carried out for The Times offers the most striking picture yet of the level of disillusionment within the profession. Most say that the billions of pounds injected into the service since 2002 have not been well spent and that services have not improved.

Faith in Labour's ability to put it right is rock-bottom. Nearly twice as many doctors would trust the NHS with David Cameron, the Opposition Leader, than with Gordon Brown, though a larger number trust neither of them.

The poll, carried out by doctors.net, Britain's busiest medical website, shows a profession disillusioned with central control, angered by the growth of bureaucracy, and deeply sceptical of initiatives such as the 20 billion pound IT system. Even more worrying for Labour, more than two fifths of the 3,092 doctors who responded are young, having graduated since 2000. More than half of respondents (56 per cent) said that there had been no improvement in the NHS since 2002, when the Government increased funding. Only 27 per cent thought there had been. Almost three quarters (72 per cent) did not believe that the extra money had been well spent, while 11 per cent said that it had. Similar views were held on the quality of care: 72 per cent said that there had been no improvement; 15 per cent said that there had been.

In a surprisingly strong rejection of the Government's belief that taxation is the only way to pay for the NHS, 79 per cent of respondents doubted that the highest standards expected of the NHS could be sustained through taxation alone after 2008, when the huge annual increases in funding will drop off.

Neil Bacon, who launched doctors.net in 1999, was not surprised by the results of the survey. "Doctors support the NHS, but they have a great deal of concern that the underlying problems are not being addressed," he said. Mark Porter, deputy chairman of the British Medical Association's consultants' committee, said: "The results of this survey are disturbing and give a snapshot view of how demoralised and frustrated some doctors are feeling. "It is of major concern that a majority of respondents to this survey are saying that they do not believe the NHS has improved since 2002 and that they do not think the increase in NHS expenditure has been well spent. It is also worrying that so many of them say they plan to retire early. "The survey also reveals a deep anxiety among doctors about what will happen after 2008, when the rate of increased funding is due to end. "It is tragic that the Government has used so much of the increased expenditure on wasteful initiatives like independent sector treatment centres and PFI. The private sector has certainly done well out of the increased funding."

Andrew Haldenby, of the think-tank Reform, which wants funding of the NHS to be opened up, said that he was heartened by the degree of support doctors had shown for the idea. "The real issue is whether the tax model can work. This poll requires all the politicians to rethink their positions," he said. "This poll suggests very strongly that at least part of the medical community has been taking notice, and it is particularly interesting that so many younger doctors have contributed."

Source



Contaminated blood inquiry

An independent public inquiry is to be held into the supply to haemophiliacs of contaminated NHS blood The Labour peer Lord Archer of Sandwell, a former Solicitor-General, is to conduct the inquiry after a campaign by Lord Morris of Manchester, president of the Haemophilia Society and a former Minister for the Disabled, who said that 1,757 haemophilia patients who were exposed to HIV and/or hepatitis C-contaminated NHS blood and blood products had died since being infected. "Many more are now terminally ill," the peer claimed.

Lord Morris said that, of 4,670 such patients exposed to hepatitis C, 1,243 were also exposed to HIV and that, notwithstanding improvements in treatments, only 2,552 patients with hepatitis C and 361 with HIV were still alive. The situation has been described by Professor Lord Winston as "the worst treatment disaster in the history of the NHS".

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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19 February, 2007

California warned on health plan's cost

Governor's projected price tag could be more than $3 billion too low, says nonpartisan analyst

Gov. Arnold Schwarzenegger may have underestimated the cost of his health care overhaul by $150 million to more than $3 billion, the Legislature's nonpartisan budget adviser said Thursday. The governor estimates that his plan to bring down insurance costs and extend coverage to the 6.5 million people without health care will cost $12 billion annually. But the actual costs may be higher, the Legislative Analyst's Office told the Senate Health Committee during the first hearing on the proposal.

Marcus Stanley of the analyst's office said the plan would cost more if medical care outpaces inflation, if the numbers of uninsured are higher than estimated, or if insurance company premiums are higher than anticipated. Though Schwarzenegger released the plan in January, Thursday marked the first time lawmakers have been able to ask questions about it in an official setting.

The proposal would require individuals to buy coverage, employers to help pay for it, and insurers to sell it to anyone who wants it. Doctors and hospitals would also be asked to chip in to help fund the expansion, which would also rely on a significant amount of new federal funding.

The debate Thursday centered on whether the Republican governor's financial model was realistic. Kim Belshe, California secretary of health and human services, testified that the governor's plan would change the health care marketplace, making insurance more affordable for working families who would be required to purchase it because more people would be participating in the system. Many of those people would be young and healthy, she said, making them relatively cheap to insure.

But several members of the Senate Health Committee said the plan relies heavily on theoretical models without guaranteeing that insurers would offer premiums that people could afford. "I don't see anything in the proposal that helps us feel confident that affordability will be achieved," said Sen. Sheila Kuehl, a Democrat from Santa Monica who chairs the committee. Kuehl said the health care debate reminded her of the debate over deregulating electricity that occurred in the 1990s. Financial models showed that, in theory, energy prices should be lower. But companies such as Enron ended up gaming the system, leading to high prices and rolling blackouts. "We should have hired a pirate to show us how the system could be gamed" during the electricity debate, Kuehl said. "We need to hire a pirate, I think ... so we can see what's coming."

The governor's staff said models show that insurance would be cheap enough that the health plan would not cause a hardship for working families. But even insurers said their prices under the new system would depend heavily on the makeup of the population they would be forced to insure. In other states that have required insurers to sell coverage to everyone, people with expensive medical needs entering the system had raised the cost for everyone, said Charles Bacchi of the California Association of Health Plans. Requiring insurers to cover everyone "is one piece of the proposal, and with that in mind we're willing to work constructively to see if we can make it work," Bacchi said. "But we do so with caution."

The California Nurses Association, which has led high-profile efforts opposing various Schwarzenegger policies since he took office, resurfaced at the hearing. Deborah Burger, Nurses Association president, said the best solution is one that Schwarzenegger is not even proposing: abolishing all health insurance and replacing it with a system of universal coverage run by the state. The insurance industry "is structurally set up to make profit by denying care, wastes 30 percent in administrative overhead [She should see the administrative overhead in a fully socialized system! Try 75%], and is the root of the present cost and quality crisis," Burger said.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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18 February, 2007

Congressional cures?

Part 1 of this article series described the FDA's recent attempts to convince its critics that it takes drug safety seriously. In fact, no one who is familiar with the FDA culture and mind-set could possibly doubt that drug safety is paramount - if for no other reason, approving a product that proves to be dangerous can ruin a government career.

Although all drugs have side effects - which can be serious and/or frequent - modern pharmaceuticals have never been safer, more effective, more innovative - or more stringently regulated. But that seems to have escaped the notice of many members of Congress. This month senators introduced two separate bills that will further obstruct innovation and threaten public health.

Senators Edward Kennedy (D-Mass.) and Michael Enzi (R-Wyoming), the chairman and ranking Republican, respectively, of the Health, Education, Labor and Pensions Committee, proposed legislation that would grant the FDA new authority to impose safety requirements on medicines after they have been approved for marketing and would also would require registration of clinical trials and the reporting of their results in public databases. In addition, Senators Chris Dodd (D-Conn.) and Charles Grassley (R-Iowa) introduced legislation that would create within the FDA a center to oversee the safety of drugs after they go on the market.

These bills are the culmination of years of drug company-bashing by a small number of activists and members of congress who have seized on high-profile events such as deficiencies in the labeling of antidepressants and the discovery of previously unknown side effects of various widely used drugs. They will discourage drug development by making it more difficult and expensive and less profitable, at a time when an aging American population desperately needs new and improved (and cheaper) medicines, and when pharmaceutical R&D is already ailing. During the past twenty years the costs have skyrocketed, with direct and indirect expenses now exceeding $900 million dollars to bring an average drug to market. Other trends related to costs are ominous as well: The length of clinical testing for the average drug is increasing, fewer drugs are being approved, and the number of applications to FDA by industry for marketing approval has been declining for more than a decade.

The FDA is already the nation's most powerful and omnipresent regulator, but the Kennedy-Enzi bill would grant new authority, supposedly to ensure the safety of drugs. Among other unwise innovations, it would require the imposition of "risk management action plans (RiskMAPs)" when drugs are approved. Not only does the FDA already have the authority to require these when regulators feel that they are necessary, but they have been overused and abusive: At times the exhaustive (and exhausting) list of requirements for physicians, pharmacists and patients seems more appropriate for weapons-grade plutonium than a pharmaceutical. Some RiskMAPS have contained requirements such as mandatory enrollment in patient registries, limited distribution, and prescribed patient behavior (such as the use of two kinds of contraception, in the case of one drug).

The requirement that drug companies disclose advanced clinical trials in a public database is based on concerns that "negative" results are often obscured or simply not reported. It is intended to prevent companies from "cherry picking" studies, divulging only those that yield favorable results and suppressing the rest.

These concerns are exaggerated. Nothing in our society is currently more stringently regulated and monitored than drug development. During each phase of clinical testing, the FDA reviews and must grant permission for every clinical trial and has access to all of the proprietary information about the drug. When the manufacturer has accumulated evidence that the drug is safe and effective, as part of the application for marketing approval the results of every trial and everything else that is known about the drug, both in the United States and abroad, must be reported to the FDA. Statistical analysis must be performed in an appropriate and pre-specified manner. Moreover, the FDA serves as a repository for data on similar drugs made by other manufacturers. All of this prevents statistical "cherry-picking" or "data mining" that could mislead regulators.

Clinical trials databases are useful to individual patients who wish to ascertain whether they are eligible for a clinical trial that is under way - a function already served by www.ClinicalTrials.gov. But, except for offering a bonanza to plaintiffs' attorneys trolling for business, the benefit of a publicly available database of clinical trial results would be minimal.

There is also the question of the meaning of "negative results" in clinical trials. In the context of scientific and clinical experiments, the term has a meaning very different from the common usage. Such trials are seldom "negative" in the sense of revealing that the drug being tested inflicts harm but for a variety of reasons, they may not be useful or applicable to the indications (uses) for which approval is being sought. The reasons can include: insufficient statistical power (that is, number of patients) in the study; inappropriate choice of route, dose or frequency of administration, or in the stratification of subjects; or simply a failure of the drug to be effective for the indication for which it was tried.

The Dodd-Grassley proposal is even worse. It would create within the FDA an anti-drug entity with strong incentives to argue for the non-approval or withdrawal from the market drugs that have significant side effects even if they offer huge net benefits. (We have seen this already from certain factions within the agency.)

These proposed legislative remedies for the FDA's problems, with more planned for later in the year in both the House and Senate, are analogous to the discredited medical practice of bleeding the patient with leeches. By intensifying the FDA's notorious risk aversion, the new measures will inflate even further the costs, difficulty and uncertainty of drug development and reduce the number of drug candidates that begin and complete clinical testing. They will drain the life's blood from innovation and inflict harm on patients. If these pieces of legislation are enacted, they will validate yet again Will Rogers's observation about Congress: "Every time they make a joke, it's a law. And every time they make a law, it's a joke." And as usual, the joke will be on us.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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17 February, 2007

Health insurance, without the "insulation"

When we build a home, or buy one that has been previously owned, one of the major concerns is about how well insulated it is, as well as with what materials. Keeping out the cold in the winter, or extreme heat in the summer, is essential, unless we wish to pay exorbitant heating and cooling bills year-round. However, the same does not necessary go for paying to maintain our physical well-being; sometimes paying for services at the point of service can actually save us money, and sometimes too much "insulation" can be a bad thing.

The lead commentary on this page this week (at least at the beginning of it) appears to coin a phrase this editor has been groping at for some time now. In his Cato Unbound piece, Arnold Kling poses the confrontation of Insulation vs. Insurance, thereby concisely defining the real battleground upon which healthcare reform must be fought. As he notes quite correctly, the biggest obstacle to true reform in the system is tied to how quickly we can wean people off the viewpoint that "health insurance" should be a first-dollar-spent process, covering every minor incidental expense, and how rapidly they can adjust to it as the emergency-brake on catastrophic expenditures it was initially intended to be.

Kling's take on the matter is simple: He terms current American health coverage "insulation, not insurance. Rather than insuring them against risk, most families' health plans insulate them from paying for most health care bills, large and small." Real insurance, he notes, "such as fire insurance, provides protection against rare, severe risk . [and] is characterized by: low premiums, infrequent claims and large claims." He contrasts this with most employer-provided insurance and Medicare, and policies written for the vast majority of Americans: "Families typically are paid claims several times per year, often for small amounts. Premiums are high - often exceed[ing] $10,000 per year per family."

The problem is, since most families only pay those premiums via the reduced take-home pay their employers might be giving them instead, they have no idea how much the services are costing, except in the often trivial co-payments they may be making. As Kling notes, "Real insurance would pay for treatments that are unavoidable, prohibitively expensive, or for illnesses that occur relatively rarely. Instead, insulation reimburses even relatively low-cost services, such as a test for strep throat or a new pair of eyeglasses."

As noted above, this editor has been trying to make this point for some time now: Until the concept of "health insurance" becomes about ensuring against huge financial calamities, instead of covering every sniffle and headache, we can hardly expect that "reform" is remotely possible. If there is to be any chance of shifting the paradigm, it must begin with the self-responsible among us taking charge: opting out of full coverage policies for catastrophic-only coverage, switching our primary healthcare allocations into medical savings accounts, and relying on continued wellness as the goal, not perfect insulation from the vagaries of life.

By focusing our attentions on the relatively low cost of annual checkups and screenings, and paying out of our own pockets at the time of service, we not only minimize the amount that goes out for "insurance," but we also may save considerably over the actual cost of such services, through discounts offered by beleaguered healthcare providers who get to save on all the paperwork and bureaucracy being sidestepped.

But what about those situations where there truly is a major ailment and expense involved. Kling again offers a scenario. Citing his own book, Crisis of Abundance, as reference, he notes that "Real health insurance would pay claims to people who come down with expensive illnesses. Typically, these expenses accumulate over a period of years." He postulates "a health insurance policy that you buy this year, but reimburses you in five years, based on cumulative expenses. Such a policy might pay nothing if your total expenses over the next five years are less than $30,000. It might pay 100 percent of expenses thereafter." Buying a string of such policies, overlapping by a year or so, would, in Kling's view, "provide a better safety net than the annual policies that we have today. The typical catastrophic illness does not stop requiring treatment on December 31."

Another option he presents is a policy that only kicks in with specific payments for specific major ailments: "First-stage breast cancer might result in a $25,000 payment. A heart condition requiring major surgery might result in a $40,000 payment. And so on. Only major medical problems would trigger claims, and payments would be for fixed amounts, not for reimbursement for procedures."

Once again, a prescription for a pathway out of this morass is presented. The question now is, what can we do to perpetuate this free-choice meme throughout the culture, so that the current outcries from all across the political spectrum for nationalizing the problem may be turned aside? It's not going to be easy, but it is going to be necessary.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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16 February, 2007

Britain: Faulty software puts child health at risk

The health of children is at risk because an NHS computer system wrecked 20 years of accurate immunisation records

Faulty software introduced in 2005 has left some primary care trusts (PCTs) unable to track whether children have been vaccinated and screened for genetic conditions, raising fears that many are unprotected against diseases. Parents are not being reminded when their children are due for jabs and check-ups. The Health Protection Agency cannot publish full statistics on the uptake of vaccines because the five worst-affected London trusts cannot provide accurate data.

When the shortcomings of the Child Health Interim Application (CHIA) software were disclosed by The Times a year ago, the Department of Health stated that the problems were being addressed. Staff were said yesterday to be "in despair" at continuing difficulties with the system supplied by BT. Christine Sloczynska, consultant community paediatri-cian at Waltham Forest PCT, in East London, said: "I'm sure there will be kids who slip through the net and will be unimmunised. Our immunisation take-up has fallen from 94 per cent to 58 per cent, but we don't know how much it is due to children missing their vaccinations, or to lack of data."

The Health Protection Agency said that five trusts had been excluded from national figures for uptake of MMR and other vaccinations as their data were considered unreliable. Pat Troop, head of the agency, said: "There is still a gap in the data, and it's something the local NHS are concerned about, not just us. Not monitoring coverage of measles is how infections might happen." Mike Catchpole, of the agency, said that it was not possible to predict when the affected PCTs could provide the data.

The CHIA software was introduced in ten London trusts when an older system was withdrawn. Dr Slocynzska said that the system could not be used to generate lists of those who match particular criteria, such as missing vaccinations. This makes it difficult for GPs to issue reminders. Parents are still issued with a "red book" listing a vaccination schedule, but the problems with the computer make it hard to tell them when new jabs are available. Birth records formerly sent online from maternity units must be entered by hand, and there is a backlog. "We are sometimes told of a child's death before we know it has been born," Dr Sloczynska said. BT has promised to replace the software.

Source



NHS corruption

SUSSEX: An NHS trust that gave a former public health director a payoff of 243,000 pounds after working less than three weeks also paid lawyers 12,000 for advice on how to manage the case. Sussex Downs Primary Care Trust revealed that it made the payments to Capsticks Solicitors, of London. The legal advice concerned the treatment of Iheadi Onwukwe, 41, who was appointed in September 2002. He worked briefly for Eastbourne Downs Primary Care Trust, which later merged with Sussex Downs Primary Care Trust, and was reported to have been paid a salary for almost three years while on “gardening leave” before leaving his post. Gina Brocklehurst, former chief executive of the trust, received 230,000 to leave as part of the reorganisation. Norman Baker, MP for Lewes, said: “This shows how endemic the problem is of the NHS writing out blank cheques with our money.”

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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15 February, 2007

Don't get old in Britain

Many doctors discriminate against older patients, giving them poorer advice and worse treatment than younger people with the same symptoms. A study has found that elderly patients with angina are less likely to be prescribed a statin to lower their cholesterol, given appropriate tests or to be offered surgical treatments. Instead they were often given a minor change in prescription and told to come back later, in spite of studies that show that all patients, regardless of age, benefit from modern treatments.

The survey, published in the journal Quality and Safety in Health Care, found that patients over 65 were given different care from those who were younger. Twenty-eight general practitioners, 28 elderly care specialists and 29 cardiologists from across southern England and the Midlands were questioned. A total of 72 fictional patients with angina were presented to the doctors as part of a computer programme, and the doctors were interviewed. The fictional patients were aged between 45 and 92, with varying degrees of heart problems.

Overall, the study found that older patients were less likely to be referred to a cardiologist and given an angiogram or exercise tolerance tests compared with middle-aged patients. They were also less likely to be offered revascularisation (opening up of blood vessels). The authors, led by Professor Ann Bowling, from University College London, found that the doctors who were influenced by age were on average five years older than those who were not.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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14 February, 2007

20 billion pound NHS computer system 'doomed to fail'

Labour's multi-billion- pound project to create the NHS's first ever national computer system "isn't working and isn't going to work", a senior insider has warned.

The damning verdict on the ambitious 20 billion pound plans to store patients' records, and allow people to book hospital appointments, on a central computer network has been delivered by a top executive at one of the system's main suppliers. Andrew Rollerson, the health-care consultancy practice lead at the computer giant Fujitsu, warned that there was a risk that firms involved in the project would end up delivering "a camel and not the racehorse that we might try to produce".

His bleak assessment was delivered in a speech on the health service's national programme for IT that he delivered to a conference of computer experts last week and which is reported in today's Computer Weekly magazine. Fujitsu is one of the main firms involved in the project after winning a 896 million pound contract to deliver systems in the South of England.

Mr Rollerson underlined his message with a series of downbeat slides, including one showing a huge oil tanker being hit by a tidal wave, one with the word "Lost?" alongside a picture of a desert island and one with a man walking a tightrope. Another slide declared "visionary leadership is still missing" alongside the famous World War One poster of Lord Kitchener declaring "Your country needs you". His presentation even featured a picture of a huge alligator with the message "We have become obsessed by the alligators nearest the boat." The final slide showed two women mud-wrestling and asked: "Where would you rather be?"

In his speech, Mr Rollerson voiced concern at the direction of the NHS programme and the lack of vision on how the health service can make best use of new technology. "What we are trying to do is run an enormous programme with the techniques that we are absolutely familiar with for running small projects. And it isn't working. And it isn't going to work," he told his audience. "Unless we do some serious thinking about that - about the challenges of scale and how you scale up to an appropriate size - then I think we're out on a limb."

Mr Rollerson added: "There is a belief that the national programme is somehow going to propel transformation in the NHS simply by delivering an IT system. Nothing could be further from the truth. A vacuum, a chasm, is opening up."

His comments are the latest sign of problems in the ambitious project, which is expected to cost the taxpayer around 7.6 billion more than estimated. Last year it emerged that there had been 110 "major incidents" involving the system in just four months. A letter signed by 23 leading computer scientists urged the Commons health select committee to launch an inquiry to "establish the scale of the risks" facing the project.

Stephen O'Brien, the shadow health minister, said: "Even those from inside the programme are now telling the Government that it is coming apart at the seams. "This is another example of the heavy-handed, top-down failing approach of this Labour Government."

The Department of Health last night insisted that the programme was a pivotal part of NHS reform. [How unwise to say that!] A spokesman said: "David Nicholson, the chief executive of the NHS, is fully committed to the national programme for IT as it is a necessary part of modern health service. "He sees this as one of his key strategic priorities as it is key to the successful delivery of patient centred care."

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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13 February, 2007

If bird flu grips Britain, NHS doctors will need guns

The NHS will be unable to handle a pandemic

Towards the end of the film Dr Strangelove, Peter Sellers discusses who will go into the mines to survive. A surreal echo came for myself and colleagues recently when we were in discussions about planning for a bird flu pandemic in the UK as part of an ethics committee. If a true pandemic of bird flu hits these shores then our notions of what we can expect from the National Health Service will have to change. Some people will have to be denied potentially life-saving treatment: there simply will not be enough beds.

Managing such a pandemic is unimaginable. While it is possible to work out what will happen if a bomb goes off in central London - we can empty intensive care units, mobilise extra staff and stop elective work - what we cannot plan for is 200,000 extra patients who need a life support machine. Arnie Schwarzenegger, the governor of California, says his state will buy thousands more machines, but who will man them? A gut reaction is to blame the government for underresourcing. It is true that we have a chronic underinvestment in intensive care compared with the United States, Australia or other European countries. In any normal situation such a criticism would be valid, but in a pandemic it becomes a statistical irrelevancy.

Who will decide, and on what criteria, those getting the chance of survival? If you and a friend get bird flu and you both end up in hospital, the estimates are that within 48 hours one of you will need life support. At conservative estimates the need for intensive care will be about 2� times more than we can provide. Allocation of such resources will have to be either on a first come first served basis or on an explicitly utilitarian basis of capacity to benefit. This shift from an egalitarian free access to a limited one based on expected outcome represents a profound shift in how we deliver healthcare.

Exclusion criteria have already been drawn up in Canada and the United States and include such contentious issues as restriction based on age or on preexisting disease such as cystic fibrosis or metastatic cancer. Saying "no" to a desperately ill child with cystic fibrosis or to a previously fit 85-year-old is not something we are morally or emotionally prepared for. By an ethical analysis it may be the correct thing to do, but will patients or their relatives be prepared to accept it?

Such arguments may, of course, be purely academic. Assumptions as to what we can do are based on the doctors and nurses, porters and technicians turning up to work. But if we do not have enough masks to protect staff dealing with infected patients, then do the staff have a moral duty to turn up for work and get infected themselves? It may be that they go to work but only once - who will want to return home and potentially infect their own family?

In Victoria, Australia, it was suggested that patients would not go to the GP but to a "flu centre". The idea that patients would go to where flu is concentrated displays an astounding lack of comprehension of human nature. Similarly, staff will be reluctant to put themselves at risk. HSBC, the banking group, was accused of scaremongering when it announced that perhaps 40% of its staff would not turn up for work in the event of a pandemic, but the NHS may suffer just as badly.

It is not only the risk of infection that may stop staff turning up to work. With such limited access to intensive care, it would be expected that hospitals might not be safe places at all. If I decide not to ventilate someone, his or her relatives might not be too happy. Threats to staff are all too common and many are worried about personal security. Consequently it has been suggested that the decision as to who gets the intensive care bed should be taken away from frontline staff in order to protect them.

At a discussion over how we would react to a biological emergency, where casualties would be decontaminated before we resuscitated them, it was asked who would protect the staff. The answer given was hospital security. Pleasant and helpful as they are, these guys are hardly equipped to deal with an angry mob. One doctor said that the most useful thing staff could be given in such an event was a gun.

Another concern is the legal position of staff who refuse treatment. In the absence of any measures put in place to protect them, one can imagine a raft of legal actions being taken out against them. If attempting to allocate resources on the basis of capacity to benefit is the right thing to do, then those making the decisions need to be protected, otherwise people will not make the decisions required. Perhaps the only equitable and fair way is to shut the intensive care units and limit treatment to the best we can achieve without artificial ventilation.

Source



Australia: Entrenched and rigid bureaucracy driving away public hospital staff

More than 12 per cent of clinical staff at Queensland Health quit in 16 months, The Sunday Mail can reveal. While the State Government trumpets a successful recruitment drive, the latest figures reveal 4438 employees in the 36.000-strong workforce resigned between June 2005 and September last year - or 277 a month.

The Australian Medical Association said doctors were fed up trying to work in hospitals without enough beds or operating theatres. Queensland AMA president Zelle Hodge said: "It is so frustrating for staff, and eventually people just say they've had enough of it and leave. "Unless the culture in Queensland Health is changed, and the focus is on the people at the coalface and how they treat their patients rather than bureaucracy, then people will continue to resign." The Forster review, released in the wake of the Jayant Patel scandal at Bundaberg, said that unless the culture of secrecy and poor working conditions in Queensland Health was addressed, the high attrition of health-workers would continue to cripple the system.

One doctor who did not want to be named because Queensland Health has banned him from talking to the media. said he did not feel valued. "We are still chronically understaffed and people are so fed up with working long hours to combat the shortage that they are saying enough is enough, he said. "Queensland Health keep telling us they are addressing the problems, but it's just all talk. Nothing changes."

Figures show 1048 doctors and 2196 nurses resigned between July 2005 and September 2006. In addition, 1194 allied health professionals such as radiographers. occupational therapists and physiotherapists quit.

Queensland Health, which boasts of "caring for people" in its latest annual report, is advertising 407 jobs. Queensland University of Technology business researcher Megan Tones said: "To have 12 per cent of staff leave in just over a year is a huge amount. Obviously not enough is being done to retain staff.

But Joshua Cooney, spokesman for Health Minister Stephen Robertson, said the rate of resignations was "normal" for Queensland Health [So that is good??]. He said all the departing staff had been replaced, with an extra 2910 employed. ''The minister has spoken on many occasions about changing the culture in Queensland Health and that is what we're doing," he said.

Opposition health spokesman John-Paul Langbroek said Mr Cooney needed to stop the spin. "I am getting calls from doctors saying nothing's changed," he said. "The Government needs to start developing strategies to retain the professionals."

The above report by Hannah Davies appeared in the Brisbane "Sunday Mail" on February 11, 2007

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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12 February, 2007

Why health care isn't fair

Bush's health insurance plan would eliminate a pernicious tax preference

You may be wondering how President Bush's health insurance plan would affect you, the taxpayer. The answer depends on whether you have medical coverage, where you get it, and how much it costs. My family, for example, gets health insurance through my wife's employer, and it costs­...actually, I have no idea what it costs. That's one of the problems Bush wants to address by eliminating the tax code's bias in favor of employer-provided medical coverage, which distorts the insurance market, promotes insecurity, and raises health care costs.

This bias was created more or less by accident. During World War II, businesses competing to attract scarce workers got around wage and price controls by offering health insurance instead of higher pay. In 1943 the Internal Revenue Service decided not to count this increasingly popular fringe benefit as taxable income, a policy codified by Congress in 1954.

In effect, notes John Goodman, president of the National Center for Policy Analysis, someone in the 25 percent income tax bracket may receive a subsidy of close to 50 percent for employer-provided medical coverage, once you consider state income taxes and the 15.3 percent payroll tax that funds Social Security and Medicare. If he buys insurance on his own, he typically gets no tax break at all.

The upshot is that most Americans get medical coverage through their employers, which is a strange situation when you think about it. People do not, as a rule, expect their employers to pay for their car insurance, their life insurance, or their homeowner's insurance. Why should employers pay for their health insurance?

In a system based on employer-provided insurance, people lose their medical coverage when they lose their jobs, a problem that becomes increasingly serious as they get older and sicker. At the same time, the seemingly free coverage makes health care more expensive for everyone.

Not only are you unlikely to know or care how much your employer spends on health insurance, but the coverage may be more generous than you would choose on your own, which means you are unlikely to know or care how much particular services cost. If you were using your own money to buy insurance, you might opt for a cheaper policy with a higher deductible, in which case you would be more conscious of things like the fee for an office visit or the difference in price between name-brand and generic drugs. Indifference to such considerations contributes to escalating health care costs.

Bush's solution to these problems is straightforward. He would reverse the policy of excluding health insurance from taxable income. To avoid an overall tax increase, he would give taxpayers with health insurance a standard deduction of $7,500 for individuals and $15,000 for families.

The White House estimates that 80 percent of taxpayers who get health insurance through their employers would receive tax cuts as a result of these changes because their coverage costs less than the deduction. (The average cost of employer-sponsored medical coverage last year was about $4,200 for individuals and $11,500 for families.) The other 20 percent would pay higher taxes, which might encourage them to seek less generous coverage and get more of their compensation in cash.

Everyone who buys his own health insurance would pay lower taxes under Bush's plan. Some people who currently cannot afford coverage might be able to swing it as a result of the tax break, which (in the example favored by the Bush administration) would amount to $4,500 for a family of four earning $60,000.

The complaint that changing the tax treatment of health insurance would encourage employers to stop providing it misses the point: If employers are offering medical coverage instead of extra pay purely for tax reasons, they should stop. Eliminating the pernicious preference for employer-provided insurance would promote a greater diversity of options and help people choose the coverage that makes the most sense for them.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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11 February, 2007

The bipartisan war on medical liberty

These days it sometimes seems like a foregone conclusion that we're going to have socialized healthcare in this country. This is quite a tragedy to contemplate.

America, for all its militarism and prisons, has had one sector where there has remained more room for freedom and less for bureaucratic power than can be seen in other Western nations: the healthcare industry. Some of these nations are much less cruel to foreigners and much less draconian with prisoners and outcasts, including those guilty only of victimless crimes. But there are some ways in which America still scores some major libertarian points over Canada and Sweden, and one of the most significant is that the US has not nationalized its healthcare sector. So for years after young Americans stopped fleeing to Canada to escape military slavery, Canadians have fled to America to avoid socialist medicine and rationing and pay cash to get operations they needed.

The conservatives have for decades rightly warned about socialized healthcare in America. It was a big goal of the communists, then the socialists, then the social democrats. Now it seems like a centrist policy goal.

National healthcare along with global warming was the progressive left's biggest issue, perhaps, before 9/11 forced them into their more libertarian stands on war and civil liberties. But they still want socialized medicine bad, as is apparent whenever you hear them defend practically any foreign government, no matter how dictatorial, so long as it finances clinics and penicillin for its subjects. The left still seems to oppose capitalism in healthcare more vociferously than in nearly any other area.

Not that America currently has a free market in medicine. First off, there is licensing, a horrible injustice by which the medical establishment protects itself by forbidding free competition. Then there're Medicare and Medicaid, which constantly deplete supply and inflate demand. And we must never forget the Food and Drug Administration, a corporatist agency that distorts the market, imposes huge costs on drug production and tramples the fundamental individual right to consume whatever one wishes to. In so doing, it has kept live-saving drugs off the market at the cost of many, many thousands of Americans dead.

America's healthcare system has long been a twisted hybrid between free enterprise and fascism. The fascist part - the part that destroys individual choice and empowers Big Pharma and the medical establishment - should be the part that leftists decry, but instead they have for the most part focused on our remaining medical freedom as the supposed ill. They are correct when they say America spends more than some other countries on healthcare, sometimes for less actual benefit to the consumer than people get under more egalitarian socialist systems. But this isn't America's free market at work; it's America's government. The only solution is freedom.

In any event, despite the many problems, there are pockets of medical liberty we still have that others don't, such as with the aforementioned operations that attract Canadian refugees. We would lose most of these remaining spheres of freedom if the left were to get its way.

The Republicans, for their part, have not mounted an organized resistance to nationalizing healthcare since gaining federal power. Far from it. With Bush's prescription drug program, Republicans saddled us with the largest expansion of medical socialism at the national level since the introduction of Medicare. In his last State of the Union, Bush did say some free-market-sounding stuff about tax deductions and health savings accounts - but he also alluded to something quite frightening: He wants the feds to dole out money to states that come up with programs to give free health insurance to the poor. This comes, perhaps not coincidentally, within weeks of Republican Governor Arnold Schwarzenegger's proposal for socialized health insurance for the poor in California, and to make it illegal not to have health insurance in the state. This medical despotism is a grave, horrific assault on the fundamental rights over one's personal life.

Unfortunately, the masses, generally more favorable to the market on other issues, have been duped by nonsensical arguments that healthcare prices are bound to rise steadily in a market economy, and only the government can fix the problem. Supposedly, technology and new innovations make rising costs inevitable - and yet in every other sector not so strangled by regulation, we see real prices drop and ever-increasing quality. Troublingly, the masses don't see how much of a role government has played in ruining healthcare.

Somehow, the left's healthcare agenda, which was seen as subversively collectivist and pinko fifteen years ago, has now become a popular priority and something top Republicans can talk openly about implementing over time. Indeed, the Republicans have already been giving us all the worst of Hillary-care, one piece at a time, and are poised to do more through "market-reform" gimmicks and with the state governments as proxies, along with some extra gigantic programs to protect the profits of their friends in the medical industry.

When you think about it, we shouldn't have expected medical freedom from the Republicans. How could conservative drug warriors, for example, really be enemies of the FDA? Take away the FDA's power to nationalize choices of what medicines and drugs one can consume, and the drug war disappears. Give the feds this kind of awesome power, and fascist or socialist medicine can't be too far away.

Leftists, on the other hand, have long been either clueless or disingenuous on these issues. They have called for more regulation of herbal supplements and alternative medicine, na‹vely thinking that anything worth promoting is worth getting the federal government interested in. They defend the FDA not realizing it is the twin of the DEA, as well as the great ally of the established pharmaceutical companies. Most hypocritically and unrealistically, the left claims to want freedom over their bodies even as they don't want the responsibility of taking care of them.

So the mainstream Republicans, almost all Democrats, and the ideological left are horrible on healthcare issues. Most moderates support moving toward more centralized control. We appear to be doomed for the short term on this issue. It is a supreme tragedy that America might lose what's left of its medical freedom. It would be one of our greatest domestic losses in some time.

What's more, if the US government becomes adamant enough, it could even use imperialism to spread its version of "healthcare freedom and democracy" around the world. Just as it has tried to push US labor regulations, US disability regulations, and, indeed, pharmaceutical regulations on the rest of the world, perhaps the US will become even more internationally belligerent in regard to the global democratic revolution of socialized medicine. A right to healthcare already made it into the US-approved Iraqi Constitution. The US already pressures virtually every other major country to accept its policy on drugs and pharmaceuticals - "regulatory harmonization" is the imperialist euphemism. And what if the US begins forbidding Americans from going abroad, such as to Thailand, as many of them already do, to get medical services less encumbered by paperwork and thus cheaper? What if the US tries to impose its hospital and licensing regulations on these other countries? What if socialized medicine is indeed a goal of world government, as the 1990s rightwing feared, and yet it will be implemented not by the men in blue helmets, but by soldiers donning Old Glory?

There are a million reasons we should have medical freedom, and they must be articulated if we are to avoid a disaster in the next several years. Libertarians must go beyond what we often hear from free-market wonks: the usual denial that there's anything wrong at all with the system, as if it's already a free market, and the usual defenses of the largest pharmaceutical companies as the most persecuted minority, what with its inflated, FDA-protected, federal-patent-ensured mega-profits under attack. We must mount a principled, radical and informed intellectual assault on the fascist and socialist threats to medical liberty if we are to restore it or even defend what's left of it.

The economics should speak for itself, but the right to control one's own life and body is the core, moral argument for medical freedom. Life and death are intimately involved with the healthcare issue as with few others. Unfortunately, for the time being, it appears that creeping healthcare totalitarianism is on the agenda of both parties. They only disagree on how fast to run us off the cliff, and who should navigate us there.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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10 February, 2007

Dentists run out of cash for NHS patients

Patients needing NHS dental treatment before the end of the financial year may not be able to get it, the Department of Health has said. Some dentists have already exhausted their budgets for 2006-07 and will have no money to treat NHS patients until the end of March. The Department of Health blamed the dentists, saying that some had been "speeding through their work" rather than spending more time with patients. Such dentists, it suggested, needed help. "The local NHS is working with these dentists to help improve the service they provide," it said. [What bullsh! Efficient dentists are a problem??]

Patients whose dentists cannot treat them have the option of going to other local dentists who have not run out of money - assuming they have appointments available - or contact their local primary care trust (PCT) for emergency care. The problem has been caused by the introduction of the new dental contract, under which dentists agree to provide a number of "units of dental activity" (UDAs) for a price.

Peter Ward, chief executive of the British Dental Association, said yesterday: "We know, from our own research, that three quarters of dentists don't believe that the UDA target they have been given accurately reflects the amount of treatment they are able to give. "There is a real danger that some dentists will run out of funding to provide care. This is a ridiculous state of affairs when there are dentists who are ready to provide additional care, and patients struggling to access it."

This is the second problem to hit NHS dentistry in as many weeks. The Government overestimated the money that would be paid to dentists by patients, who pay a proportion of treatment costs. Dentists are seeing more patients who are exempt from charges than was expected, so income is down.

A survey by Health Service Journal suggests that in each PCT a small number of practices will face problems. In Bradford and Airedale, for example, 10 out of 73 practices are in danger of completing their contracted work too soon. The Cornwall and Isles of Scilly PCT is monitoring a "small number of practices" to try to ensure that they do not complete their contracts early. In Essex, between 15,000 and 20,000 patients could be affected, according to Tony Clough, secretary of the Essex Dental Committee. He said that some dentists were putting off routine checkups until April.

Potentially worse, he said, were those who were underachieving, by up to 30 per cent. [Fast is no good. Slow is no good. How lucky we are to have bureaucrats who know better than the dentists themselves exactly what dentists should be doing] "Their funding for 2007-09 will be reduced, which means they won't be able to treat as many patients in the future. "Dentists struggling to meet their targets are put off big cases. Dentists are looking in patient's mouths and saying: `what targets should I be achieving today?' It's ludicrous."

The Department of Health said that the guidance given to PCTs about how to deal with the problem was available on its website. "The new contracts were designed to give dentists exactly what they asked for - more time with their patients," a spokesman said. "A small minority of dentists say that they are going to deliver their agreed services before the end of the year. This suggests that they may be speeding through their work."

Andrew Lansley, the Shadow Health Secretary, said: "The Government was relying on its hike in NHS dental charges to pay for changes to the system, but all this has done is force patients to the private sector."

Source



Dutch doctor: why Britain's NHS is failing on superbugs

AS a doctor who has worked in Britain and Holland, Hajo Grundmann could not have a better insight on why the two countries are so far apart in the battle against the superbug MRSA.

While Holland, along with Norway, has emerged as the nation with the lowest rate of MRSA in Europe, Britain has one of the highest, together with Cyprus, Malta and Portugal. In Norway and Holland less than 1% of all bloodstream infections are drug resistant, while in Britain the figure is 44%. Figures compiled by the European Antimicrobial Resistance Surveillance System, which Grundmann co-ordinates, show that Britain has higher rates of the superbug than all comparable European countries, including Germany, France and Spain.

Grundmann, a consultant microbiologist, said the differing levels of cleanliness between Britain and Holland were apparent to anyone entering the hospitals. "In Dutch hospitals, you are struck by their modernity and the design of the wards. This translates into the ability to isolate patients in single rooms and there is certainly greater availability of beds," he said. "Levels of cleanliness in Britain are on the low side when compared to other European standards. Cleanliness explains only a proportion of the transmission of MRSA but it is important because it is a marker for diligence and commitment and shows that staff are taking their work seriously."

Grundmann said overcrowded British hospitals were a big contributor to infection. British hospitals have fewer single rooms and so isolating all infected patients is impossible. As a result, patients with MRSA need to be cared for on communal wards and risk passing on the bug. He said the proximity of beds, the high percentage of beds occupied at any given time and the rapid turnover of patients fuelled the high rates of MRSA in British hospitals. "The drive to bring down the waiting lists by increasing the number of interventions and reducing the average length of stay is not helpful. This imposes a lot of work on an already overburdened system and staff and this always results shortcuts in hygiene," he said.

The inability to isolate patients due to lack of space and pressure to have wards open to keep waiting times down contrasts starkly with the drastic action taken to control MRSA outbreaks in Holland. Grundmann recalls an outbreak in a large Dutch hospital in 2003, affecting 28 patients. Managers reacted by closing two wards, including an intensive care unit, and spent 2 million Euros screening all staff and patients. Staff found to be carrying MRSA were sent home.

Ironically, the process of screening patients for MRSA and isolating those found to be carrying the bug, a technique known as "search and destroy", was devised in Britain. But, in the mid-1990s when the MRSA rates began to soar, managers found it impossible to isolate all infected patients - there simply was not enough space. The latest MRSA bloodstream infection figures, released last week, show that there were 3,391 cases in England from April to September 2006, down 5% from the same period in 2005. However, the figures appear to have reached a plateau, with the rate of decline being too slow to meet the target set in November 2004 by John Reid, the then health secretary, of a 50% reduction in MRSA cases before April 2008.

The number of deaths from MRSA in England and Wales has increased from about 50 in 1993 to 1,170 in 2004. The youngest victim was two-day-old Luke Day, who died at Ipswich hospital in 2005 after contracting MRSA. Sheldon Stone, a consultant in healthcare of the elderly at the Royal Free hospital in north London, said Britain needed to set up special isolation wards where all the patients with MRSA are treated. Failing this, he said, special nurses should be designated to look after only MRSA victims, to prevent the bug being transmitted to other patients. The Department of Health said many NHS trusts had been successful in bringing down the rates of MRSA, especially by encouraging staff to wash their hands. [Brilliant! Finally catching up with Lister -- in the 19th century]

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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9 February, 2007

Plans to strip British public hospitals of maternity units

Midwives are cheaper so no doctor for you! Too bad there is a shortage of midwives too

Women in labour could face lengthy journeys by ambulance to distant specialist units under plans which would strip dozens of local hospitals of consultant-led maternity services. Department of Health proposals unveiled yesterday seek a smaller number of consultant units to deal with the most complicated births and the sickest babies. It would be left to local, midwife-led units to handle the majority of births, while more women would be encouraged to have their babies at home.

Unusually, the health minister responsible for maternity services, Ivan Lewis, was not present at the report's launch. Mr Lewis, the MP for Bury South, has been active in the campaign to save the maternity unit at Fairfield Hospital in his constituency.

The Conservatives have already identified 22 consultant-led maternity units which are threatened with closure, as well as 21 midwife units. Andrew Lansley, the shadow health secretary, demanded to know why Mr Lewis was unavailable for comment at the briefing to launch the report, Making it Better for Mother and Baby. He said the Conservatives had repeatedly asked for clinical evidence to show the need for a reconfiguration of maternity services and the report failed to provide this. "Government nationally seems to be saying that everything has got to change and smaller units have got to be shut down, while locally, Labour ministers say they don't believe it and it's not justified. There's a hypocrisy in that. "These changes are being driven by financial deficits in the NHS and this kind of nimbyism displayed by health minister Ivan Lewis and Hazel Blears, the Labour Party chairman, is patronising to expectant mothers who want to access good maternity services within travelling distance, and to midwives who tell us that they are unable to get a job," he said.

The report, and another on services for children and young people, comes from Dr Sheila Shribman, the maternity and children's health tsar. She said the plans were about change not closure. Dr Shribman, a paediatrician, said she was not able to say how many consultant-led units would close. Decisions would be made locally and reflect local needs, she said."There is no national blueprint. Women will not be losing access to a consultant should they need one. They might not be just down the road — there might be midwifery care down the road."

She denied the move was about saving the NHS money. "I don't believe that the changes are about budget. In fact, if you look at some reconfigurations proposed there might be a need for increased investment."The report was about normalising childbirth which had become too technical in recent years, she said.

The Royal College of Obstetricians and Gynaecologists was cautious in its response.It said the care and safety of mothers and newborn babies should be at the heart of maternity services planning and women should always have the choice of where to have their babies. Prof Shaughn O'Brien, the vice-president of the college, said no woman would be forced to have her baby at home or in a midwife unit and all should receive "full and accurate" information on the risks if there were complications in labour.

The Royal College of Midwives said there was a shortage of 10,000 midwives and the service was facing cuts, job freezes, shortages and financial crises.Miss Blears is the most prominent Labour MP among about a dozen to be protesting on behalf of constituents about local maternity unit closures. She was criticised for joining a demonstration against the closure of the maternity unit at Hope Hospital, Salford, while remaining in the Cabinet.

Source



British obstetrics bad and talk of improvement unconvincing

Childbirth has leapt from the outer reaches of the NHS, where I and many other mothers have laboured in what I can only describe as the Dark Ages, on to centre stage. Ten ministers have broken ranks to campaign against the closure of maternity units in their constituencies. Patient groups are lining up to highlight the risks of longer travel times to fewer regional centres. The Tories are calling the moves "a desperate bid to save money" - although it used to be Tory policy that thrift was a good thing. It is, frankly, confusing.

Are these threatened maternity units as god-awful as the ones that I and my friends have suffered in? In which case, should we rue their demise? Will they be replaced by the warm, cosy corners evoked on Tuesday by the Government's maternity czar (I kid you not), who offered a rosy vision of home births and small, midwife-led centres nestling alongside larger, regional centres with consultants 24/7? It is hard to say, since her report was almost entirely data-free. She also refused to say what distance between home and hospital was considered safe. Ivan Lewis, the minister responsible, did not even turn up to the launch of Sheila Shribman's report. He, of course, has also been campaigning to save maternity units in his constituency.

If the minister is not convinced, should we be? The consensus that all closures are bad is almost certainly wrong. But government really has to do better in selling them to us. Announcing closures soon after trusts went into debt was bound to convince campaigners that the first was a consequence of the second, although it was not.

The plans for larger units are being driven partly by neonatal paediatricians who want to increase the survival rates of sick babies. In Manchester, they hope to save up to 30 lives a year by reducing the number of units in the city. In Nottingham, consultants want to merge two units that are only five miles apart, because they feel that they cannot provide adequate neonatal care if they are spread across two sites.

There is a logic to this. Consultant time is fixed. Junior-doctor time has been severely limited by the Working Time Directive. Consultants want trainees to be trainees, not amateur stand-ins. You can make better use of doctor time at delivery if you make patients travel farther. Several doctors have assured me that a longer journey rarely affects the outcome, because few deliveries are that quick. But it would be nice to know what the consensus is about how far is too far. We could have one unit treating all 722,000 births a year. But we don't. So where do you stop?

Other doctors say that we have already gone too far: Britain already has the largest and most centralised maternity units in Europe. The largest French unit handles about 4,000 births a year, and the largest in Germany 3,000. Each of the units that would be merged in Leeds and Nottingham are already considerably larger. A report by the think-tank Reform in 2005 found no evidence that larger units were safer. Reform also pointed out that maternity care now generates more than half of all negligence claims against the NHS. Most are allegations that brain damage or birth defects were caused by mistakes at delivery. The bill is potentially enormous, up to 4 billion pounds. That is eight times the size of last year's deficit.

It seems to me that there is a simpler argument in favour of larger centres. This is the need to bring more women closer to doctors who are actually available. Only about 60 per cent of women now achieve a normal birth. About a quarter end up having a Caesarean and the rest need forceps or ventouse deliveries. All of these require a doctor. It is impossible to predict which births are going to be tricky. As new mothers get older, it is frankly meaningless to offer them a "choice" of home births and midwife-led centres. The reality is that fewer and fewer clinicians will let them make that choice.

Dr Shribman's vision of 24-hour consultant care is a myth. Even the biggest units have consultants on site for less than half the time. But maximising access to a doctor during delivery - the time when most women are at greater risk than at any other time in their lives - is surely a sane objective. My first child was born at a weekend when the doctor arrived only after the midwives had had me pushing for an hour and a half. He said it was too early and was putting the baby at risk. Only three days ago one friend was told that she was not in true labour and did not need a bed, when in fact she was fully dilated. The stories are endless. Many of us who expected a normal delivery ended up relieved to see the operating table, because it was the first time we felt we were in the hands of a professional.

Midwives are the weak link that no one wants to talk about. When there are 10,000 midwife vacancies, when 60 per cent of those who do work are part-time, some cannot even spot a woman in labour, let alone provide the one-to-one support that controlled trials have shown can significantly reduce adverse outcomes. And when so many are patronising or panicked, the effect can be disastrous. One reason that the number of Caesareans is so high is because so many women become terrified by the feeling that no one is in charge. It stalls their labour.

Ministers are talking about efficiency. Mothers are talking about feeling safe. Right now, we do not. We need far more good midwives. We need to know how far is too far to travel, so that we can distinguish between what is inconvenient and what is life-threatening. We need a minister making the arguments, not a community paediatrician masquerading as a "maternity czar". If we had that, then frankly the proposed closure of 14 out of 282 maternity units might not have become such a controversial issue

Source



Questions not even a doctor should answer

Politics invade Australian medical schools

You might think that medicine is the one field that prides itself on making decisions based on objective evidence. Wrong prognosis. When it comes to selecting medical students, our finest universities are in the subjective business of social engineering. And that experiment appears to be failing dismally.

According to a study published on Monday in the Medical Journal of Australia, the present method of choosing medical students - a combination of written tests and interviews aimed at finding the best critical thinkers and problem solvers - is a poor predictor of how students will perform during their medical course. The gurus running the medical schools like to describe the process of turning a fresh-faced 18-year-old student into a fully fledged doctor as a complicated business. It is also an expensive business. Given that our tax dollars go into producing most of those doctors, that makes the method behind choosing who makes the cut our business.

This latest study appears to confirm concerns raised in The Australian last year from some inside the profession that good old-fashioned class envy and its twin sister, social engineering, are behind an interview process that pushes some of the most academically gifted students away from medicine. Being a son or daughter of a medico is now a handicap.

So too is going to a private school, said former deputy chancellor of The University of Adelaide, Harry Medlin. “I personally believe that to select medical students predominantly on their skills in an interview is a horrendous thing to do,” added John Horowitz, director of cardiology at two Adelaide hospitals.

Others voiced similar concerns. Like all pendulum swings, the move away from academic merit is turning out to be plain dumb, no matter how good the intentions pushing the pendulum. In trying to refute the claim, Lindon Wing, chairman of the Committee of Deans of Australian Medical Schools ended up confirming the bias.

In a letter to this newspaper last year, Wing defended the selection processes by pointing out “that medical doctors are among the most represented profession among parents of medical students in Australian universities. In some institutions, students whose parents are medical doctors number close to 20 per cent.” There. We have enough of the progeny of the bourgeoisie - 20 per cent is plenty. For Wing, it would be irrelevant if the age-old drive of human nature for children to follow their parents’ footsteps into a calling meant that 50 per cent of the qualified candidate pool were doctors’ children. Instead, the deans of the nation’s medical faculties centrally plan what they think is the best demographic make-up of medical students. And once they fill their pseudo-quota for doctors’ offspring, it wouldn’t matter how smart or well suited to medicine a doctor’s child was. When the quota is full it’s time to start engineering some results more to the planners’ liking.

And working out just who they like seems to involve asking the young students questions about gay marriage and the Iraq war. Many in the medical schools busily tried to defend the status quo, arguing they carefully train interviewers so that bias is not an issue. Reading some of the experiences on a website that provides feedback from those who sat through interviews suggests bias is indeed an issue.

One student from the 2003 intake in Queensland advised other interviewees: “Don’t expect medically orientated questions. Mine were about reconciliation, forest clearing, stem cell research, war in Iraq etc.” Other students were asked about their views on capital punishment and IVF for gay people. Students are a canny lot. The smarter ones know what interviewers want to hear. Here’s a sample. One student who secured a place in medicine in 2005 advises that a question about hobbies is a “disguised volunteer-work question”. Not wanting to look coached, the student says: “I did not list volunteer work first. I mentioned that I play soccer, guitar and working with kids.” Another student remarked that the interviewers “particularly delved into my volunteer work”.

It’s all being done, say medical schools, in the name of finding a cohort of future doctors able to reason and communicate. But as one leading Sydney specialist told The Australian: “If I had been asked, as an 18-year-old, whether I thought Australia should go to war in Iraq, I might have answered, Well, is the beer any good in Iraq?” This distinguished doctor says he may not have made it through the interview process. For the record, he is a dab hand at heart and lung transplants, is a top-notch communicator and his views on Iraq are now more advanced.

Now, as far as cartels go, you’d be hard pressed to find one more tightly knit than the medical fraternity. So, when doctors start criticising their own, you know something is awry in the nation’s medical schools.

Reinforcing the PC madness, it’s all about diversity, say those running medical schools. But what’s to stop interviewers, deliberately chosen for their diversity, imposing their own diversity filters on the interview outcomes?

Of course, raising questions about the interview is immediately sniffed at by those supporting the status quo as nothing more than nostalgia for old-fashioned elitism. It’s true that relying on objective academic results to allocate scarce resources is not the perfect solution. But it’s better than leaving the decision of who will make a good doctor up to the whims of two or three people on the basis of a 45-minute interview.

Refreshingly, even before this latest study, some medical administrators admitted the lack of evidence to suggest that interviews are producing a better calibre of students.

Ken Donald, former head of the University of Queensland’s medical school, told The Australian that introducing interviews was an “interesting experiment” but it was time to rethink the admission process because “people who perform poorly in the interview sometimes turn out to be the best in the class”. The corollary is also true: those who score highly in the interview are not necessarily the best performers down the track.

“I have a bit of sympathy with the assertion that unless the interviewers are well trained and the interview is well structured, there is the potential to misjudge liars, cheats, psychopaths etc,” adds Donald. “There is no good evidence anywhere in the literature, even in the published papers on this, that the interview, at least the one we have been using, is reliable as a predictor of performance,” he said.

Now, Queensland University’s medical school is reviewing the interview process. Abandoning interviews will restore fairness. No longer will talented young students be denied opportunities because the interviewers didn’t like their politics, or their parents’ background. But there is another more fundamental reason to dump interviews. They don’t work. Central planning never does. Would someone please tell the doctors.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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8 February, 2007

Good risk, bad risk

Americans puzzle me in respect to taking risks. We are notoriously poor savers, running up personal debts that put many in precarious danger of financial failure. In spite of high bankruptcy rates, we continue to live close to the edge, spending almost all of what we can earn... spending far beyond our needs... a nation of rabid consumers. We seem to believe that prosperity cannot be stopped, no matter what we do.

I don't remember our Great Depression, but I grew up knowing people who lived through it, including my father. Dad's life was completely upset by the depression, as was common throughout the country. It's fair to say that he never really recovered fully after starting life from scratch again in his late 30's. World War II followed shortly after that, putting recovery on hold for another 5 years.

If you've had the opportunity to spend any time with anyone who lived through the depression and WWII, you likely found them to be quite frugal, and adamant, almost fanatical, about savings... about spending less than they earned, putting it aside for emergencies and opportunities. That attitude seems to have been completely lost through succeeding generations.

When I was young it was difficult to borrow money. Credit was anything but easy. There were no credit cards. Most working people bought goods on a layaway plan, paying a little each week, not getting the goods until they were paid for. Getting a home mortgage required that one have a substantial cash amount to put down on the purchase, so most people saved for years before buying a house.

Huge risk debt load

We've become an easy-credit society. Credit is a nice alternative to have access to, but it IS risky, and Americans don't seem to have learned to judge that risk well. The past ease of declaring bankruptcy and getting rid of old debts may have taught us to underestimate the risk. The rapidly-rising value of houses for so long also contributed to a feeling that we were making money just by owning property, and led many to ignore the ever-rising debt they carried via multiple refinancing of mortgages. Americans have become used to carrying large amounts of credit card debt as well.

Been there, done that too... and it can be nerve-wracking. Carrying debt is a RISK that Americans have become accustomed to dealing with, and it is a BIG risk for a great many people. Far too many people are one or two paychecks away from complete economic failure, and they know it, and they live with that risk.

The other risk that people won't take on

Health insurance programs have only been around a few decades. The idea of paying premiums to an insurance company who will then cover most of the costs you incur for health care is a pretty recent development. I remind you, as I used to remind insurance clients, that insurance companies will make a profit on the risks they underwrite. If they don't, they'll be out of business. So, health insurance is like a lottery... lots of people will pay extra for the care they receive and a few will get more care than they've paid for. But, with insured health care, there is also a lot of complication that once didn't exist between doctor and patient. Paperwork in huge amounts... simply because there is a third party involved, between doctor and patient. Add in government programs like Medicare and Medicaid, and the paperwork increases far more. For each doctor, there are 4 other workers involved in the process.

I don't want to deal here with all of the complications that have been added on top of third-party payment of health care, but it has gotten completely out of hand. Government stuck its ugly nose in and made it far worse by mandating many coverages, and by over-regulating everyone involved. When it became unmanageable for insurance companies, they sought to control the caregivers... doctors, hospitals, and suppliers. Health care has become a mess... a terribly expensive mess.

The average cost for a business to cover an individual worker's health care coverage is now at least $6,700/year... $558 per month. All of the factors stuffed into what once was, and still amounts to, a doctor helping you with a problem, has created mass insanity. The costs of the massively complex system have risen to the point that people have become deathly afraid of doing without it.

A recent survey showed that 75 percent of respondents said they would rather have a company health plan than a pay raise of $6,700. Thirteen percent said no pay raise would be big enough to get them to part with employer coverage.

The bulk of the American working population has become so unwilling to accept ANY responsibility for their own health care that they're willing to pay far, far more in prepaid premiums than the cost of likely health care costs. I've known many people who stay in jobs they hate, or dead-end jobs, just to keep their health coverage. That is living in slavery to health insurance coverage.

Zero-risk health care

For all those people under job-related health plans, they're paying exorbitant premiums, that could be taken in wages, for what amounts to taking no personal risk on their own health. I cannot help but believe that being in that situation contributes to increasing health problems. Isn't there less incentive to be careful with your health if your health care is guaranteed?

The real intent of insurance is to protect against catastrophic loss; loss that could not be covered out of savings or current income. Of course, covering small losses rather than overpaying an insurance company to do it means that we do need savings or disposable income. Therein may lay the rub.

As long as Americans insist on spending all they earn, and carrying heavy debt, it will seem sensible to take zero risk on health care, because there is little or no savings or disposable income. Many people who pride themselves on shopping for low prices are somehow able to ignore their overblown health insurance premiums. Others will even invest money while wasting other dollars on zero-risk health care coverage... wise enough to save and invest, but not wise enough to recognize how much they're throwing down a health care rathole.

So... health care continues to become more convoluted by paperwork, driving small providers out of business and forcing doctors and clinics to become part of ever-bigger paper-shuffling corporations. Care becomes more impersonal and less trusting as stress builds in the system. Increased patient load leads to more mistakes, causing providers to cover their potential liability with more tests and precautions, driving costs still higher.

Insurance has an extremely valuable place in our lives, but when it is used to provide zero-risk rather than as a safety net, it can warp everything connected to it. Politically, the result has been for Americans to look to government to protect them against losses caused by their own failure to control their personal risks. That is a path toward becoming dependent slaves to government.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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7 February, 2007

Government Should Stay out of Drug Business

On December 2, the news provided vivid, painful proof that drug innovation is indeed a very risky business. The American pharmaceutical firm Pfizer was in the final stages of testing a new drug for heart disease that would not just lower bad cholesterol, as its Lipitor does, but also increase good, artery-clearing cholesterol. The drug, torcetrapib, would have been a blockbuster, offering huge promise of actually reversing heart disease--the nation's number one killer.

The independent researchers monitoring the trial, however, alerted Pfizer that the late stages showed a higher death rate among participants. The company quickly pulled the plug after having invested close to $1 billion and 15 years on it, taking a $20 billion hit on its market capitalization.

It would be wise for members of the incoming Congress to pay attention to the riskiness of this business. Pfizer has other promising drugs in the pipeline, but if Congress decides to put price controls on the industry, it will certainly dry up the resources needed for new drug development and the capital required to take risks like this to tackle heart disease, Parkinson's, Alzheimer's, obesity, and the many, many other killer diseases that could be treated and even cured.

For proof, we need only look at Europe's dying pharmaceutical research industry, which has been decimated by shortsighted government policies and price controls that dry up the resources for research. We don't want to go there.

Source



Australia: Review urged of selection for medical education

Politically correct approach not working

Experts have called for an urgent rethink of selection processes used by medical schools after finding the tests used to admit students fail to identify the best applicants. Researchers who measured the subsequent performance of students who did well in the tests said good results bore little correlation with how well the students performed during their course.

The study -- published today in the Medical Journal of Australia -- also found the structured interviews used by many medical schools with the tests were too subjective, and there were "serious qualms" over their ability to highlight the best candidates. The findings are likely to reignite a controversy revealed by The Australian last year, after senior doctors criticised interviewers for asking would-be students their views on gay marriage, the Iraq war and whether their parents were doctors.

In three accompanying editorials also published in today's MJA, experts condemned other aspects of medical education, including poor tuition of newly-graduated doctors working in hospitals, and the adoption of "problem-based learning", which had displaced traditional teaching methods in many university medical schools. Queensland medical education expert Richard Hays, currently head of the medical school at Keele University in Britain, said despite its enthusiastic uptake, problem-based learning had not been based on strong evidence.

Chris McManus, a British professor of psychology and medical education, and Australian psychology professor David Powis, said the "sad reality is that surprisingly little is known" about how best to select students. Professor Allan Carmichael, chairman of Medical Deans Australia and New Zealand, said entry processes were under review and welcomed the findings as adding to the evidence of what worked. However, he said the editorials were individual opinions, and the new study was based on a small sample. Previous studies disagreed with it, he said. "One would take note of it, but not go in for a wholesale change of selection processes on the back of this study," he said.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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6 February, 2007

The other Republicans' health care plan

California State GOP caucus offers a more market-based approach than the governor's

California Senate Republicans have unveiled an appealing plan to improve the availability and affordability of health care for all residents without imposing new taxes or forcing businesses or individuals to buy or provide anything. The plan announced Tuesday by the Senate Republican Caucus relies heavily on tax incentives for individuals, employers and health care providers, and on redistributing existing funds to improve health care coverage for children and the uninsured. Republicans claim their plan would provide "bare bones" health care for 3 million of the 6 million Californians now lacking insurance.

So far this year, Republicans have offered both carrot and stick incentives for improving health care. Republican Gov. Arnold Schwarzenegger's plan wields the stick - mandates, taxes and fees - while Senate Republicans now extend the carrot - tax breaks, loosened regulations and no new taxes. Also unlike the governor's plan, the Republican Caucus doesn't want to pay for illegal immigrants' health care. Instead, the plan would send the federal government a bill for $2.2 billion, "the cost of providing federally mandated health care services to illegal immigrants." That tab might be hard to collect.

However, there is much to like about the Republican Caucus' plan, which is dubbed, Cal CARE, an acronym for "comprehensive, affordable, responsible, effective." Cal CARE appears to be fairly comprehensive and might achieve affordability if its tax incentives and loosened regulations bring down costs as envisioned. The plan certainly is responsible since it leaves in the hands of individuals rather than the state the task of obtaining and paying for insurance and health care.

One of its most promising aspects is the proposed change in state regulations to allow health plans and insurers more flexibility in co-payments, deductibles and in modifying state mandates regarding health insurance benefits. If Republicans can pull that off, consumer choice will be greatly enhanced, and costs should drop accordingly.

Whether the plan will be effective, however, depends on the details. And considering the Democrat Party's dominance in Sacramento, making Cal CARE a reality could be a long shot. The Republicans propose that at least one part of the plan - redirecting tobacco taxes to children's health - be decided by voters through a ballot initiative.

The legislative parts of Cal CARE just might work if Republicans can communicate their message to build broad enough public support, which sometimes can influence even Democrat legislators. Unfortunately, it's a complicated message. (In that regard, it's also unlike the governor's plan, which by comparison is easily understood. With its mandates, costs and taxes, it's abundantly clear the governor's plan hurts just about everyone, employers and employees, providers and insurers.)

The Republican Caucus' plan doesn't have nearly as many negatives, but it's also a confusing myriad of spending reallocations, targeted employer incentives, budget priority shuffling, low-interest loans, tax credits, regulatory changes and ever-vague concepts like, "expansion of more affordable health coverage products available for consumers." There's also the matter of cost. Unlike the Schwarzenegger plan's $12 billion price tag, Senate Republicans claim no "out-of-pocket expenses." But it's unclear what the cost will be to increase Medi-Cal reimbursement rates, as the caucus desires. A large portion of the caucus plan relies on reallocating existing funds, for example, to expand primary-care clinics and provide care for children. However, the plan doesn't identify how much tax revenue will be lost by providing "the same tax benefit" to employees currently enjoyed by employers. We're anxious to see whether it will be the devil that is in the details, or something more pleasing.

Source



TIBOR MACHAN ON SCHWARZENEGGERISM

Several years ago Arnold Schwarzenegger seemed to have embraced the libertarian thinking of the late Milton Friedman. He even contributed some work to Friedman's famous TV program, Free To Choose, although I cannot recall exactly what that amounted to-an introduction to the DVD version or something.

I never had much hope for Arnie even back then because he never came right out and gave any clear statement of his political thinking. Moreover, although I am weary of reading people from afar, there were signs afoot suggesting that what Arnold Schwarzenegger is most interested in is being liked! Take, for example, the name he gave his famous restaurant in Santa Monica, "Schatzi." In German it means "little treasure" and is used mainly as a term of endearment toward someone one likes very much-"Mein Schatzi" or "My little treasure."

When someone is a political powerhouse but there is no real clue to what principles guide his or her conduct, it is difficult to tell what policies he or she is likely to support and oppose. That is when one is tempted to look to other factors to understand and explain the person, and this seems to be called for in the case of the current California governor. No one has a clue as to what he believes, what general ideas he adheres to, what his overall vision is. So then perhaps gaining a clue from his favorite German term is fair game.

But there is more. Consider that his massive spending plan, including the out and out socialist idea of universal health insurance to be paid for by the government, does not call for any rise in taxes. Instead he wants to pay for it by way of floating bonds, which is to say transferring the cost to members of future generations. What is noteworthy about this is that those members do not vote, they aren't even alive yet, so they aren't going to be angry at the gov much. And the current citizens of California will be able to continue the status of recipients of apparently free goods, delivered to them by their little treasure. He will, it seems, continue to be liked since the burden of his ill founded ideas will fall on people he will not have to face.

There used to be a famous slogan about taxation-there should be none without representation. Not quite what I would defend but better than how taxes were dealt with in the feudal past-more democratic, which is some progress. But now, as logic would suggest, politicians have become so habituated to promising and trying to deliver "free" goods they need not account for that they are willing to abandon the idea completely. Instead, "Let's just charge it, so the voters will not have to experience the cost of their benefits."

I, as did the governor, came to America as a refugee, only not from Austria but communist Hungary where health care was provided to all-in dreadful shape, of course, as anything that costs nothing much must be. It was also peddled with the sentimentalist notion that everyone is owed it, which is a crock. Many people don't want health insurance-I personally know quite a few such people. They'd rather save up for emergencies and do other things with money left over. And some simply haven't managed to come to afford health insurance, just as they haven't many other things they want and even need. None of this justifies having the likes of Arnold spread the cost on people who did make the needed effort to afford health insurance. And the idea that some are coerced to pay for the health care of others is criminal!

This dream of universal health insurance is no different from a dream of, say, universal fine dining or splendid vacationing or exquisite leather shoes. Health care workers need to be paid and the money doesn't grow on trees, so if those who receive the benefits will not pay, someone else must either voluntarily help out or be made to do so. The last is exactly as the communist viewed the situation. Maybe we ought to get a governor who really opposes tyranny, no matter what the excuse.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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5 February, 2007

THE LESSON FROM SINGAPORE

President George W. Bush's plan to abolish the tax deductibility of corporate health insurance, while granting a tax break for its private purchase doesn't solve many of the US health system's problems. Not surprising; the incentives involved in healthcare purchase are bizarre, and always have been. Only when this reality is recognized, and the economics of the system adjusted, will healthcare become affordable for the long term future.

Healthcare purchase has always been largely directed by faith rather than reason. The medical profession didn't reach what a cynical MBA would call "operating break-even" in which it cured as many people as it killed until at least 1925 or so, maybe even until the invention of antibiotics in the 1940s. Nevertheless, medical expenditures before this time were very substantial. In 1900 advanced countries such as the United States and Britain spent fully 3% of Gross Domestic Product on medical services that had a net negative effect on life expectancy.

George Bernard Shaw's splendid 1906 play "The Doctor's Dilemma" illustrates this. The play involves interaction between six Harley Street specialists, five of whom are highly-qualified quacks while the sixth is the only doctor with a treatment that might cure a particular patient suffering from tuberculosis. Even Shaw's hero has ideas that are pretty weird by modern standards. However since he was young he may eventually have achieved lifetime medical break-even by surviving into the 1940s and curing more patients in the 1940s with early antibiotics than he killed in 1906 without them!

All six of Shaw's doctors made very good livings indeed, and three of them had been knighted. Nevertheless a patient entering one of their consulting rooms at random had at most a 1 in 6 chance of medical benefit (even granting Shaw's thesis that his hero knew what he was doing.) It may be objected that in the other five cases the patient could try again, so putting him above medical breakeven for his huge expenditure in consulting Harley Street specialist after Harley Street specialist, but that's assuming the other specialists didn't kill him first. We learn for example that the patient allowing Sir Colenso Ridgeon to "stimulate the phagocytes" had about a 50-50 chance of losing an arm or two in the process!

It is thus clear that the patient consulting Shaw's Harley Street was wasting his money. Similarly the Jane Austen heroine waiting anxiously for the doctor to arrive was wasting her time. Maybe Sir Colenso Ridgeon's bedside manner was so suave and authoritative that a few patients recovered through a placebo effect, but that surely cannot go far to justify the enormous expense involved in consulting him. To summarize: the 3% of GDP spent in 1900 on healthcare was completely wasted, an utterly irrational use of resources.

If pretty well all medical expenditure was economically irrational in 1900, why should we suppose that much such expenditure is not equally irrational now? It is in this context that we should judge the 16% of U.S. GDP spent currently on healthcare. It's not as if the underlying economic realities have been revolutionized. The United States spends more of its income on healthcare than any other country, yet does not achieve better results in terms of life expectancy and chronic illness. Meanwhile, an average of 250,000 patients died in the U.S. through preventable medical error in 2002-04, according to HealthGrades, and that's not counting deaths even today due to diagnoses and treatments like Sir Colenso Ridgeon's, thought appropriate at the time but later found to be fantasy.

Not only are consumers ignorant of the realities of their healthcare treatments, they are incentivized by the U.S. third-party payer system to spend even more on healthcare than the irrationally large amount they would spend in a free market. The Bush tax plan does nothing to address this. In addition, by failing to address the problem that health care premiums rise with age, it provides an extra subsidy of the young and healthy at the expense of the middle aged, surely unnecessary when life has subsidized the young and healthy so much already!

Lovers of the British National Health Service needn't smile in a superior fashion. Apart from costing less than the U.S. system, it has no other noticeable benefits. It is more or less a producer cartel, except that because of the 1948 Labour Party's slavery to the unions, the doctors in the NHS have almost no power and the mass proletariat of cleaners and low level administrative staff collectively controls the system. The principal objective of Aneurin Bevan at the system's inception was the properly 1940s-Soviet one of defenestrating Sir Colenso Ridgeon; this was achieved, but at what a cost! In the long run, socialized medical systems are freeloaders off the innovation in private systems. This is inherently unstable, particularly as private medical systems become socialist themselves.

A well designed healthcare system will discourage people's willingness to spend uneconomically large amounts of money, particularly other people's money, on healthcare. It will also recognize the unfairness of life, and the need to subsidize (but not ad infinitum) those who through no fault of their own incur large medical expenses in youth or middle age. Conversely, it will recognize that death comes to us all in the end, and that there is no point in prolonging life beyond where it is economically or hedonically useful. Finally, it will recognize that in healthcare as in everything else, rich people can afford more than poor people; this is not an inequality that should be removed from the system.

If people tend to spend too much rather than too little money on healthcare, then healthcare expenditures should be as far as possible made through health savings accounts, or some equivalent mechanism whereby the expenditure is directly out of pocket to the consumer. These should be much larger than has been suggested by all past discussions, perhaps funded by a levy of 10% of the individual's total income until the age of 75. They would need to be, because as well as the individual's own health care expenses they would need to cover the medical costs of the individual's children under 18, with the general principle that both biological parents should pay equally for children's treatment.

By mandating healthcare savings accounts at such a high level, the President and Congress would increase the U.S. savings rate, and would redress the balance between youth and middle age - payments would be a constant proportion of income through the early and middle parts of life, with the effect of building up large balances that were spent down later.

Surprisingly, one possible model for such a system has existed since 1984, in Singapore's Central Provident Fund (motto "Integrity, Service, Excellence" - not what one finds in government bodies nearer home!) This compulsory savings scheme provides for healthcare, retirement, life insurance and home ownership, provides accounts that remain the property of the individual at all times and offers a variety of investment options. Contributions are 33% of employees' wages until age 50 of which 13% is paid by the employer; the contributions scale down at higher ages. For the self-employed, the system is limited to a medical savings account, with premiums of 6-8% of earnings. There is also a catastrophic medical insurance scheme, for early major illnesses. Medical costs are paid directly out of the CPF Fund, and the saver is advised to stay in "affordable wards" to make his Medisave funds go further. Funds can be withdrawn on retirement, subject to retention of a minimum sum, converted to an annuity for basic living expenses and a Medisave minimum for end-of-life medical expenses. At death, an individual's CPF holding is transferable to his heirs.

The principal benefit of the Singapore system is that it makes almost all healthcare costs payable by the patient, directly from his healthcare savings account. There are no insurance intermediaries adding costs, determining what treatments are acceptable, or negotiating in their own interest with healthcare providers, attempting to get cost discounts compared with the uninsured. Hospitals and other healthcare providers are forced to provide a transparent fees schedule, and estimates of cost in advance of treatment, so that the patient or his near relatives can make an informed decision as to which treatments to select.

Needless to say, the Singapore system is so sensible that it is most unlikely to be adopted in Britain or the U.S. Although the compulsory savings must seem high to the young, tax rates are correspondingly lower; the top marginal rate of Singapore's individual income tax is only 20%, so tax plus CPF contribution totals a maximum marginal 40%, still reasonable. Furthermore, by diverting health and retirement payments to the private sector, with contributions and payments administered through the CPF, it reduces the size of government itself, which in Singapore absorbs only 16% of GDP, far below its percentage in the U.S. or Europe.

By reducing the proportion of the economy administered by third parties, and forcibly raising the national savings rate, the CPF system brings two huge economic benefits which would enormously help the performance of both the US and British economies. It need hardly be added that by reducing the resources available to government, the CPF also reduces corruption; Singapore ranks fifth on the Transparency International Corruption Perceptions Index, with a 9.4 ranking, compared to the U.S. at 20th with 7.3.

Anyone who has watched TV news broadcasts on healthcare subjects has seen that healthcare naturally appeals to the lowest common denominator sentimentality of the voting public. Hence healthcare funding, if subjected to a democratic process is particularly subject to subversion and cost escalation. If Demos governs the system, economically sensible solutions such as rigid caps on uninsured cost reimbursements are impossible to implement. However, without economic rationality, healthcare costs in socialized and insurance-based systems alike are likely to continue expanding until they have swallowed the entire wealth generating capacity of the economy.

Economic rationality is unlikely in the short term; this isn't Singapore. Instead policymakers, notably including George W. Bush, Tony Blair and Gordon Brown, will treat healthcare funding like Sir Colenso Ridgeon treated medicine, stimulating the phagocytes until the patient's arm drops off!

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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4 February, 2007

Crunch time for the NHS - will it pull through?

Reform of the health service is slowing just as it needs to intensify. If we don't accelerate now, billions of pounds will have been wasted, warns the top cancer consultant Karol Sikora

This month saw a blast of more bad news about our beloved health service. Too few nurses, too many doctors, no money, operations cancelled, another radiotherapy scandal, staff threatened with redundancy and entire hospitals going bust or being bailed out. Many must be wondering where all the taxpayers money that's been poured into the service has gone. After all, if you increased the budget of any commercial organisation from 34 to 84 billion pounds a year you would expect to see some dramatic improvements. But car parking is impossible, the loos still dirty and people sit around endlessly clutching pieces of paper when you can travel the world with an invisible electronic ticket.

I have worked in the NHS for 34 years, so it comes as no surprise. It's a large monopoly provider employing 1.4 million people that sometimes seems more responsive to staff needs than to those of its customers. Buffeted by the winds of political and social change, assaulted by a barrage of new expensive technologies, faced with consumers who are more demanding than their parents, it is now struggling for survival. And in 2008, current increases in NHS funding of 7 per cent a year dry up. So what is the solution?

It has to be reform. Not tinkering at the edges but pushing quickly forward with the bold plans already in place. Increased pluralism with new players providing innovative services will lead to real competition and a market driven approach. Novel ways of working will lead to greater efficiency, better motivation and allow staff to work together to drive innovation rather than whinge about the lack of it. The key is to get the multiplicity of professionals working together in the best way for patients. This will need to close but not intrusive management.

We have nothing to fear from further implementation of payment by results (PBR) - which simply means paying hospitals and GP's for what they actually do. It is exactly what happens in any other service industry. Imagine a supermarket that gets paid the same wad of money each week regardless of how much it sold. PBR changes patients from being service users to welcome customers. Consider high-street opticians. The old lady with her shopping trolley living alone on her state pension is as welcome as the girl about town in Prada and pearls who wants Gucci frames. Both come out seeing better. Can we not apply the same model to cancer and hearing aids?

The trouble is, as the think tank Reform recently pointed out, the whole process of change has slowed down just when it needs to accelerate. Waiting times in some areas have actually risen and novel rationing systems have emerged. There was an outcry from both left and right when a Department of Health report on workforce numbers was leaked. But these were probably only the back of an envelope of doodles by civil servants, rather than a serious assessment of demand, technology improvement, patient preference and skill mix.

The real issue is that by 2008 we should have moved from central to devolved planning. Local, not central, management should be deciding what staff to hire, what they should be doing, how many of what grade are needed and how much to pay them just as in high street shops. Real incentives for productivity, completely omitted in the recent, very costly, doctors' pay award, are vital in a pluralistic marketplace.

Stripping away bureaucracy to reduce costs is an essential component of therapy for the NHS. One report suggests that we are heading for a 7 billion deficit in the NHS by 2010 and that's not allowing for step changes in technology. That represents a 2p in the pound increase in income tax for everybody unless we can make things more efficient.

Major new investment capital is available from City institutions subject to robust business plans. The usual emotional statements of need or woolly wish lists simply won't do. Doctors hold the key. They can carry the other health professionals by providing decisive leadership. Getting good rapport between local medical leaders and managers is vital as is delivering services to patients in convenient settings rather than city-centre teaching hospitals, while retaining access to technological advances.

The NHS staff that I have known over many decades, have the talent, skills and education to make the transition. Whether it's dealing with a child with a complex leukaemia, a coach crash on the M25 or managing an elderly man with cardiac failure, we can do it as well as the best in the world. But only by intensifying the current reform programme will the NHS reform ever be got out of intensive care and sufficiently revived to make the long transition to a consumer-driven marketplace of health. Whatever our political persuasions, we must all surely agree that a speedy recovery is in everyone's interests.

Source



FDA puts a bandaid on its wounds

The Food and Drug Administration said yesterday that it is making changes in the way it operates to prevent the kind of drug safety controversies that have dogged the agency in recent years. Officials outlined plans to better monitor safety problems after drugs are approved and to make internal changes to increase the profile of agency scientists who raise red flags about drugs. The steps were announced in response to a report last year by the congressionally chartered Institute of Medicine (IOM) that called for an overhaul of the FDA's culture and structure following safety controversies over drugs such as the painkiller Vioxx.

Officials said the steps will restore the trust and confidence of Congress and the public. They also pledged a renewed commitment to good science as the best way to counter critics who say the agency is too cozy with drug companies. "We will fight back against those perceptions and that cynicism," said Steven Galson, head of the agency's Center for Drug Evaluation and Research, the division that evaluates new drugs and that has been at the center of the maelstrom.

A member of the Institute of Medicine panel said the FDA had taken steps in the right direction but had fallen short. "In a number of cases, the FDA does not go as far as the IOM recommendations, but they are first steps and in the right direction," said R. Alta Charo, a professor of law and bioethics at the University of Wisconsin.

A central contention of the IOM report was that the agency did not focus enough on monitoring drugs once they were approved. Most approvals are based on clinical trials involving a few hundred or a few thousand patients, and many uncommon side effects do not emerge until a drug is being used by millions. The IOM report said FDA officials who monitor drug safety were being ignored, because top officials were focused on approving new medications rather than monitoring those already on the market. "There was an asymmetry in esteem and funding between these two groups," Charo said. While the changes the FDA announced yesterday to integrate drug safety experts in the process were a start, she said, the agency's drug safety specialists still lacked power.

When FDA safety officials see a problem with a drug, Charo said, the agency is required to discuss proposed warnings, labeling changes or limits on distribution with the manufacturer. What FDA safety officials need, she said, is the power to impose fines and restrictions on companies that do not voluntarily follow the FDA's directives.

Agency officials said some of the changes proposed in the IOM report require congressional action, because they call for new powers. But officials also said they are starting a pilot program to produce report cards on some new drugs 12 to 18 months after their approval -- a process that would bring problems to light.

FDA Commissioner Andrew von Eschenbach and other senior officials said they were largely in agreement with the institute but called its report useful advice, not a blueprint. The agency is taking steps to break down internal walls and strengthen the role of safety specialists on advisory panels, they said. Referring to the IOM's concern about a "lack of respect" between agency staff who approve new drugs and those who monitor drug safety, Galson said, "We need to improve the way scientific disagreements are handled and resolved."

Besides the "cultural" issues within the agency, officials outlined a number of initiatives to better understand which patients may be susceptible to particular types of side effects, and which patients may be most likely to benefit from a particular drug. "This new science of safety will help us make products safer from the get-go," said Janet Woodcock, the FDA's deputy commissioner for operations.

The agency also said it is seeking alliances with the Department of Veterans Affairs, the Centers for Medicare & Medicaid Services and private insurers to gather better information about problems with using drugs and the challenges that physicians and patients encounter in the everyday use of medications.

Officials also promised greater transparency in how they select experts to serve on influential panels that assess new drugs and devices, as well as policy issues facing the agency. Some of these panel members have come under criticism for having ties to the drug industry. While greater transparency is a good thing, Charo said, the FDA also ought to limit the overall number of panel members who have conflicts of interest.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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3 February, 2007

Answering the critics of the Bush health plan

President Bush made bold health policy proposals in his State of the Union message. First, he would level the playing field between individual and employer purchase of health insurance. Second, he would eliminate provisions in the tax law that reward waste and penalize economy in the purchase of health insurance. Third, he would allow the states to redirect federal funds used for charity care and use them to subsidize private insurance instead.

The plan has drawn praise from the right and the left. It gets high marks from the Urban Institute and the Brookings Institution, as well as the Heritage Foundation and the American Enterprise Institute. Yet the critics have been quite vocal. Let's look at their complaints.

Is the Bush Plan a Sop to the Rich?

Families USA claims that the Bush health plan would benefit the rich at the expense of the poor. The same charge was made by Paul Krugman in the New York Times and some Democrats in Congress. But as Steven Pearlstein and Ruth Marcus explain in separate editorials in the Washington Post, the opposite is the case.

The Bush proposals would redistribute tax subsidies for health insurance from the haves to the have-nots. Specifically, the plan would grant everyone a health insurance standard deduction of $15,000 (family) or $7,500 (individual), regardless of the cost of the insurance or how it is purchased. Families whose insurance costs less than $15,000 would pay less in taxes than they currently pay. Families whose insurance costs exceed $15,000 would pay taxes on the excess. Thus, for the first time, people who must purchase their own insurance would receive the same tax relief as people who obtain insurance through an employer.

Under the current system, the federal government dispenses more than $200 billion a year in tax subsidies for private insurance. Families with incomes in excess of $100,000 get seven times as much subsidy as families who earn less than $30,000. [See the figure.] The Bush plan takes a large step toward a fairer arrangement.

According to White House estimates, about 20 percent of taxpayers - mostly those at the top of the income spectrum - would pay higher taxes. These are the 30 million people with expensive employer-provided plans. By contrast, the Bush plan will cut in half the cost of health insurance for a typical uninsured family.

Would Employer Coverage Erode?

The New York Times complains that the Bush plan makes it easy for employees to leave their employer plan and purchase their own insurance. This exodus of employees would cause employer plans to crumble. Some business trade groups make the same complaint. Does this criticism have merit?

In virtually all group plans, employers pay half the cost of the insurance, and in the average plan, they pay three-fourths for family coverage. Even on a level tax playing field, an employee exiting an employer plan leaves three-fourths of the premium payment behind. If the employee can find a better plan for one-fourth of the premium dollars (to say nothing of the economies of group buying), the employer plan would have to be extremely wasteful. Some employer plans may be that wasteful. If so, all would gain if the employer gets out of the health insurance business and pays more wages instead. (See the next question.)

Would Employers Drop Their Health Plans?

Paul Fronstin (Employee Benefit Research Institute) says, "The president's proposal would mean the end of employer-based benefits as we know them." Is this really true? Under the Bush plan, individual and group coverage would compete on a level playing field. In such a world, employers would not offer insurance at all unless they had a comparative advantage in doing so in their competition for labor. Undoubtedly, many large companies do have an advantage - they can do for their employees things the employees cannot do for themselves. Many small firms, however, have no such advantage and would probably be better off paying higher wages instead of paying for health insurance. These issues should be resolved in the marketplace, rather than by the tax-writing committees of the U.S. Congress.

That said, where employers can add value - say, through economies of group purchase - the Bush plan creates new and stronger incentives to do so. The reason: For millions of people, the tax subsidy for purchasing insurance will be higher and the tax penalty for failure to purchase will be lower. (See the next question.)

Would the Plan Increase the Number of People with Health Insurance?

Paul Krugman, Families USA and other critics claim that the Bush plan will do little to insure the uninsured. Even if the plan failed to induce a single new person to obtain insurance, it would still be worth enacting. Tax fairness - treating equals equally under the tax law - is a worthy goal in its own right and is long overdue. Similarly, eliminating incentives to make wasteful health insurance purchases is also a worthy goal.

That said, the Bush plan will make health insurance more attractive for millions of families that are currently uninsured. The White House estimates 3 million to 4 million additional insured. That estimate is probably too conservative.

Consider a family with the opportunity to purchase a $5,000 high-deductible, no-frills health plan. Under the current system, the family would receive a tax subsidy (if purchased through an employer). Under the Bush plan, the size of that subsidy would triple. The reason: The family gets to exclude $15,000 from income and Social Security taxes, regardless of the premium cost. Conversely, the penalty (taxes owed on $15,000 instead of $5,000) would also triple if the family failed to insure.

The Bush plan is likely to encourage insurance in another way. By redistributing the benefits from the haves to the have-nots, the plan makes health insurance far more attractive to low- and moderate-income families. For example, two-thirds of the uninsured (nearly 30 million individuals) are families with incomes under $50,000. Under the current system these families receive a tax subsidy of only about one-quarter ($733) of the subsidy families earning more than $100,000 receive ($2,780). Under the Bush plan, a $15,000 standard health insurance deduction would be potentially worth $4,545 in subsidy (15 percent federal income tax and 15.3 percent payroll tax).

Would the Plan Cripple Safety Net Hospitals?

Sen. Hillary Clinton says the Bush plan would take money away from public hospitals that cater to the poor. The New York Times agrees. Yet the White House points to Gov. Mitt Romney's health plan in Massachusetts as an example of what it wants states to be able to do; and the Romney plan was endorsed by Massachusetts hospitals, along with a huge majority of Republicans and Democrats in the state - including Sen. Ted Kennedy.

Safety net hospitals exist to provide care to indigent patients who cannot afford health insurance. These hospitals receive government subsidies to reimburse them for the cost of providing "uncompensated" care. In a market with few uninsured individuals, safety net hospitals should not need the current subsidies and would have to compete for patients against other hospitals.

Under the Bush plan, low-income families would no longer be trapped in public systems where the quality of care is frequently suspect and there is often rationing of care, especially rationing by waiting. Instead, states would be able to apply federal funds previously allocated to hospitals to subsidize the purchase health insurance for the poor.

Conclusion. While not perfect, Bush's plan would be a considerable improvement over the system we have today.

Source



Britain: Why New Labour is losing the health war

Want to really know how well - or not - the Government is doing? Ask a senior minister. No, really: an outbreak of candour has descended upon those reaches of the Cabinet who generally prefer to tell us that everything is going marvellously.

But today the Health Secretary Patricia Hewitt tells this paper that she wishes NHS reforms had been begun earlier and gone faster. Hazel Blears told us the same thing last week on state schools. In the no-man's land between the Blair-Brown leaderships, ministers are anxious to defend their record and stake their claim to a place in the next phase of the New Labour story.

Mrs Hewitt is to be commended for her openness, but even she does not reflect the degree of political concern inside the party that it could "lose health". A splenetic memo from Mr Blair's favourite pollster Philip Gould reflects that fear and recommends health as the first area of policy which needs to be addressed to get the party on course for a fourth term.

"Just tell me," asks one young minister, "How did we contrive to lose our way quite so badly in the one area Labour has a cast-iron, in-built advantage as the party which founded and defended the NHS?" The voters are confused - a hitherto impregnable poll lead over the Tories on competence to run the NHS has entirely disappeared.

A wave of "reconfigurations" - the newspeak for unpopular hospital closures to create bigger treatment centres is underway, the NHS is struggling with massive deficits - five hospital trusts in London alone are in the red.

Between now and the next election, Labour has to get the budget back into balance, close hospitals and reorganise services accordingly - and deliver the promised maximum waiting time of 18 weeks. It is a very tall order indeed. No wonder David Cameron is starting to enjoy himself with a "campaign" against Labour's "cuts" - serving up the same jibes that used to be turned on the Tories as a preliminary salvo.

Tony Blair began his NHS reforms seven years ago, with a barnstorming speech about dragging the service "out of the Forties and making it fit for the new century". What has been lacking is not good intentions - as always, he saw more clearly than many around him that the NHS needed to change to satisfy the demands of modern users.

What has been lacking is consistency of implementation. "The trouble with Tony," says a civil servant who worked closely with him, "is that he thinks that just because he says he wants something to happen, it is going to happen." Delivery tsars have come and gone, but implementing reform has always been the Achilles heel of the Blair years.

To which the PM might well respond that it might have happened a bit faster had healthcare reforms not become a football kicked between Number 10 and the Treasury, with the Chancellor intervening to stymie some of the plans for autonomy developed by Alan Milburn as health secretary and then approving large pay increases across the board with too few guarantees of value for money in return. Either way Mr Brown is set to inherit a lot of unfinished business at an inconvenient time in the electoral cycle.

Consultants' restrictive practices still go unchallenged, managers become mere administrators tied to clipboards and computers and we have acquired some of the most expensive GPs outside Europe thanks to the 2004 Treasury pay deal, without securing reliable out-of-hours cover that does not rely on jobbing locums of variable quality.

To add to the good news, a Department of Health leak reveals that the Government will miss its MRSA target and the BMA claims today that waiting lists are being routinely fiddled. (The BMA, we should remind ourselves, is a trade union with a posher name: it is good at producing Jeremiads but is not exactly putting its shoulder to the wheel to make things work either.) The most well-argued account of what isn't working I have come across recently comes from Ian Smith - a near-miss form the job of NHS Chief Executive - in the Health Service Journal.

"There is no doubt, " he writes, " that health outcomes have increased over the last 10 years," he writes. "The Government deserves credit for acting to change historic weaknesses in healthcare - under-provision of resources and inadequacy of policy design ... (but) pouring money into an unreformed, poorly managed system has inevitably created waste and will continue to do so."

Mr Smith cannot see how this can be remedied without giving managers far greater freedoms to be accountable and responsible for what they produce and allowing the Health Service to be radically decentralised. Nor can I. The people presently appointed to lead change, he points out, are senior NHS managers and officials. "It s not possible for someone brought up within the system to have the inclination, derive experience and perspective to change it."

Mr Blair once told me that he has nothing in principle against the private sector managing parts of the NHS if that yielded the best results. But NHS management has not really crossed this Rubicon. Private sector management thrives on risk and reward: yet whoever loses their job at senior level in the health service for failing to deliver?

Mrs Hewitt, or a successor, cannot be expected to control everything from her perch in Whitehall. A complex, modern health service has to give responsibility to managers to ensure that agreed changes are driven through from the top to the bottom as efficiently as possible, and allow a market in incentives to make it happen. I suspect that will mean acquiring the very best managers, many from the private sector with experience of this sort of process, paying them accordingly to deliver results and toughing out the reaction from the vested interests. Most importantly, they should be left by the politicians to get on with it.

Mr Brown is no slouch on political strategy. He knows that rescuing New Labour's reputation as the party which enjoys most public trust on health is a key defence against the Tories and he will focus his efforts here. Yet it remains mysterious to me what mechanism he believes will transform the service into a more consistently excellent one.

On past practice, he looks an unlikely figure to embrace Mr Smith's nostrum of more independence from Whitehall and the Treasury and expansion of private sector management. One of his keynote speeches in the last parliament outlined his vision of the "limits of the market" in health. But without some more radical prospect, all he has to fall back on, seven years after the Big Bang on NHS reform started, are the old remedies of targets (yep again) for three per cent efficiency savings and exhortations, patchily implemented in the wards and surgeries.

New Labour rallied voters in 1997 with the promise to "save" the NHS. It had time to do so and patience is running out. Mr Brown can deliver a political surprise and seek to show he is a real healthcare reformer: or he can trust a continuation of the present in-between solutions will convince the voters next time. That would be quite a gamble, and one he might lose.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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2 February, 2007

Britain: Shortage of midwives puts mothers and babies at risk

A shortage of midwives is putting mothers and babies at risk, in spite of a Labour manifesto pledge to increase the numbers so that every pregnant woman would be cared for throughout by the same nominated midwife. Research shows that many baby units are failing to meet targets for the number of midwives and that Labour’s promise is far from being achieved.

The Royal College of Midwives has issued a warning of cuts to services, stress on staff, fewer home visits, less chance of a home birth for those who want it, and a shrinking workforce — at a time when the number of births is increasing.

The college’s assessment is supported by the healthcare analysis company Dr Foster. It examined the numbers of births and the numbers of midwives across England to see how close the NHS was to meeting the informal but generally accepted target of 32 births per full-time midwife per year. More than 62 per cent of trusts in England, and more than 56 per cent in the UK as a whole, were failing to meet this target.

The company also found that shortages of midwives often led to maternity unit closures. In the past year, units in England were closed for almost 4,000 hours, or 165 days. This meant that women expecting to give birth at a particular hospital were transferred elsewhere at the last minute.

The Healthcare Commission has investigated one unit, at Northwick Park Hospital in northwest London, where ten mothers died between 2002 and 2005. Although a midwife shortage was not to blame, the report said that the trust was too reliant on agency and part-time staff. The trust has since recruited 20 more midwives.

The commission is now conducting a review of maternity units throughout the country, and the King’s Fund has also announced a review of safety in maternity units, to start next month.

Training budgets for midwives are being cut, in some cases by 75 per cent or even 100 per cent. Fewer midwives are being employed than was the case a year ago, even though the number of births is rising at about 6,000 a year.

Three years ago the Government urged nursing students to become midwives, but now the college says that there is no money to employ them. Louise Silverton, the college’s deputy general secretary, said: “The midwifery shortage is getting worse at a time when we are experiencing a significant increase in the number of births. Graduates can’t get jobs and it has cost the taxpayer £45,000 to train each one.”

The college published a survey this month in which two thirds of midwifery heads said their units were understaffed.

Women who want to have babies at home are often denied the opportunity because of the shortage. As times2 reports today they can be let down at the last minute if there is no midwife available.

The Dr Foster figures show that staffing problems are greatest in the East Midlands, the East of England, and London, all areas where more than 80 per cent of units exceed the target of 32 births per midwife. In the East Midlands the average figure is more than 41.

The best area is Wales, with under 23 births per midwife and Scotland also does well, at just under 24. The Department of Health has admitted that improvements are needed. On the home births commitment, a spokesman said: “Nobody claims it will be easy, but the manifesto commitment is there. We would expect that home births would be a realistic option for women with an uncomplicated pregnancy.”

Source



Britain: £13bn hospital plans 'at risk from incompetent managers'

Dozens of privately financed hospital projects could face meltdown if the Government does not take a firmer grip, the Public Accounts Committee has said. Millions of pounds were wasted by “amateur and incompetent” NHS managers who tried to rebuild three hospitals on a single site in Paddington, West London, without a proper plan or sufficient land. The same could happen in other places if the Department of Health does not improve supervision and continues to depend on local NHS managers who are out of their depth in managing huge building projects.

The Paddington Health Campus collapsed after almost £15 million had been paid to consultants, lawyers and architects, the PAC says in a report. The Department of Health sat by while the project unravelled and the participants argued among themselves.

The parliamentary committee said that with PFI programmes worth £13 billion being planned, some could go the way of Paddington. The department admits that it blundered in not terminating the Paddington project sooner, but claims that the same will not happen again.

Edward Leigh, the chairman of the committee, said: “The collapse of the ambitious Paddington Health Campus project after five years was the direct result of appalling planning and forecasting of costs by the NHS trust partners, rows between them over the way forward and uncertainty over the Department of Health’s degree of support for the scheme.

“The department, in effect, left this £900 million construction project to local NHS staff who were rapidly out of their depth and floundering.”

The plan was to combine St Mary’s Paddington with the Royal Brompton and Harefield hospitals on a single site. But the Brompton and Harefield (itself the product of a merger) never agreed to merge with St Mary’s. Indeed, it made it a condition of its participation that it would not do so.

The department and local NHS managers nevertheless let the plan go ahead, incurring costs, for five years. What began in 2000 as a £300 million project had by May 2005 ballooned to £894 million. The completion date, set for last year, had slipped to 2013.

The failure of the plan can be traced to “ill-informed decisions taken by the NHS in northwest London”, the report says. When the scale of the problems became evident in 2002-03, there was a lost opportunity to pull the plug.

Mr Leigh said: “The department must look long and hard at whether its private finance unit is really up to the task of supporting local NHS trust procurement teams.”

The report sharply criticises the trusts for failing to put together a proper business case for the project, failing even to consult doctors and nurses over what facilities they needed. It then took “several years” for the partners, hampered by “insufficient manpower and capability”, to reach a clear position on the costs, planning issues, land required and afford-ability, it said.

The MPs criticised the North West London Strategic Health Authority for failing to halt it in 2003, but said that the Department of Health itself was also to blame. Eventually it was the Treasury, and not the DoH, that terminated the project.

The department is reviewing £13 billion of PFI hospital-build-ing plans, and aiming to reduce the total spend to between £7 billion and £9 billion. In evidence to the committee, Hugh Taylor, Permanent Secretary of the DoH, said it was “regrett-able” that the project had not been terminated sooner. But he was confident that it would not happen again, a confidence not universally shared by the committee, which concluded: “It remains to be seen whether this action will be sufficient to get a grip on a programme which continues to be managed by the NHS locally.”

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

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1 February, 2007

BRITISH TB SUFFERER DIES BECAUSE OF DELAYED TEST

Six months to get a test for TB? A normal NHS wait, no doubt. An American doctor would almost certainly have ordered all possibly relevant diagnostic tests and examinations immediately -- and got the results in short order. In Australia where I live, most diagnostic tests are done on the day that they are ordered and the results take only a few days to arrive. This case is made worse in that an important part of an early test report was ignored. The test interpreter did his/her job but the doctors were apparently to cocksure to heed the warning. The penalties for malpractice are usually negligible in Britain so why should they take care?

A grandfather died two days after doctors admitted they had spent six months treating him for the wrong disease, it emerged yesterday. Tony Bannister, 73, endured gruelling radiotherapy treatment for bone cancer before experts told him he was actually suffering from tuberculosis. Following the discovery, the former managing director was immediately put on a course of antibiotics and admitted to hospital - but two days later, he suffered a massive heart attacked and died. An investigation has been launched into the father-of-three's diagnosis and treatment after his widow insisted doctors were responsible for his death.

Marian Bannister, 68, said from the couple's home in Chichester: "It was too little, too late. "If they hadn't settled for an easy cancer diagnosis then they would have been able to treat Tony and he wouldn't have died." Mr Bannister, who worked for an electroplating company, became ill in August 2005, when he lost weight and began to suffer from flu-like symptoms. By September of that year, he was suffering from such severe back pain that he was given morphine to help him cope with the pain. Mrs Bannister, 68, said: "I told the doctor they had to do something. It was awful to see him in such pain. "The GP sent him for a bone scan and when it came back it showed terrible damage to three vertebrae and a disc. "A radiographer had written on the results of the scan 'Damage to the disc, suggested possibly infection'. "This should have been picked up on. "Cancer isn't an infection - but TB is."

Following the bone scan at St Richard's Hospital, Chichester, Mr Bannister was diagnosed with bone cancer and referred to St Mary's Hospital, Portsmouth, where he received months of treatment. However, medics told to the family the bone cancer was secondary and they were still searching for the primary cause of the cancer. "The radiotherapy was awful," said Mrs Bannister. "I told the oncologist 'You have almost killed him. What have you done?'" It was not until April 2006, when Mr Bannister was referred back to St Richard's for a bronchoscopy - an investigation into his airways - that the truth was discovered. Instead of revealing the source of the cancer, the examination revealed that Mr Bannister had tuberculosis.

He was put on a course of antibiotics and admitted to hospital, but passed away two days later after suffering a heart attack. A post mortem examination called for by the family later confirmed the cause of death was TB. Mr Bannister's distraught family then complained to the hospital, which is investigating the chain of events that led to his death.

His family have no idea how he contracted the infectious disease, which was almost eradicated in the Seventies after a prolonged vaccination programme but is now on the rise again. Tuberculosis is caused by the the bacteria Mycobacterium tuberculosis, and is spread by other sufferers. It can be cured with a prolonged course of antibiotics if caught early - but if left untreated it will kill more than half its victims. Mr Bannister's daughter Rachel, 43, from Brighton, said: "My dad was white, middle class and lived in Chichester. "He wasn't the type of person who gets TB - he was the sort of person who gets cancer."

A spokesman for the West Sussex Primary Care Trust said: "I can confirm that this patient's case is currently subject to investigation and therefore we are unable to comment any further."

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Dr Gerry shows why cash can't cure NHS

Considering what he's done in the last decade, you wouldn't trust Sir Gerry Robinson to run a bath, let alone the National Health Service. He's demonstrated that charm can take you a long way, but is a poor material for building lasting businesses. Television viewers may remember him as the man who tried to Show Them Who's Boss by going into dozy companies and making those in charge look like idiots. Entertaining telly, perhaps, but of limited value for those running an enterprise..... Before that... oh, but anyway, you might have expected his treatment of the NHS to be charmingly facile and practically useless.

Yet those who have invested three hours this week watching Dr Robinson's diagnosis on the telly couldn't describe his efforts as a waste of his time or ours. Probing beneath the "caring" image which seems to protect every health-service employee from criticism like a carapace, he exposed the determined resistance to even the smallest changes, and proved once again that the committee is the finest mechanism yet devised to prevent progress.

Inside the health service there is a profound disbelief in the market, or indeed in the ability of those at the workface to make sensible decisions if they are given the chance. This goes right to the top of the Department of Health, as was demonstrated by last week's leak of its submission for the Comprehensive Spending Review. The projection of a surplus of consultants and a shortage of nurses was so laughable that a spokesman was reduced to claiming that the document was merely an early draft.

As Karol Sikora, professor of cancer medicine, said: "It's difficult to imagine how this is done, but I suspect there is a bank of computers and people writing on the backs of envelopes. That's central planning." Nowhere is this Stalinist mentality clearer than in the looming disaster of the world's most expensive nonmilitary IT project, to put every NHS patient onto a national database. The costs are out of control, the medical profession hates it, and it will make everyone's medical records available to any half-competent hacker.

If we hadn't already strongly suspected it, the fact that health service managers don't actually manage in any way that would be recognised outside the public sector would have made for shocking television. By dint of great effort (and the mind-concentrating presence of the camera) Gerry actually helped make Rotherham General a slightly less inefficient place. As a demonstration of why throwing cash at the health service won't cure it, the Robinson report was worth half a dozen conventional inquiries. So not another unkind word about him, please, or at least not this week.

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Wait grows for elective surgery as Australian public hospitals struggle

Patients are waiting longer for elective surgery, despite a significant increase in government spending on public hospitals. A federal Government report found 4.8 per cent of patients waited more than a year for elective surgery in 2004-05, up from 3.9 per cent in 2003-04. Ninety per cent of patients were treated within 217 days, up from 193 days in 2003-04.

Australian Healthcare Association executive director Prue Power said hospitals were struggling to find qualified staff. "Demand is increasing due to the ageing population and technological advances. New medical technologies and new drugs allow us to keep people alive much longer," Ms Power said. "What we need to do to keep up with the demand is actually keep people out of hospitals by concentrating on health promotion and prevention of disease."

According to the Productivity Commission's Report on Government Services 2007, released today, the number of public hospital beds across the nation increased from 53,300 to 55,100. Total spending on public hospitals rose by 4.9per cent to $21.8billion. "The problem we've always had, with the federal and state governments both running the system, remains," Ms Power said. "There are still people waiting in public hospitals longer than necessary to be discharged to aged-care facilities, and we still have a shortage of staff."

The report shows the number of nurses has remained steady at about 4.6per 1000 people. However, a report released by the Council of Deans of Nursing and Midwifery found a shortage of 3200 nurses nationally. The council estimates that increased demand on the health system will lead to critical shortages in some states by 2010. It predicts a shortage of almost 1500 nurses in Queensland, and about 900 in Victoria. Council chairman John Daly said most states would need more nurses in the next three years. College of Nursing executive director Judy Lumby said more nurses were in the workforce, but many were part-time. Attempts to increase the workforce were hampered by state and federal governments operating at cross-purposes, she said. "Thousands of nurses have left the public hospital system to work as practice nurses with GPs," she said. "The project to promote practice nurses came from the federal Government, which is responsible for helping GPs. However, those nurses left the public hospital system, which is run by the state governments."

The Productivity Commission report reveals that efforts to introduce a national system for reporting medical errors in hospitals have stalled. NSW, Victoria and South Australia were the only states to provide figures on the number of "sentinel events" such as medication errors and procedures performed on the wrong patient or body part. In 2004-05, there were 97 sentinel events in those states.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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