Category: UK/NHS

NHS reforms: Moving care to the community | Healthcare Professionals Network | Guardian Professional

NHS reforms: Moving care to the community | Healthcare Professionals Network | Guardian Professional:

Expanding community services does not simply mean moving care out of hospital – it means developing a whole new way of caring.

“This is not a like-for-like shift,” says Nick Goodwin, senior research fellow at the King’s Fund. “We’re not taking current activities in hospital and placing them into the community. We’re creating a capability in the community [to remove some of the demand for] a range of different activities in hospital.”

Goodwin predicts that groups of general practices will increasingly work in federations or networks. He sees a “fairly limited” role for the private sector but a significant increase in not-for-profit partnerships with the public sector. Goodwin believes telehealth, whereby health-related services are delivered over the internet, will be “as common as internet banking and hole in the wall cash machines”.

Numerous examples exist of diagnostic tests and procedures being moved to the community. NHS Suffolk has transferred echocardiography (which uses ultrasound to investigate the heart), while Cambridgeshire has moved sexual health, musculoskeletal services and minor oral surgery out of hospital.

Ear reconstruction service and rationing, US v UK

Ear reconstruction service

Recently I found out, by accident (ask me in person how), that my local BC/BS carrier only pays for ear reconstruction if hearing is an issue, not for cosmetics. I was curious about whether England’s NHS would be so, well, “rationing” of care. Turns out, they are OK with it. But remember, your insurer never denies the procedure, they just deny the payment! There, feel better?

Ear reconstruction is considered as one of the most challenging operations in plastic surgery. It is usually undertaken in specialist centres, where, with the appropriate training and case availability it is possible to attain excellent results. The majority of plastic surgeons see 1-2 cases per year. In view of the rarity of the condition specialist centres such as the Royal Free Hospital have developed to provide a national tertiary referral service. Ear reconstruction is requested by two main groups of patients: those who have an underdeveloped ear at birth (a condition known as microtia) and those who have lost a normal ear through trauma, disease or previous surgery.

NHS or US healthcare? | Poll | Comment is free | guardian.co.uk

NHS or US healthcare? | Poll | Comment is free | guardian.co.uk:

Which system would you rather be treated under?

89.9% —- The NHS, every time

10.1% —- I’d prefer to avoid the waiting lists and go stateside

 The website TownHall did a piece on a UK-NHS “horror story” and so I comment bombed them with posts on US anecdotes, international health care, and so on. It is amazing what a bubble these people live in. Read the comments and be prepared to bemoan the US educational system and our media environment. All of their prejudices are clearly pulled right out of Fox, IBD, WSJ, and the rest. Heaven forbid actual research.

I also found this poll from a few years ago that I thought was useful.

– Sent using Google Toolbar

Why doctors’ pay keeps on rising – Herald Scotland | News | Politics

Why doctors’ pay keeps on rising – Herald Scotland News Politics

“GPs, who earned an average of £80,959 in 2007, benefit from “aspiration” and “performance” payments under the Quality and Outcomes Framework (QOF).”

This is an article about bonus payments to GP’s in the NHS for a variety of things, including taking care of oncology patients, MRSA screening, practicing in underserved areas in the UK, among others. The grumbling is that they are getting paid pretty well, since a new contract from 2004, and they are out sourcing night call to other services.

They were doing this in London back in 1984 when I was there for some medical school electives, and they were grumbling about it then, too. My feeling is that, especially with the upcoming generations, that life style is important and it is important to bring in people to the profession who are bright and enthusiastic. A miserable life style makes that less likely.

For the record, the £80,959 average salary in US Dollars equals $125K at the current exchange rate, comfortably in the top quintile of earners. But it comes without hundreds of thousands of dollars in expense/debt to get through college and medical school.

Escaping To England To Find Treatment She Can Afford

From Kaiser Health News Today:

Sometimes my husband Roger gripes about what he calls the British “nanny state.” So much is done for the English, he maintains, they can’t think for themselves anymore. Showers, for instance, are statutorily equipped with automatic shut-off valves on the thermostats. In case the water gets too hot. I remind him that the opposite of the nanny state is me in the U.S. with breast cancer and no steady job and insurance.

I had some wonderful doctors in New York, caring and helpful. But I also had to fight with my hospital there to get the tests I needed, and several of the specialists were so difficult to deal with I chose medical protocols to avoid them—no matter what the best option for treatment was. What I really notice about the health care providers in England is that they seem to have more than half a second for me – and they actually listen.

A nice piece about the nightmare that medicine is not in England. She left the US to go to England because she couldn’t afford the US health care system, and found out there were other bonuses to a differenet model of financing health care.

T.R. Reid: Can We Really Fix U.S. Health Care?

From the Commonwealth Club of California Podcast is here.

Friday, September 18, 2009, 12:34:52 PM

T.R. Reid, Correspondent, The Washington Post; Commentator, National Public Radio; Author, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

For 100 years, U.S. presidents have unsuccessfully strived to provide universal health coverage. When LBJ created Medicare in 1965, he thought the program would gradually be extended – to people over 60, then 55, then 45, etc., so that everybody would have government health insurance by 2000. Decades later, the Clinton plan failed. George W. Bush created Medicare Part D. Barack Obama says we have the best chance ever this year to fix our health-care system. Is he right? Reid weighs in and reveals what we can learn from health-care models across the globe.

This program was recorded in front of a live audience at The Commonwealth Club in San Francisco on September 14, 2009.

A very good listen. Excellent tid bits about health promotion in Britain, insights into the minds of Canadians and more!

IBD, Stephen Hawking and Nice

You have by now all read of the very funny folks at Investors Business Daily thought England’s NHS was so awful that a poor soul like Stephen Hawking would be long dead had he to depend on those slugs in England for his care.

Just in case you missed it, here’s the correction:

Editor’s Note: This version corrects the original editorial which implied that physicist Stephen Hawking, a professor at the University of Cambridge, did not live in the UK.

But, enough hilarity. If you read the rest of IBD’s editorial, you might notice their attack on England’s National Institute for Health and Clinical Excellence (NICE), an arm of the NHS, for its ruthless analysis of the cost and effectiveness of drugs. The bastards!

Anyway, the editorial contains this sentence, “In March, NICE ruled against the use of two drugs, Lapatinib and Sutent, that prolong the life of those with certain forms of breast and stomach cancer.” This is interestingly the exact same sentence that appeared in a WSJ op-ed on July 7th. But it’s a beautiful sentence. Who can blame IBD?

IBD also has this gem: “The British are praised for spending half as much per capita on medical care. How they do it is another matter. The NICE people say that Britain cannot afford to spend $20,000 to extend a life by six months. So if care will cost $1 more, you get to curl up in a corner and die.”

I can just see the clinicians and scientists at their final meeting, throwing patients under the bus for that dollar/pound. Bastards! The corollary to this, when you think about it, is the pharmaceutical company not lowering the price for the wonder drug by this apocryphal dollar. Bastards!

But what about these heartless beasts at NICE and these wonder drugs the British public is being denied.

From the NICE report on Lapatinab for breast cancer:

Clinical Benefit Rate
Using the independent assessment a greater proportion of subjects in the lapatinib + capecitabine group (29%) than in the capecitabine group (17%) achieved clinical benefit (odds ratio: 2.0, 95% CI: 1.2, 3.3, two-sided p-value: 0.008; cut-off date 3 April 2006). Using the investigator assessment of the clinical benefit response rate a greater proportion of subjects in the lapatinib+capecitabine group (37%) than in the capecitabine group (21%) achieved clinical benefit (two-sided p-value: 0.001).

Duration of Response
For subjects who responded to treatment, the median duration of response was 32.1 weeks in the lapatinib+capecitabine group and 30.6 weeks in the capecitabine group.

Get that? They are being denied a drug that increases the median duration of response by a staggering 1.5 weeks for the additional 12% who had some response to treatment!

The same paper included an analysis of a study on brain metastases that showed no significant difference in outcomes there, either.

Don’t get me wrong. I am all for research and pushing the envelope. Continuing to study these drugs is fine, as long as all the appropriate ethical guidelines are followed, particularly with regards to real informed consent. But arguing on the basis of a study as described above that this should be placed into mainstream use is ridiculous.

My other pet peeve about these types of treatments is the cruel, false hope given to so many patients as they are offered “the next” chemotherapy regimen, intensive care, and so on.

I also have no objection to choosing to continue these treatments to the bitter end, as long as one understands the choice. I often get patients on “salvage” chemotherapy, palliative chemotherapy or palliative radiation treatments who don’t understand what those terms mean. Maybe they were too rattled when the discussion took place and simply don’t remember. But my experience with these patients and their families is that the discussion never took place in earnest.

Being told that the cancer has come back or spread to your brain or whatever and that here’s what we can do next is far different than having a really hard conversation about your prognosis and all of your options.

Maybe your options are 2 or 4 or 6 months with “salvage” chemo if things go well (or a much more abrupt end if they don’t!) versus 1 or 3 or 5 months without, but at home, having your symptoms aggressively managed by a palliative care specialist and working with hospice for a peaceful dignified end. And more than likely the 2 or 4 or 6 months with aggressive treatment means a lot of that time spent in the hospital, dying in an intensive care unit, hooked up to life support until someone finally tells you, too late, the hard truth.

Let’s not kid ourselves about this disturbing side of American medicine: our often mindless devotion to doing “everything” up until the nails are being hammered into the coffin is, more often than not, in stark contrast to doing “the best things” for our patients.

What do other countries do? – Kansas City Star

What do other countries do? – Kansas City Star:

“In Britain, famously, they wait.

“To replace a hip, for instance, means months before surgery.

“Spaniards and Italians have single-payer health care systems, but they leave it to the cities and villages, not the capitals, to run things. The Greeks demand all medical bills be covered by universal insurance, but let doctors hit up patients for more.

“The Swiss are required to buy health insurance, and virtually all do.
Health care systems around the world vary like cuisine, reflecting customs and history. Some ingredients travel better than others.”

Bravo to writer Scott Canon of the KC Star for doing a piece on international health care systems.

I quibble with some of it, particularly the first line, and wrote Canon about it:

Thanks, Mr. Canon for your piece “A Universal Pain”, which appeared in my Pittsburgh Post-Gazette today. This kind of reporting is in very short supply and should be front and center in our ongoing discussions on health care, not relegated to the disparaging remarks hurled at Canada by conservatives.

But, I am curious about where you got some of your information. Some seems more up to date than mine, and some less so.

The most glaring one is in the first paragraph regarding waiting times in the UK. Here is more recent news:
http://cmhmd.blogspot.com/2009/05/exclusive-nhs-hospital-waiting-times.html

Further, there are countries with universal health care unlike us, but without significant waiting times, and with better quality outcomes than our own (and I know you praised Germany’s system, which is my favorite model):
http://cmhmd.blogspot.com/2009/05/oecd-waiting-times-study-executive.html

A final point, although health care is pushing budgets to the brink internationally, it is very important to remind the public that increasing expenditure from 8 or 9 or 10% of GDP by one or two percent, compared to our 17 or 18 or 19% in our system is a big difference.

Do we do better in the US on prostate cancer?

Four Pinocchios for Recidivist Rudy – Fact Checker:

This is not about Rudy Giuliani, he’s irreleveant, but this is about the mythology that remains in the World of Fox about poor outcomes elsewhere. Somebody brought this one up recently (prostate Ca) so I put this here for future reference.

“Let’s begin by deconstructing the original Giuliani claim, featured in a campaign ad in New Hampshire. It rests on a crude statistical calculation by his medical adviser, David Gratzer, on the basis of a 2000 study by a pair of health experts from Johns Hopkins university. According to Gratzer, ’49 Britons per 100,000 were diagnosed with prostate cancer, and 28 per 100,000 died of it. This means that 57 percent of Britons diagnosed with prostate cancer died of it; and consequently, that just 43 percent survived.’

There are several problems with this line of reasoning, according to health experts.

In order to make statistically valid comparisons in epidemiology, it is necessary to track the same population. Because prostate cancer is a slow-developing tumor, it is probable that the Britons who died of prostate cancer in 2000 contracted the disease 15 years earlier. They represent an entirely different cohort of cancer sufferers than those who were diagnosed with the disease in 2000. The number of Britons diagnosed with the disease is itself a subset of the number of Britons with the disease.

‘You would get an F in epidemiology at Johns Hopkins if you did that calculation,’ said Johns Hopkins professor Gerard Anderson, whose 2000 study ‘Multinational Comparisons of Health Systems Data’ has been cited by Gratzer as a source for his statistics. ‘Numerators and denominators have to be the same population.’

Five-year prostate cancer survival rates are higher in the United States than in Britain but, according to Howard Parnes of the National Cancer Institute, this is largely a statistical illusion. Americans are screened for the disease earlier and more systematically than Britons. If you are detected with prostate cancer symptoms at age 58 in year one of a disease that takes fifteen years to kill you, your chances of surviving another five years (until the age of 63) are obviously much higher than if your cancer is detected in year eleven, at the age of 68. Both Anderson and Parnes say that it is impossible, on the basis of the available data, to conclude that Americans have a significantly better chance of surviving prostate cancer than Britons.

Whether or not early screening actually reduces mortality from prostate cancer is the subject of much controversy among researchers, both in the United States and Europe. According to Otis Brawley, chief medical officer for the American Cancer Society, “at least 50 percent of men diagnosed with prostate cancer don’t need to be treated. The problem is that we can’t figure out which men need treatment, and which don’t.”

In an attempt to figure out if screening for prostate cancer does indeed save lives, the National Cancer Institute has been following 70,000 men since 1992, but has yet to a firm conclusion, Brawley said. Half of the men in the sample are being screened and the other half are not being screened. An August 2007 NCI report said it was still unclear whether “earlier detection and consequent earlier treatment” led to “any change in the natural history and outcome of the disease.” Screening can lead to “over-treatment” which can in turn result in undesirable side effects such as erectile dysfunction and incontinence.

“This is getting completely ridiculous,” e-mailed Giuliani spokesman Jason Miller. “You are still not getting it. The point the mayor has made is that privatized medicine is better than socialized medicine. If you can find one person who said they’d rather be treated for prostate cancer in the UK instead of the US, we’d like to meet them.”

UPDATE WEDNESDAY 4:30 P.M.: Reader Jim Crowder asked an interesting question this morning, in response to Dr. Brawley’s statement that at least 50 per cent of men diagnosed with prostate cancer “don’t need to be treated.” Crowder asked, “OK, If I am in the 1/2 group that would benefit by earlier treatment, wouldn’t I rather be in the US and receive it? In fact I have received treatment.”

I [Fact Checker] asked Dr Brawley to respond. Here is what he says:

We know that at least half of the screened and detected do not need treatment and any treatment they get can only give them side effects of treatment, including a 0.5% to 1% chance of death from treatment.We do not know that we benefit the other half who have a disease that is destined to disrupt their life by causing symptoms and in many death. Indeed some of our clinical treatment studies are designed to figure out whether we cure those who need to be cured.

Connecticut versus Washinginton State comparisons show that men in Washington State have a much higher risk of prostate cancer diagnosis and treatment and side effects of treatment, but have the same risk of death as men in Connecticut. In several papers, [including] one by me, this has been attributed to the higher rates of screening in Washington compared to Connecticut. Both have had the same decline in mortality rates.

Winston Churchill, Comm-Symp

NHS at 60: A vision in which we still believe – Telegraph:

“In 1942, he [Beveridge] proposed the creation of a national health service, as part of a system of compulsory social insurance to slay ‘the five giants of want, disease, squalor, ignorance and idleness’.

“Such was the enthusiasm for his ideas that there were queues to buy the report outside His Majesty’s Stationery Office.

“The plans were backed a year later by the prime minister, Winston Churchill, but when the Conservatives lost the general election in 1945, Churchill’s Labour successor, Clement Attlee, pledged to introduce the changes, with free medical treatment for all by the establishment of the National Health Service in 1948.

“While the plan was popular with the public, not everyone was keen.

“The British Medical Association famously opposed the creation of the NHS, with the health minister, Aneurin Bevan, later admitting that he had ‘stuffed their mouths with gold’ via a generous contract which allowed them to carry on doing private work, and provided lucrative bonuses.”

Also, from Churchill, March 2, 1944

“The discoveries of healing science must be the inheritance of all. That is clear. Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion… Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

And, in contrast, from the former British Medical Association Chairman, Alfred Cox, “I have examined the Bill and it looks to me uncommonly like the first step, and a big one, to national socialism as practised in Germany. The medical service there was early put under the dictatorship of a “medical fuhrer” The Bill will establish the minister for health in that capacity.”

Conservatives, always so prescient.