Monday, July 31, 2006


Post lifted from the Adam Smith blog

A few days ago the House of Commons Health Select Committee published its report on NHS Charges, dealing among other things with the controversial charges for when you park at a hospital to visit your seriously ill relatives. However, much more important, MPs admitted for the first time that tax financing alone will not be a sustainable future for the NHS in view of future challenges to health care.

Given the three major cost driving forces of an aging population, increasing consumer demand and rapid medical progress "the NHS may not be able to pay for every possible medical treatment….", the report states. "Some treatments or procedures may have to be charged for."

This approach would divide NHS care into a free core service and an additional choice-driven service with co-payments. Which is exactly what many health experts and doctors are expecting as the solution to the current financial difficulties of the NHS.

That is a significant shift and certainly good news, because the long-due debate on mixed funding of health care has now begun. And it also heralds a healthy paradigm shift for the NHS from a reactive to a proactive service that will favour prevention over mere cure, by increasing patients' involvement and responsibility.

That this actually works is why US "consumer-driven health care plans are placing more emphasis on preventive care as patients seek to avoid medical complications" according to a recent report. In response, more US employers are investing in wellness programmes, hoping to temper insurance cost increases by improving the health of their employees. And those who have already done so report positive results. So why not kill two birds with one stone: improve your health now and thus save money in the long term? It is a principle that certainly makes sense for the NHS too.

Killer doctor still practicing

Yet Another case of your regulators protecting you

A manslaughter charge has been recommended against a prominent Queensland surgeon who continues to operate out of a private hospital with full registration through the state's Medical Board.

Four years ago, Nardia Annette Cvitic checked into Brisbane's Mater Hospital for a hysterectomy to be performed by David Ward, who was then a respected professor of medicine at the University of Queensland. But the 31-year-old mother of two died after a drain inserted into her pelvic area during surgery reportedly punctured a major vein - an error that was allegedly compounded by Dr Ward prescribing her a bloodthinning agent.

An inquest into Cvitic's death, headed by Deputy State Coroner Christine Clements, has heard evidence that after the operation the operating theatre resembled the scene of the Granville train disaster in NSW in the 1970s. The Weekend Australian has obtained a draft submission from counsel assisting the inquest. Richard Perry informing Ms. Clements and other parties in the case: "There is sufficient admissable evidence upon which a properly instructed jury could conclude that Dr Ward is guilty of the offence of manslaughter."

He recommended that Dr Ward be committed for trial. "Further, it must be acknowledged, and done so openly and honestly, that a great tragedy occurred in this case." Mr Perry states in his draft submission. "Ms Cvitic's death is one which was, in some senses, entirely avoidable, not simply because of what may or may not have occurred during the operation ... but also because her condition, however it was caused, was one which ought not to have resulted in her death."

Dr Ward's barrister, David Tait, did not return calls yesterday and Dr Ward has previously declined to comment. Cvitic's family was unavailable. Michael Coglin, medical officer for Healthcope, which owns the Sunnybank Private Hospital in Brisbane, said yesterday Dr Ward "occasionally" operated at the hospital and there was no reason for him not to do so. "In view of some of these concerns, we've checked with the Medical Board of Queensland and we've been advised that Dr Ward is in good standing with the board, he's fully registered, and there's no reason he should not continue to practise in Queensland and our hospital," Dr Coglin said.

While the Mater had referred Dr Ward to the Medical Board, a spokeswoman has said "all appropriate action was taken" and no conditions had been attached to his registration. A District Court judge recently sanctioned an out-of-court settlement in which the Mater, the University of Queensland and the Queensland Government will put $115,000 in a trust fund for Cvitic's 10-year-old son and $60.000 in trust for her 16-year-old son.

The coroner has heard there had been complaints about Dr Ward's surgical techniques and management style before Cvitic's death, and two professors who audited some of his patient files in 2003 warned: "Something is radically wrong and it cannot continue." Russell Strong and Alex Crandon, commissioned by the Mater to conduct the audit, raised problems over Dr Ward's surgical techniques, communication skills, post-operative care and medical judgment. In only three of the 10 patient files examined did they find Dr Ward had no case to answer.

The Mater subsequently withdrew Dr Ward's surgical credentials, as did the Royal Women's Hospital, and he lost his role with the university the same year.

The above article appeared in "The Australian" newspaper on 29 July, 2006


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 Page is here or here.


Sunday, July 30, 2006

The terminally ill and their right to drugs


In the United States people who need medications to treat illness are dependent on the mercy of Food and Drug Administration (FDA). It serves as a gatekeeper to drug services, deciding which medications will and will not be available to consumers. The FDA demands that developers and manufacturers of drugs furnish data on a drug's efficacy and side effects, which it uses to make its determinations. Some organizations are demanding a change in the process to permit terminally ill people to gain speedier access to possible cures. Their demands have so far been rebuffed by regulators. Below I argue the case for liberalizing the approval process.....

Opposition to allowing terminally ill people to bypass the drug testing and approval process involves three criticisms. First, that the court decision creates a "right to experimental drugs"; that is, it creates a positive right that will impose on certain people an obligation to provide other people with experimental medications.

Second, that giving people access to experimental drugs outside of clinical trials will lessen the incentives for patients to participate in randomized, controlled trials that the FDA uses to determine whether drugs are "safe and effective," its criteria for drug approval. Thus, giving access to drugs outside the clinical trials process will undermine the FDA's ability to evaluate the risks and benefits of drugs and decide which ones deserve approval and which ones do not.

Third, that very ill patients are desperate, may not be able to rationally evaluate the choices available to them and will tend to pursue any remedy anyone claims will help them regardless of its risks or effectiveness. It follows, therefore, that such patients need to be protected from the possible adverse consequences of non-rational decisions they might make as a result.

All of these criticisms are flawed. For purposes of this argument, I will leave aside the more fundamental question of whether the FDA should even have a role in deciding which drugs are "safe and effective" and should be available to consumers. Although that is an important issue, which has been well argued by others, [9] [10] the changes sought in this court case could represent an improvement in the system we have to live under now. If objections to it can be addressed, this kind of incremental change could benefit at least some very ill patients who are now being harmed by the current system, and the change sought by the Abigail Alliance can result in a system that is both more just and more beneficial for all patients.

The "right" to experimental drugs

The first argument against access to experimental drugs for the terminally ill springs from the idea that the court victory by the Abigail Alliance creates a positive right to certain drugs. This is erroneous. The right at issue in the court case, and in this article, is a negative right: the right of a willing drug manufacturer and a willing drug consumer to engage in a voluntary transaction for a medication without interference from a third party, such as the FDA.

It has been suggested that requiring the FDA to allow consumers access to certain untested drugs may create a legal avenue to force insurers to pay for them. However, this is a defect created by government intervention in the insurance market, not a logical consequence of the right under consideration.

The drug testing process: patients in conflict?

The second major argument is that the drug testing process needs to be a balancing of opposing interests, with the interests of terminally ill patients who immediately want untested drugs balanced against those of less critically ill patients who must wait for drugs to receive FDA approval. Such approval will not be forthcoming until clinical trials have been completed and the drugs' risks and benefits are defined.

By allowing free access to drugs that have not gone through trials, the argument goes, we undercut the incentives for individuals who want the drugs to participate in trials. This ends up sacrificing the interests of those who will not get access to a drug until it has been further tested. Thus, individuals who might benefit from access to experimental drugs outside of trials benefit at the expense of other patients and society in general, and "The benefit of a few desperate patients would come at a steep cost to the rest of us." But the assumptions underlying these objections are not necessarily true, and basing the drug approval system on them is unjust.

First, it is doubtful that giving patients access to drugs outside the clinical trial system will undercut the incentives to participate in trials. People have different preferences and tolerances for risk. Based on risk preferences, patients seeking treatment for a disease can roughly be divided into two groups. One group consists of those who are willing to try untested or barely tested drugs. This may be because they have run out of meaningful therapeutic options (their disease is refractory to treatment with available therapies), or existing therapies don't do enough for their disease to give them the quality of life they desire.

They may also feel that having people who are willing to try untested drugs first is an important part of advancing the knowledge and science of disease therapy. The second group consists of patients who are more risk-averse. These patients do not want to take drugs unless they have been tested and their risks and benefits are defined to some extent (i.e., the drugs have been tested on other human beings first and the outcomes of this testing are known). Although it tends to be overlooked, there may be seriously or terminally ill patients who fall into this second group.

Some people in the first group of patients might want access to drugs that have not gone through the clinical trial system. But since they are willing to tolerate risk from drugs that have unknown effects, they also provide a pool of people who are willing to participate in clinical trials, for their own benefit and the greater benefit of others with the same illnesses, because they are willing to go first.

The only way the clinical trial system breaks down is if every single patient with a given disease wants immediate access to drugs before they have gone through any trials. Unless every patient with a given disease has the exact same level of risk tolerance, this is an unlikely scenario. Instead, the dynamics of the market can meet the needs both of patients who want immediate access to drugs and those who want better-tested drugs.

It's vital to keep in mind that manufacturers of drugs develop and market them because they see an unmet demand for the drug, and thus a possible profit opportunity. Some of that unmet demand and profit opportunity will be among patients who want drugs immediately, and are willing to take the risks involved in being the first to try them. But meeting the demand only of these patients ignores another profit opportunity: the demand created by individuals who want drugs whose risks and benefits have been defined to a greater extent by testing on other individuals. The more risk-averse second group - the individuals hesitant to try drugs that haven't been tested on others first - will still drive the demand for medications that have been rigorously tested in the clinical trial setting.

Even if drug manufacturers were permitted to sell untested medications to patients who wanted them, they would be marketing to the few people willing to take an untested or barely tested drug. It is doubtful that these people will create a market so profitable that drug companies will abandon the profit opportunities presented by drugs that have gone through the clinical trials process, and simply start selling untested drugs directly.

The larger drug market, and hence unexploited profit opportunities, will still be people who want drugs that have been through the clinical trial process. The market will adapt to meet this demand for testing and information, sustaining a system of clinical trials done to meet FDA approval standards. In this way, giving access to experimental drugs outside of trials does not actually undercut the clinical trial-based FDA approval system.....

Paternalism for the Terminally Ill

The third major argument against access to experimental drugs - that of protecting the very ill from their own choices - is a thornier problem because it rests on the same attitude of paternalism that is the entire underlying justification for the FDA. It assumes that certain individuals possess the ability to decide when other individuals are incapable of making good or rational decisions on a subject, and should be able to substitute their own judgment accordingly, forcing the original person to live with the substitute decision-maker's choice.

Note that by "ability to decide" I mean the supposed capability of one person to make a better decision for another person than that person would have made for themselves, not simply to the power Congress has conferred on some people to make other people's decisions for them. The government can give you the ability to make choices for other people. That does not mean that your choices are automatically superior; it simply imposes your own risk preferences on another person. [9] But the argument for substituting the "more rational" judgment of regulators for the "less rational" judgment of terminally ill patients is flawed.

If we are using the standard of rationality to justify paternalism, we must immediately confront the question of how we judge a patient's ability to decide rationally. Bioethicist Ezekiel Emanuel defines "the desire for unproven treatments by a few patients" as "the height of irrationality born of desperation." The first major problem with this is that individuals make real choices to try untested drugs in the context of clinical trials all the time. If they did not, these trials would not exist!.....

So is it possible to assess terminally ill patients' choices at all? Here, we can borrow the central economic insight that all value is subjective. This is usually applied in the context of individuals evaluating economic goods. But we can also apply this insight when we consider how people form valuations of the risks and benefits of disease treatment options: ".both the expected benefit of using a product and the burden of risk bearing are subjectively experienced and knowable only to the individual actor."

Thus, even the way that different people value the quality of their own lives, the value of a life with or without disability, the value of a risk to their life or health, and the value of a tradeoff between the two, is subjective. The value of those kinds of tradeoffs is not the same for every disease, or even for every individual with the same disease. ....

If the value of competing therapeutic alternatives for individual patients is subjective, then there is no objective standard an expert can use to determine how other individuals do value or should value their lives and their health. Yet we allow regulators to carry out this kind of valuation for patients all the time, without asking them if the patients themselves want it done for them.....

The value attached to different risks and benefits cannot be measured or defined in any way that would make it possible for one person to claim that they can make a more rational decision about them than another person. How, then, can we base people's access to drugs on the idea that some people can, and will, make better decisions for patients than those patients would make for themselves? We cannot, and should not, allow access to medical innovation for the sickest people to rest on such a weak and unjust foundation.


Although it may seem like a small victory, reforming the system for the most seriously ill is progress not only for them, but for every patient. As fundamentally flawed as the FDA drug approval system is, it is entrenched, and the majority of people are convinced that we cannot survive without it. Even so, the situation is not hopeless. We can take on the arguments justifying the FDA one at a time. We can argue convincingly that incremental reforms making drugs more widely accessible to more patients will not end in disaster, bring medical progress to a halt, or leave a trail of dead and dying people in their wake.

Allowing terminally ill people to bypass the drug testing and approval process will not create a "right to experimental drugs." It will not destroy the incentives for patients to participate in the clinical trial system. It will not make it impossible to gather scientific data on how drugs work. What it will do is allow individuals who are fully capable of rational choice to make the most important choices of all according to their own values. For the sickest people, it is not only beneficial and just, it is a matter of life itself.

More here

Your regulators will protect you (again)

Employing a loony as a psychiatrist was a good one!

Vincent Berg, the Russian immigrant exposed as an allegedly bogus psychiatrist at Queensland's "Dr Death" medical inquiry, is undergoing treatment in a psychiatric ward at the Gold Coast Hospital. Mr Berg, 54, was scheduled to face a committal hearing in Southport Magistrates Court on the Gold Coast yesterday on a charge of indecently dealing with a boy under 16. But the hearing was adjourned to January 25 next year after Mr Berg's lawyer, David Gilmore, told the court his client had voluntarily admitted himself to the psychiatric ward.

Mr Berg, who was in court for the brief hearing, is accused of sexually molesting the teenage son of one of his patients when he was employed as a psychiatrist at Townsville Hospital in 2000. The allegation was revealed during the Queensland hospitals inquiry by commissioner Tony Morris. Magistrate Ron Kilner expressed frustration that committal proceedings had still not begun, despite Mr Berg's arrest in September last year. Mr Gilmore said the defence required a psychiatric assessment of Mr Berg before he could face a committal hearing.

But prosecutor Mark Whitbread said: "He has had an opportunity to see a large number of psychiatrists, and no one has been able to give him the report he desires." Outside court yesterday, Mr Gilmore said he expected Mr Berg to apply to have his case heard before the Mental Health Tribunal. Mr Berg could face further charges resulting from his 12-month tenure as a psychiatrist at Townsville Hospital, using allegedly bogus qualifications. Geoff Davies, who took over from Mr Morris as health inquiry commissioner, recommended in his final report that police should investigate whether Mr Berg should be charged with fraud, forgery and "attempts to procure unauthorised status".



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 Page is here or here.


Saturday, July 29, 2006

Life Expectancy and Infant Mortality are Unreliable Measures for Comparing the U.S. Health Care System to Others

Excerpts from here. See the original for tables and references

How does the United States health care system fare when compared to the rest of the industrialized world? This is an important question. Accurately measuring our health care system relative to those of other nations can yield insight into the types of health care policies America should pursue. New York Times columnist Paul Krugman has expressed the view that the U.S. health care system is inferior:

The United States spends far more on health care than other advanced countries. Yet we don't appear to receive more medical services. And we have lower life expectancy and higher infant mortality rates than countries that spend less than half as much per person. How do we do it?

Life expectancy and infant mortality are two measures that are widely cited, yet seldom questioned. This is unfortunate, because life expectancy and infant mortality tell us little about the efficacy of a health care system. This paper examines the deficiencies of using life expectancy and infant mortality to measure a health care system. It also examines the question: How should we measure a health care system?......

Any statistic that accurately measures health-care systems across nations must satisfy three criteria. First, the statistic must assume actual interaction with the health care system. Second, it must measure a phenomenon that the health care system can actually affect. Finally, the statistic must be collected consistently across nations.

Under the first criterion, the phenomenon being measured must be one in which the individual actually has contact with the health care system. More specifically, he must have contact with a health care professional, be it a doctor, nurse, lab technician, etc. A statistic measuring the rate of cancer survival satisfies this criterion, since diagnosis and treatment of cancer requires health care professionals. By contrast, a statistic measuring the rate of car accidents would not satisfy such a criteria since health care professionals are not essential to identifying car accidents.

Some statistics may assume interaction with the health care system, but the phenomena they measure are not ones on which the health care system can have any meaningful impact. Take, for example, the rate of cancer incidence. While this statistic assumes interaction with the health care system (an incidence of cancer cannot be known without the diagnosis of a health care professional), there is little a health care system can do about the rate of cancer. Rather, cancer incidence is affected by factors such as genetics, diet, lifestyle, etc., over which the health care system has no control. Thus, to be an adequate measure of the effectiveness of a health care system, a statistic must measure a phenomenon that health care professionals can actually affect.

Finally, a statistic must be collected consistently across nations. While this seems simple in theory, in practice it is quite complicated. Nations use diverse definitions of health phenomena. This leads to some nations excluding a segment of their populations from the collection of a statistic while other nations include those segments. In such circumstances, cross-national comparisons are largely meaningless. Thus, for health care systems across countries to be meaningful, there should be little to no variation in how statistics are collected. As shown below, both life expectancy and infant mortality are poor measures of a health care system because each fails to satisfy at least one of the above criteria.

Life Expectancy

Life expectancy is a poor statistic for determining the efficacy of a health care system because it fails the first criterion of assuming interaction with the health care system. For example, open any newspaper and, chances are, there are stories about people who die "in their sleep," in a car accident or of some medical ailment before an ambulance ever arrives. If an individual dies with no interaction with the health care system, then his death tells us little about the quality of a health care system. Yet all such deaths are computed into the life expectancy statistic.

Life expectancy also largely violates the second criterion - a health care system has, at most, minimal impact on longevity. One way to see this is to reexamine the table constructed by the Center for Economic and Policy Research. The interpretation that the Center for Economic and Policy Research wants readers to derive from Table 1 is that the United States would be better off with a system of universal health care. However, a careful examination of that table yields a more accurate interpretation: There is no relationship between life expectancy and spending on health care. Greece, the country that spends the least per capita on health care, has higher life expectancy than seven other countries, including Belgium, Denmark, Finland, Germany, Netherlands, the United Kingdom and the United States. Spain, which spends the second least per capita on health care, has higher life expectancy than ten other countries that spend more.

More robust statistical analysis confirms that health care spending is not related to life expectancy. Studies of multiple countries using regression analysis found no significant relationship between life expectancy and the number of physicians and hospital beds per 100,000 population or health care expenditures as a percentage of GDP. Rather, life expectancy was associated with factors such as sanitation, clean water, income, and literacy rate. A recent study examined cross-national data from 1980 to 1998. Although the regression model used initially found an association between health care expenditure and life expectancy, that association was no longer significant when gross domestic product (GDP) per capita was added to the model. Indeed, GDP per capita is one of the more consistent predictors of life expectancy.

Yet the United States has the highest GDP per capita in the world, so why does it have a life expectancy lower than most of the industrialized world? The primary reason is that the U.S. is ethnically a far more diverse nation than most other industrialized nations. Factors associated with different ethnic backgrounds - culture, diet, etc. - can have a substantial impact on life expectancy. Comparisons of distinct ethnic populations in the U.S. with their country of origin find similar rates of life expectancy. For example, Japanese-Americans have an average life expectancy similar to that of Japanese.

A good deal of the lower life expectancy rate in the U.S. is accounted for by the difference in life expectancy of African-Americans versus other populations in the United States. Life expectancy for African-Americans is about 72.3 years, while for whites it is about 77.7 years. What accounts for the difference? Numerous scholars have investigated this question. The most prevalent explanations are differences in income and personal risk factors. One study found that about one-third of the difference between white and African-American life expectancies in the United States was accounted for by income; another third was accounted for by personal risk factors such as obesity, blood pressure, alcohol intake, diabetes, cholesterol concentration, and smoking and the final third was due to unexplained factors. Another study found that much of the disparity was due to higher rates of HIV, diabetes and hypertension among African Americans. Even studies that suggest the health care system may have some effect on the disparity still emphasize the importance of factors such as income, education, and social environment.

A plethora of factors influence life expectancy, including genetics, lifestyle, diet, income and educational levels. A health care system has, at best, minimal impact. Thus, life expectancy is not a statistic that should be used to inform the public policy debate on health care.

Infant Mortality

At first glance, infant mortality appears to be a good measure of a health care system. First, it assumes interaction with a health care system since most babies born in the industrialized world are born in a hospital or other health care facility. It also satisfies the second criterion of assuming that health care professionals can affect the outcome, since doctors and nurses have a direct impact on the survival chances of a newborn. If infant mortality were accepted as an adequate measure based on those two criteria alone, then the U.S. health care system is one of the least effective in the industrialized world. This can be seen by constructing a table using the data on infant mortality utilized in the report from the Physicians for a National Health Program. Table 2 shows that on infant mortality, the U.S. ranks below all nations save New Zealand.

But infant mortality tells us a lot less about a health care system than one might think. The main problem is inconsistent measurement across nations. The United Nations Statistics Division, which collects data on infant mortality, stipulates that an infant, once it is removed from its mother and then "breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles... is considered live-born regardless of gestational age." While the U.S. follows that definition, many other nations do not. Demographer Nicholas Eberstadt notes that in Switzerland "an infant must be at least 30 centimeters long at birth to be counted as living." This excludes many of the most vulnerable infants from Switzerland's infant mortality measure.

Switzerland is far from the only nation to have peculiarities in its measure. Italy has at least three different definitions for infant deaths in different regions of the nation. The United Nations Statistics Division notes many other differences. Japan counts only births to Japanese nationals living in Japan, not abroad. Finland, France and Norway, by contrast, do count births to nationals living outside of the country. Belgium includes births to its armed forces living outside Belgium but not births to foreign armed forces living in Belgium. Finally, Canada counts births to Canadians living in the U.S., but not Americans living in Canada. In short, many nations count births that are in no way an indication of the efficacy of their own health care systems. The United Nations Statistics Division explains another factor hampering consistent measurement across nations:

...some infant deaths are tabulated by date of registration and not by date of occurrence... Whenever the lag between the date of occurrence and date of registration is prolonged and therefore, a large proportion of the infant-death registrations are delayed, infant-death statistics for any given year may be seriously affected.

The nations of Australia, Ireland and New Zealand fall into this category. Registration problems hamper accurate collection of data on infant mortality in another way. Looking at data from 1984-1985, Eberstadt argued that, "Underregistration of infant deaths may also be indicated by the proportion of infant deaths reported for the first twenty-four hours after birth." Eberstadt found that in the U.S. and Canada more than a third of all infant death occurred during the first day, but in Sweden and France they accounted for less than one-fifth. Table 3 shows that the pattern still holds today.

Inconsistent measurement explains only part of the difference between the U.S. and the rest of the world. Were measurements to be standardized, according to Eberstadt, "America might move from the bottom third toward the middle, but it would be unlikely to advance into the top half." Another factor affecting infant mortality Eberstadt identifies is parental behavior. Pregnant women in other countries are more likely to either be married or living with a partner. Pregnant women in such households are more likely to receive prenatal care than pregnant women living on their own. In the U.S., pregnant women are far more likely to be living alone. Although the nature of the relationship is still unclear (it is possible that mothers living on their own are less likely to want to be pregnant), it likely leads to a higher rate of infant mortality in the U.S. In summary, infant mortality is measured far too inconsistently to make cross-national comparisons useful. Thus, just like life expectancy, infant mortality is not a reliable measure of the relative merits of health care systems.


Life expectancy and infant mortality are wholly inadequate comparative measures for health care systems. Life expectancy is influenced by a host of factors other than a health care system, while infant mortality is measured inconsistently across nations. Neither of these measures provides the United States with conclusive guidance on health care policy, let alone serve as reliable evidence that a system of universal health care "should be implemented in the United States."

Do measures that would permit accurate cross-national comparisons of health care systems exist? The most exhaustive source of cross-national data is the Organization for Economic Co-operation and Development (OECD). Yet the OECD notes that in most cases its data is not "internationally comparable" because "there is a lack of international agreement on the most promising indicators and many definitions of each indicator that could be adopted."

To rectify this problem, the OECD and the Commonwealth Fund have embarked on a collaborative effort to develop comparable measures across nations. Called the "OECD Health Care Quality Indicators Project," it is taking the "first steps towards a comprehensive reporting system for quality of care in OECD member countries." A recent report updating the progress of this project looks promising. For example, one standard that an indicator must meet is its "susceptibility to being influenced by the health care system." The researchers pose important questions on this regard, including, "Can the health care system meaningfully address this aspect or problem?" and "Does the health care system impact on the indicator independent of confounders like patient risk?" In other words, these statistics will assume interaction with a health care system and measure phenomena that a health care system actually affects. Furthermore, the aim of this project is to assure that data is collected consistently across nations, so that national policymakers have "the opportunity to compare the performance of their health care delivery systems against a peer group"

While the project researchers have chosen many indicators that measure phenomena that are actually affected by a health care system, comparability issues across nations remain. For example, one indicator measures the fatality rate within 30 days of those diagnosed with acute myocardial infarction (heart attack). However, the report notes that some "countries are able to track patients after hospital discharge, [while] some are not."

Hopefully such difficulties can be resolved as the project progresses. In the meantime, policymakers, pundits and reporters should stop referring to life expectancy and infant mortality as meaningful comparative measures of health care systems.


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 Page is here or here.


Friday, July 28, 2006


A giant American firm is poised to take over the responsibility for spending more than 4 billion pounds a year of NHS money in the biggest privatisation yet seen in the health service, The Times has learnt. Novation, the Texas-based group, is in the final stages of negotiating a far-reaching contract that will make it and its German partner, DHL, responsible for buying everything from bandages to hip implants for the health service. The move will mark a massive step towards opening up the NHS to outside companies and is certain to inflame simmering tensions within the Labour Party over what is perceived as creeping privatisation.

Unison, the largest public sector union, announced plans yesterday to ballot members on strike action over the move, and accused Tony Blair of accelerating his market-driven NHS reforms. Such action could coincide with the party conferences and put the battle for the soul of the Labour Party centre stage as Mr Blair comes under pressure to set a timetable for his departure. Many in the party want to draw a line on private sector involvement in the NHS but Mr Blair says that the test of keeping the health service public is whether services are free to the user.

Karen Jennings, head of health at Unison, said: "The Government's decision to privatise is driven by pure dogma and an obsession with market-testing."

The Times has learnt that DHL/Novation is expected to take over from the NHS Logistics Authority and much of the NHS Purchasing and Supply Agency, which are responsible for 4.2 billion pounds a year of purchasing and distribution, or about 5p out of every NHS pound. The disclosure comes less than a month after The Times revealed that the world's largest private health companies were being asked to submit tenders for control of primary care trusts, which spend 80 per cent of the NHS's budget. The advertisement was withdrawn soon afterwards for "redrafting".

Novation has promised big savings by making tougher, more efficient buying arrangements, alarming unions and the medical devices industry. John Wilkinson, director-general of the Association of British Healthcare Industries, has written to Andy Burnham, the Health Minister, to raise a concerns including fears over "the concentration of such buying power in a single entity". DHL/Novation would make savings by concentrating on a few large suppliers, squeezing out smaller ones that could not compete on price, he said. That, he added, would have a profound impact on whether patients received new and innovative treatments - which often come from smaller companies - and would undermine the strategy of the Treasury and the Department for Trade and Industry to encourage such companies. "We support the need for better procurement in the NHS, but nobody in their right mind would hand over this much power to one organisation when savings, not quality, is the target.

"These small, innovative companies are forging the latest medical breakthroughs for patients, yet the Government's NHS policy is going to send many of them into bankruptcy. Thousands of jobs are at stake and patients will miss out on the latest care. "We would welcome a system of several purchasing organisations to provide contestability, not this proposed monopoly."

DHL/Novation will be paid on the basis of the money it saves the NHS, with no similar incentive for quality. The contract is expected to cover a huge range of equipment, from bandages and syringes to pacemakers and hip prostheses. The Department of Health has refused requests to disclose the full list, on the ground that it is a confidential part of the negotiations. It was no secret that NHS Logistics, responsible for distributing products to hospitals, was due to be privatised, and that DHL/Novation was the preferred bidder. But it appears that the privatisation will go much wider than thought, to include much of the NHS Purchasing and Supply Agency as well. NHS Logistics employs 1,400 staff in five distribution centres, making an average of 1,200 deliveries a day to 10,000 destinations. Unison represents about 1,000 of its staff.


Californian health care "Summit"

Schwarzenegger listens to proposals

Gov. Arnold Schwarzenegger hasn't come up with a concrete plan to help Californians contend with spiraling health care costs. He says he'll unveil one next year if he's re-elected. To date, his position on health care largely has been defined by his opposition to ideas that impose new costs on businesses and government. But to demonstrate that the issue is important to him, Schwarzenegger on Monday sat for four hours in a room with about 200 experts on health care and health costs, including union heads, CEOs of big businesses, directors of health-insurance companies and consumer advocates.

The event -- pointedly called a summit on health care affordability, rather than coverage -- underscored the largest division between two sides in the debate: those who believe the solution is to expand the number of people, especially the working poor, who have health insurance and those who believe the answer is to cut costs by making health care more efficient and requiring consumers to pay more up front to discourage them from using health services if they don't really need them.

Though he hasn't explicitly outlined his position, the Republican governor suggested Monday that he falls more into the second category. At the end of the four-hour session, he said he was particularly struck by the market-based solutions, such as technological innovation and "patient responsibility" that some of the speakers advocated. "We all have the same goal, which is to make health care affordable, accessible and make it more efficient," he said.

Schwarzenegger has also made it clear that he opposes a Democratic measure in the Legislature, Senate Bill 840, that would insure all Californians through a "single-payer" system operated by the state, calling it a "tax increase."

The governor said he called Monday's meeting as a first step toward formulating a plan for solving the health care crisis in a state where insurance premiums are up 55 percent in the past five years and 20 percent of residents -- nearly 7 million people -- are uninsured.

His political opponents called it an election-year ploy. Schwarzenegger's Democratic challenger in the general election, state Treasurer Phil Angelides, followed the governor to UCLA to hold a health care summit of his own. And about two dozen members of the California Nurses Association picketed Schwarzenegger's event, saying his policies were unfriendly to consumers. "What he's talking about when he talks about universal health care is all the health care an individual can afford," said CNA President Rose Ann DeMoro, whose organization has not yet endorsed a candidate in the gubernatorial race. "There's no drug company or insurer that this governor doesn't love."

To date, the governor has blocked health care solutions that would require both private industry and government to pick up the costs. He vetoed a Democratic bill that would have expanded public health insurance programs so all children in the state would be insured. He supported the repeal of Senate Bill 2, a state law requiring all large businesses to provide coverage to their workers.

Until last week, when he changed his stance, he opposed using the state's purchasing power to financially punish drug companies that did not discount their products for the uninsured. Acting on a request from hospitals concerned about the financial impact, the governor tried to overturn a requirement that hospitals have one nurse on duty for every five patients. The nurses stymied that effort in court.

Schwarzenegger's event included participants from all ends of the political spectrum, including Safeway CEO Steve Burd and Andy Stern, national president of the Service Employees International Union. But Democratic Mayors Gavin Newsom of San Francisco and Antonio Villaraigosa of Los Angeles, who were invited, did not attend. Nonetheless, the governor said the solution must be bipartisan.

One of the featured speakers was Timothy Murphy, the head of the Office of Health and Human Services in Massachusetts, where Democrats and Republicans just enacted a universal health insurance program for all residents that expands government coverage for the poor, requires citizens to pay for coverage if they can afford it and works to bring down the price of health insurance for individual buyers who can't get it through their jobs. The key to getting it done was blending many approaches, Murphy said. "You need to be able to compromise and trade," he said.



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 Page is here or here.


Thursday, July 27, 2006


More than 50,000 patients contracted one of the most serious hospital superbugs last year, a rise of more than 17 per cent on 2004, latest health figures reveal. Experts from the Health Protection Agency, the public health watchdog, gave warning yesterday of increasing numbers of Clostridium difficile cases, including rarer infections in patients under the age of 65. The HPA statistics, which showed annual totals of 51,690 cases for C. difficile and 7,087 for MRSA, followed the release of a damning report into superbug outbreaks at one hospital where 65 patients died. The Healthcare Commission, the Government's health inspectorate, said that a culture of poor hygiene and serious inaction by senior managers at Stoke Mandeville Hospital in Buckinghamshire was to blame for many of the deaths.

The commission revealed that a total of 33 people died as a result of two separate outbreaks of C. difficile at the hospital in the past three years. The deaths of a further eight people could also be traced to C. difficile, while complications linked to the bug claimed a further 24 lives. The report detailed a catalogue of serious hygiene offences, including faeces on bed rails, patients' clothes kept on the floor, soiled commodes and a shortage of nurses. The HPA's statistics offered further evidence of the failure of hospitals to address the problem of superbugs, most of which affect the elderly.

Peter Borriello, director of the HPA's centre for infections, said that the 17.2 per cent rise in C. difficile cases could be attributed both to an increased number of cases and improved reporting. He added that more instances could well occur if stronger action was not taken. In the past year 60 per cent of all trusts reported an increase in C. difficile cases. The data revealed a more positive picture for methicillin-resistant Staphylococcus aureus (MRSA), with the number of cases down slightly from 7,233 in 2004-05. However, it fell far short of government targets for a 50 per cent cut by 2008.

Significant decreases were seen in London, previously the worst-affected region, and Yorkshire and Humberside, but there was a slight increase in the North West. The figures also showed that 25 per cent of patients with MRSA had the disease on admission to hospital, 8 per cent of cases were in renal patients and 15 per cent were diagnosed while in intensive or high-dependency care. While older people are particularly at risk from C. difficile, the figures showed a rise among younger age groups. A quarter of all cases occurred in those aged under 65.

Almost 30 per cent of the samples in 2005 were caused by a particularly virulent strain of the bug, known as type 027, which has been associated with several serious outbreaks, including those at Stoke Mandeville Hospital. In 2004 there were 2,247 deaths in which C. difficile was the underlying cause mentioned on death certificates in England and Wales and a further 1,168 deaths in which MRSA was mentioned, according to the Office for National Statistics. Andy Burnham, the Health Minister, said that new powers meant that "improvement notices" could now be served on trusts that still failed to follow government guidelines on hospital infections.


Australia: A view from close-up of a dysfunctional government health system

For many years I have been working as an emergency nurse at a busy Brisbane hospital. My first few years in emergency nursing were so rewarding. Every day I felt like the team I worked with was not only saving lives but also changing lives for the better. But soon the excitement wore off and the reality hit me of what was happening to the Queensland Health system. For years I have watched staff struggle to even keep their practice safe due to the conditions that we are enduring day in and day out. I have seen first-hand what it's like in the public health system. Let me tell you it's not pretty.

It is a harsh truth that there is a growing demand on the system and the money injected into it is not sufficient. Those who pay the price are not the politicians who decide how much money to allocate to health, but rather the likes of your loved ones and friends. There is increasing pressure on emergency departments due to many reasons:

* People are presenting with ailments that GPs could fix, but there are not enough bulk-billing services or after-hours clinics.

* Increasing lack of skilled staff in areas such as emergency due to high numbers of trained staff who are leaving the field.

* An increasing population, therefore an increasing number of people presenting to emergency departments, which means an increase in the patient-to-staff ratio.

* Not enough operational hospital beds. Hospitals throughout Brisbane have wards that are fully stocked but are empty of patients because there is no funding for staff.

Patients are waiting in emergency departments for up to 24 hours to get a hospital bed. Do you understand the implications of this? I am often forced to choose which patient should come off a trolley so that a more critically ill patient can have a bed. Sometimes I cannot take anyone off a trolley. Sick patients are put in chairs because there are simply not enough resources. I have watched patients have cardiac arrests on ambulance trolleys in the corridor while waiting for a bed in the emergency department. Ambulance officers can wait more than two hours to offload a patient at times.

I have seen nurses conduct cardiac tests on patients lying on the floor because there was absolutely no place to put this patient having a heart attack. Every day, patients wait far beyond their allocated triage time to receive medical treatment. As a triage nurse, it is terrifying to see someone with a potentially life-threatening condition wait up to three hours when they should be seen within 30 minutes.

The patients and their families become really angry about this and I don't blame them. Daily now I am verbally abused and so are my colleagues. It has become a frequent occurrence for an angry patient to threaten my life. I have seen the stress of working in this environment take its toll on many doctors and nurses, including me. Lots of excellent staff have left or are in the process of leaving because it seems the situation is only going to get worse.

Once we just had to deal and cope with the reality of what our jobs involved. Now we are not only trying to save lives, but also trying to do this within a system that is potentially killing our patients. I suggest to the state and federal governments that they send a representative to work a full 10 days straight with an emergency nurse - not just walk through an emergency department when you are campaigning. What true reality will that give you? It is obvious that you are not aware of the extremely dangerous conditions patients are being put in or I simply would not be writing this.

To the public I say, next time you feel like threatening a health professional, maybe instead you should consider voicing your anger in a letter to The Sunday Mail. It is time for you to speak up for your rights before someone you love is hurt by the public health system this State Government has created. I write this anonymously because I am bound to a contract with Queensland Health. A condition of my employment is that I don't disclose any information to the media or public regarding what happens within the hospital I work. So the sad truth is the public really have no idea what is happening behind closed doors - until it's happening to them.



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 Page is here or here.


Wednesday, July 26, 2006


They wouldn't even sit her up to give her a cup of tea. She died of thirst -- in a supposedly modern hospital, of all places!

A family who claimed their elderly mother endured a terrifying death after being deliberately starved by a hospital doctor put their case before a coroner yesterday. Norfolk and Norwich University Hospital allegedly decided that Olive Knockels, a former school matron who had suffered a stroke, would have no quality of life if she recovered. The case, in 2003, prompted renewed debate about guidelines giving doctors the power to let elderly patients starve. An inquest was told that Mrs Knockels, 91, died despite a court injunction forcing doctors to reinstate nutrition and hydration as well as antibiotics. They were also told to stop prescribing the powerful painkiller diamorphine without the written consent of the patient's daughter, Ivy West.

The order was made by Mr Justice Forbes in the High Court on October 6, 2003, after an application by Mrs Knockels' grandson, Christopher West. Four days earlier all food and fluid had been withdrawn. The next day, however, the order was varied by the judge when David Maisey, a consultant, telephoned him. In the amended order, of October 7, nutrition and hydration were to be reinstated only "so far as is medically possible". On October 8, Mrs Knockels, from Holt, Norfolk, died.

In a statement to William Armstrong, the coroner, Mrs West said her mother had begged her for something to eat and drink, or a cup of tea, but the request was refused by a nurse, on the doctor's orders. Her last days were spent with her false teeth and hearing aid removed from her bedside, in a cold hospital room. She was admitted on September 14, 2003, after a suspected stroke.After two weeks Dr Maisey allegedly told Mrs West that he was surprised her mother was still alive and said that if the family intervened, he would have them arrested. Mrs West said that on another visit her mother had looked terrified and had tried, unsuccessfully, to tell her something. Three days later she pleaded with her daughter: "Help. Help me please."

The family contacted SOS-NHS Patients in Danger, which has criticised deliberate dehydration and starvation and the inappropriate use of sedatives and diamorphine. Julia Quenzler, the founder of the organisation, advised the family of their legal rights and the High Court injunction followed. In a statement, Christopher West said: "I told Dr Maisey: `I wouldn't treat my dog like that', and he said it was easier for vets because they . . . can put animals to sleep."

When Mrs Knockels was admitted, she was given intravenous fluids but, ten days later, nurses found they could not gain access to a vein so it was decided fluids would be given by subcutaneous infusion. But, the inquest was told, on October 2, medical staff found fluid leaking and the removal of the equipment was ordered. Two attempts were said to have been made to insert a naso-gastric tube, but without success.

Dr Maisey told the coroner: "The prognosis was very poor. Mrs Knockels was almost certain to die . . . within the next few weeks. She was lying flat. To have put any food or liquid in her mouth would have led possibly to asphyxiation." The cause of death had been recorded as cerebral infarction, but Michael Jarmulowicz, a consultant histopathologist, told the coroner that death was due to a lack of food and fluid and that the cerebral infarction was the secondary cause of death.


Politicians forced to over-rule irresponsible medical regulators

Doctors love their own. This is an update of a report posted previously on July 7, 2006

Premier Peter Beattie will consider changing the law to stop some convicted criminals from practising medicine in Queensland after the Medical Board this week re-registered a convicted rapist and known drug addict. Despite pleading guilty in 2002 to rape, attempted rape, deprivation of liberty and assault, James Samuel Manwaring is considered fit to practise medicine in Queensland. Manwaring is now listed as a registered doctor on the Medical Board's public access website.

He had a history of drug addiction while practising in Australia, the US and UK. After pleading guilty in 2002 to a vicious attack against his then wife, he was told by District Court judge Brian Hoath that nothing could 'excuse your involvement in these offences'. However, the Health Practitioner's Tribunal last July allowed him to immediately apply for re-registration after he had met a stipulation to submit hair for drug testing. The tribunal further imposed 24 conditions on his registration which would be strictly monitored. The conditions are listed on the board's public access inter-net register.

The Premier called for a report into the board's decision after revelations earlier this month that Manwaring was eligible for re-registration. He demanded that the board explain its position saying he was 'buggered if he knew' how Manwaring could qualify to practise again. Mr Beattie last night said he had received advice that legislation could be passed to 'prevent candidates from being registered or re-registered if they have been in-volved in specific criminal or other activities which affect their fitness to practice'. "I will now seek advice from the Health Practitioners Registration Board on the possible effects of such legislation," he said.

Manwaring's registration was listed on the board's website at the weekend, to the horror of his victim, Pat Gillespie. Ms Gillespie, a former journalist and public servant, has voluntarily identified herself as his victim. She said she was stunned to hear of the board's decision to re-gister Manwaring, given his his-tory of drug abuse and violent criminal convictions. She called on Mr Beattie to ensure Manwaring would never practise in Queensland again. "Someone has to warn the public what Manwaring is like," she said. "The medical board will not tell the public that he is a convicted drug addict, rapist and wife-basher."

The Medical Board yesterday defended Dr Manwaring's registration, saying it was forced to implement the tribunal's decision if he met eligibility criteria. [A lie. They have a power of discretion]

The above article appeared in the Queensland "Gold Coast Bulletin" (p. 9) on 19 July, 2006


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 Page is here or here.


Tuesday, July 25, 2006


A hospital for people with learning disabilities, at the centre of an investigation into patient abuse, will close. The Cornwall Partnership NHS Trust, which runs Budock Hospital, near Falmouth, was criticised in a report for “widespread institutional abuse” of patients. The report, part of an inquiry by the Healthcare Commission and the Commission for Social Care Inspection (CSCI), was published this month, describing years of abusive practices, “underlying problems that have never been addressed” and the failure of senior trust executives to face up to concerns. It is understood that 14 people with learning disabilities at Budock Hospital will be relocated by December. The Cornwall Partnership Trust will also be handing over the care of nearly 170 people in 46 community homes. A spokesman for the trust confirmed that the hospital would close.

Several treatment centres and units for people with learning disabilities were investigated throughout 2005 after allegations of abuse first surfaced in October 2004. Government inspectors found evidence of 64 incidents of abuse over the five years to last October, including staff hitting, pushing and dragging people in their care. There were also reports of staff withholding food, forcing patients to take cold showers and relying too much on medication to control behaviour. Staff also restrained people illegally. The investigation team found that one person spent 16 hours a day tied to their bed or wheelchair, with staff “wrongly believing” it was for the patient’s own protection. The report also revealed that one person suffered multiple injuries over time, including a fractured skull.

During the investigation 40 people with learning disabilities were referred by a CSCI and the Healthcare Commission to Cornwall County Council under the procedure for the protection of vulnerable adults. A few weeks after the East Cornwall branch of the charity Mencap first raised concerns, seven staff were suspended by the trust, five of whom have since been dismissed. Patricia Hewitt, the Health Secretary, has announced an audit of all services in England for people with learning disabilities who are in NHS or private-sector care.


Another killer doctor in a Queensland public hospital

Officials at one of Queensland's top hospitals approached the family of a dead patient to offer an out-of-court settlement after discovering that her surgeon -- a respected professor of medicine -- had a questionable safety record. Nardia Annette Cvitic, a 31-year-old mother of two, died from massive blood loss and organ failure after a hysterectomy performed by Bruce Ward at the Mater Hospital in 2002. A coronial inquest has heard that the operating theatre after Cvitic's operation resembled the scene of the Granville train disaster in NSW in the 1970s. A drain inserted into her pelvic area apparently punctured a major vein, a mistake compounded by Dr Ward wrongly prescribing a blood-thinning agent.

Documents obtained by The Australian show that guardians for Cvitic's two sons were approached by Mater officials in early 2003 and encouraged to make a medical negligence claim for "loss of dependency". The Mater had earlier commissioned a surgical audit from two professors who examined Dr Ward's treatment of 10 patients, including Cvitic, and warned "something is radically wrong and it cannot continue". Russell Strong and Alex Crandon identified problems with Dr Ward's surgical techniques, communication skills, post-operative care and judgment.

After being urged to pursue a claim, lawyers for Cvitic's family entered negotiations with Dr Ward's three employers -- the Mater, the Queensland Government and the University of Queensland -- and sought medical and psychiatric opinions on the impact Cvitic's death had on her two young sons. But it was not until Deputy State Coroner Christine Clements began public hearings in March this year that the claim was accelerated, with a mediation hearing in April setting out the proposed settlement amounts.

District Court judge Helen O'Sullivan approved the settlement last week, a legal requirement given the age of the beneficiaries. Cvitic's youngest son, a 10-year-old diagnosed after his mother's death with Asperger's syndrome, will have $115,000 held in trust, while her eldest son, 16, will have $60,000 held in trust. Dr Ward's employers will pay legal and administration costs, but the figures represent only what Cvitic would have provided for her children had she not died, and do not cover damages or compensation, even though dependency claims are usually an acknowledgement of negligence.

Ms Clements -- who will decide whether Dr Ward should face manslaughter or criminal negligence charges over Cvitic's death -- has yet to set a date for the resumption of public hearings in the inquest. Dr Ward's lawyers could not be contacted last night, nor could members of Cvitic's family. Dr Ward was a professor at the University of Queensland for 10 years but left in 2003. While the Medical Board of Queensland has maintained his registration, he has lost the right to operate at the Mater and other public hospitals, but is understood to still work at Brisbane's Sunnybank Private Hospital.

Australian Lawyers Alliance state president-elect Ian Brown said dependency claims were capped by the state Government. "Dependency claims, just like all others, are governed by the unfair restrictions of the liability reforms," Mr Brown said.



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 Page is here or here.


Monday, July 24, 2006


Hard to get needed surgery but easy to get unnecessary surgery -- Just another government bureaucracy doing the sort of thing that government bureaucracies do

Patients with ailments that could be cured by drugs are instead undergoing unnecessary and painful surgery simply because of where they live, according to England’s Chief Medical Officer. Professor Sir Liam Donaldson said that by scrapping operations such as hysterectomies and tonsil removal the NHS could save billions of pounds a year. His annual report, which was released yesterday, calls for urgent action to reduce the wide variations in care experienced across the country and urged the National Institute for Health and Clinical Excellence to issue guidelines on which treatments doctors should stop prescribing.

Sir Liam said that tonsillectomies and hysterectomies were still regularly performed despite guidelines recommending treatment through drugs. He said that children from low-income areas were more likely to have their tonsils removed, but if the tonsillectomy rate in low-income areas matched that of higher-income ones, about 8,000 operations could be avoided every year, saving about 6 million pounds.

Doctors performed about 38,000 hysterectomies in 2004-05. However, there were fewer operations in north central London than in Northumberland and Tyne and Wear. “In my view, this level of variation in clinical practice is not acceptable,” Sir Liam said. “If the average rate of hysterectomy in England could be reduced to that achieved in the 20 per cent of the country with the lowest current rates, then 5,900 operations, costing 15 million pounds, could be avoided per annum.”

Sir Liam’s report also highlighted the wide variations in the treatment of coronary heart disease. In some parts of the country, heart attack patients who needed revascuralisation — a procedure that improves blood flow to the heart — were twice as likely to be offered less intrusive but just as effective operations as those in other areas. Another example of waste was the 574 different hip joints the NHS used. He said that these could be reduced significantly.

Sir Liam proposed a system of incentives and penalties to encourage doctors to prescribe appropriate treatments. He said that computers in hospitals and GP surgeries could be programmed to block a doctor from prescribing a treatment that had little or no evidence of its worth. The NHS could also learn a great deal from the aviation industry and adopt standard operating procedures. This would not only encourage equitable care but also help to ensure better patient safety, Sir Liam said. “Inappropriate variation may be a function of poor knowledge, the flawed application of the correct knowledge, a lack of resources or the inappropriate allocation of extant resources,” he said.

More here

'Third World' health care in Queensland government hospitals

The report below gives you an idea of why nearly half of all Australians go to Australia's superb private hospitals instead

Hospital patients are waiting on trolleys, in chairs and even on the floor for up to 24 hours before a bed is available at a Brisbane emergency department. Staff at the Royal Brisbane and Women's Hospital are struggling with 30 per cent more patients to treat than they have beds for. They have told the Australian Medical Association that all 950 beds are full and capacity is overflowing. AMA president Dr Zelle Hodge said hospitals needed to operate at no more than 85 per cent capacity in order to be safe and to cope. "By operating at 130 per cent capacity, the Royal Brisbane Hospital is making conditions unsafe for patients and pushing staff beyond their limits," she said. "This is distressing for patients and their families, and is not the treatment they should be subjected to. "There are a lot of better ways the Government could spend taxpayers' money rather than advertising."

A nurse at one Brisbane hospital, who did not want to be named for fear of losing her job, said emergency patients were being put in extreme danger. "I have watched patients have cardiac arrests on ambulance trolleys in the corridor while waiting for a bed in the emergency department," she said. "Everyday patients wait far beyond their allocated time to receive treatment."

Government targets say treatment should be given within 30 minutes but a Federal Government annual report published this month shows that in 2004-05, Queensland emergency departments treated just 58 per cent of emergency patients within the recommended time. This month the Beattie Government boasted of more hospital beds and shorter waiting times in a glossy brochure "Keeping Our Promise" mailed at a cost of more than $300,000. Between December 2005 and May this year, the Government spent almost $2 million of taxpayers' money to reassure people about the health system is meeting their needs.

In contrast, Queensland Health reports released in April show patients are also waiting longer than the clinically desirable time for scheduled operations. Many who require urgent surgery are waiting up to a year, despite guidelines saying the operation should be carried out in 30 days.

Opposition health spokesman Dr Bruce Flegg said the Government must stop wasting money on publicity. "Clearly the situation with emergency departments has not improved, and no amount of spin and glossy brochures is going to make any difference," he said. Health Minister Stephen Robertson denied the occupancy rate at the Royal Brisbane had ever reached 130 per cent. He said the Government was investing $280.3 million into emergency departments over five years, and would increase the number of beds across the state by 860 over three years.



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 Page is here or here.


Sunday, July 23, 2006


At least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications, the influential Institute of Medicine concluded in a major report released yesterday. Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day he or she occupies a hospital bed, the report by a panel of experts said.

Following up on its influential 2000 report on medical errors of all kinds, the institute, a branch of the National Academies, undertook the most extensive study ever of medication errors in response to a request made by Congress in 2003 when it passed the Medicare Modernization Act. The report found errors to be not only harmful and widespread, but very costly as well. The extra expense of treating drug-related injuries occurring in hospitals alone was estimated conservatively to be $3.5 billion a year. "Even I was surprised and shocked by how common and serious a problem this is," said panel member Albert Wu, a drug safety specialist at Johns Hopkins University. "Everyone in the health-care system has to wake up and take this more seriously."

Many of these medication errors could be avoided if doctors adopted electronic prescribing, if hospitals had a standardized bar-code system for checking and dispensing drugs, and if patients made more of an effort to know about the risks of the drugs they take, the report said.

The panel members said the problem requires immediate action and that many key players in health care have been slow to take the steps -- and invest the money -- needed to significantly reduce medication errors. At least a quarter of the injuries caused by drug errors are clearly preventable, the report said. "Everyone in the health-care system knows this is a major problem, but there's been very little action, and it's generally remained on the back burner," panel member Charles B. Inlander said in an interview. "With this report, we hope to give everyone involved good, hard information on how they can prevent medication errors, and then create some pressure to have them implement it."

Common errors include doctors writing prescriptions that could interact dangerously with other drugs a patient is taking, nurses putting the wrong medication -- or the wrong dose -- in an intravenous drip and pharmacists dispensing 100-milligram pills rather than the prescribed 50-milligram dose. The report spotlighted the case of Betsy Lehman, a 39-year-old health reporter for the Boston Globe who died in 1994 after being given an erroneously high dosage of an experimental chemotherapy agent.

The study, funded by the Centers for Medicare and Medicaid Services, was assembled by 17 experts in related fields who analyzed research in the field, as well as government reports and data. They also held public forums to hear from representatives from the health-care system. Panel co-chair J. Lyle Bootman, of the College of Pharmacy of the University of Arizona in Tucson, said there is enough research and data on medication errors to conclude that there is a major problem, but not enough to fully understand and address the issue. He said the nation should spend $100 million a year to research drug errors, especially among pediatric and psychiatric patients and in long-term care facilities, where medications are heavily used.

The report looks to new technologies in addition to electronic prescribing to dramatically reduce the number of medication errors. Hospitals, for instance, could greatly benefit by having a standardized bar-code system to ensure that a patient gets the correct medicine, it says. But drug companies and vendors have created six distinct systems requiring different bar-code readers, the report said, making them a far less useful safety tool for hospitals.

The report did not address whether some drugs should be pulled from the market because of their intrinsic risks or whether the Food and Drug Administration does an adequate job of ensuring that approved drugs are safe for general use. That is the subject of another institute study expected to be released soon. But the panel members made clear that they believe the pharmaceutical industry and the FDA have not done enough to make drug information accessible to consumers and to make drug packaging as error-proof as it could be. The report said, for instance, that many medications would be better dispensed in blister packs that make it easier to identify them and for consumers to remember whether they have taken that day's dosage. It also said too many drugs have similar names that are easy to confuse.

In a statement, the FDA embraced the report and said it "provides a much needed perspective on the frequency, severity and preventable nature of medication errors." It said the recommendations "are supported by efforts already underway at FDA in the areas of medication error prevention, patient education and label comprehension."

The report endorsed much wider use of electronic prescribing. Inlander, president of the People's Medical Society, a Pennsylvania consumer health advocacy group, said chain pharmacies have been "ahead of the pack" in adopting such prescribing. The report said that all health-care providers should have plans in place by 2008 to move to electronic prescribing and dispensing, and that doctors should give up their traditional prescription pads by 2010.

Cecil B. Wilson, board chairman of the American Medical Association, also voiced support for "e-prescribing" and other information technology, but he said that "physicians face a dizzying array of choices when trying to purchase [the technology], while struggling with high costs, interoperability and ease of use." Michael C. Tooke, chief medical officer of the Delmarva Foundation, which works on health-care quality in more than 30 states, said e-prescribing will bring a needed end to deciphering physicians' illegible handwriting but cannot guarantee that a drug order is typed correctly. "E-prescribing is just going to allow us to make different errors and faster," he said. "It never just boils down to one thing."

The report's most striking findings concerned hospitals and long-term care facilities, which it said generally do not report errors to patients or family members unless they result in injury or death. The panel said all health-care organizations should report medication errors to patients, whether or not they cause harm. Based on past studies, the panel estimated that drug errors cause at least 400,000 preventable injuries and deaths in hospitals each year, more than 800,000 in nursing homes and facilities for the elderly, and 530,000 among Medicare recipients treated in outpatient clinics. The report said the actual numbers are probably much higher.

Locally, more than four dozen Maryland hospitals take part in comprehensive annual surveys of their safety measures, including procedures for averting medication mistakes. Frederick Memorial Hospital has a particularly active medication safety program, which includes a computerized system to "reconcile" medications at numerous steps in a patient's stay. The system has helped to quickly catch problems, including the omission of needed drugs, which clinical nurse specialist Susan Archer said "can make all the difference."



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 Page is here or here.


Saturday, July 22, 2006

S.F. OKs Universal Health Plan

San Francisco moved closer Tuesday to becoming the nation's first city to provide health care coverage for all its residents. The city's Board of Supervisors unanimously approved a plan that would give adults access to medical services regardless of immigration or employment status. The plan's estimated cost is $200 million a year.

Financed by local government, mandatory contributions from employers and income-adjusted premiums, the universal care plan would cover the cost of everything from checkups, prescription drugs and X-rays to ambulance rides, blood tests and operations. Unlike health insurance, it would not pay for services obtained outside San Francisco. Participants would have to receive care at existing clinics and public hospitals and from doctors who already participate in an HMO for low- and middle-income clients.

The Board of Supervisors must vote on the plan, which has been strongly opposed by the business community, once more for it to become final. Businesses with more than 50 employees would have to start participating next July, while smaller enterprises would begin in April 2008.



By Theodore Dalrymple

There are many heroin addicts in prison. Most of them, for obvious reasons, say something like: “I would give up the heroin, if only I got the help.” This implies, of course, that there exists a technical means by which the behaviour of addicts can be changed, so that no further effort at abstinence will be necessary on their part. The addict sees himself as a person who is ill, like someone with pneumonia, whom it is the duty of the “system” — the paraphernalia of doctors, nurses, social workers, drug counsellors and so forth — to cure. Until such time as the system fulfils its duty, the addict can continue in his habit, secure in the knowledge that he is not to blame, but the system that has failed to cure him.

This is a point of view that the Government has accepted in its entirety, indeed welcomed with a song in its heart; for does it not represent a job creation opportunity? The Government believes, or affects to believe, that the connection between crime and heroin addiction is a simple one: namely, that addicts rob, steal and burgle in order to pay for the heroin without which they will suffer the most terrible withdrawal symptoms. This is nonsense.

Actually, addiction to opiates is not incompatible with work. The great anti-slavery campaigner William Wilberforce took a tincture of opium every day of his very productive life. In the United States in the 1930s, it was found that the majority of injecting morphine addicts still worked, despite their problems with supply.

The criminal records of most addicts who end up in prison are extensive before they ever took up heroin — indeed, a few of them claim to have first taken heroin in prison. In the 1950s, it was found that at least three quarters of the still very small number of heroin addicts in Britain (the numbers of such addicts having increased by between 2,500 and 6,000 times since then to between 150,000 and 300,000) had criminal records before they ever took heroin. In other words, in so far as there is a causative connection between addiction and criminality, it is that criminality — or whatever predisposes people to it — causes addiction and not addiction that causes criminality.

This is borne out not only by the statistics, but by the biography of one of the most famous addicts of recent times, William Burroughs. Burroughs was born into a well-to-do family in St Louis, and from an early age found criminality alluring, at the age of 12 being much influenced by reading the memoirs of a violent criminal called Jack Black. After Harvard, but before he addicted himself to heroin, Burroughs spent some time robbing down-and-out drunks on the New York subway, which is not a sign of a refined moral sensibility, to say the least. (He later disembarrassed himself of his wife by shooting her dead while they were in Mexico, and though he generally disdained his own bourgeois background, he had no hesitation in using family money to bribe himself free.)

It is true that addicts who are prescribed methadone as replacement for their heroin commit fewer burglaries and other crimes than they did before they were prescribed it, I suspect largely because methadone is more consistently sedating than heroin. But it is not true that they become law-abiding citizens after taking methadone: in one series, addicts given methadone committed (on self-report) three acquisitive crimes a month, not exactly a sign of irreproachable uprightness.

Nor is it true that addicts can give up if, but only if, they receive the “help” they claim they want. Huge numbers of American servicemen addicted themselves to heroin during the Vietnam war. Almost all of them gave up spontaneously soon after their return to the US, and two years later their rate of addiction was no higher than that among drafted conscripts who never made it to Vietnam because the war ended.

Moreover, Mao Zedong managed to “cure” 20 million opium addicts by his usual rather uncompromising methods. It wouldn’t have made sense for Mao to have threatened retribution for people who contracted, say, appendicitis or cancer of the bowel, in the hope of reducing the incidence of those conditions: this suggests that addiction to opiates is a pretend illness and treatment is pretend treatment.

It is not true that heroin addicts take a couple of doses and then find themselves enslaved. On the contrary, addicts usually spend a year or so taking heroin intermittently before they decide to take it regularly. It would be truer to say that they hook heroin, than that (as they usually put it, in order to deny their own responsibility) they are hooked by heroin. It is simply implausible to suggest that addicts become addicted by inadvertence or ignorance: the vast majority of the addicted come from backgrounds in which ignorance of history and arithmetic is perfectly possible, but not ignorance of the heroin way of life.

Is any great harm done by pretending that opiate addiction is a disease like any other? After all, a portion of mankind will always resort to mind- altering drugs to obscure the existential problems that confront us all. Certainly methadone when prescribed carelessly — as it is in Britain — is a dangerous drug, and can cause nearly as many deaths as heroin itself.

There is a more intangible harm, however, to the pretence: the existence of drug clinics sends a message to addicts that they are ill and in need of treatment rather than they have chosen a disastrous path in life. It conceals from people their responsibility for their own lives, a responsibility we all find irksome at times, but acceptance of which is the only basis of a meaningful life.



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 Page is here or here.


Friday, July 21, 2006

Deadly government medicine in the Australian State of Victoria

Here is a frightening statistic that should focus the mind. On some estimates, 3500 people have died unnecessarily in Victoria since the Bracks Government was elected. Think that through. What if the road toll had suddenly surged by so many? There would be public fury. What if the murder rate had leapt by 500 a year or terrorists were picking off Victorians at about ten a week? What if poor regulation of hygiene in the food industry was killing two people each working day? The pressure to fix it would be massive. If any other collection of problems was allowing so many people to die unnecessarily there would be public outrage and the full community focus would be on analyzing and solving the problem. So why are these lives different?

They are all people with families, and they are all equally dead. Why accept this? These people haven't died behind the wheel or at the wrong end of a gun, the accusation is that they have died because Victoria's health system is not working well enough. That much now seems beyond dispute, although the awful statistics have been sharpened by a passionate doctor who represents medical staff in public hospitals. Dr. Peter Lazzari is chair of the chairs of medical staff in the hospitals and himself a senior physician. His concern has provoked a flair for dramatic language that has been overly harsh but aimed to seize attention and did.

He has accused Steve Bracks of behaving like an undertaker and claimed the Australian Medical Association has abandoned patients: ``I officially declare a state of war, ``he said. ``The beds are bursting and the Government is architect of genocide against innocent Victorians.'' That is the ridiculous language of intense frustration. But the government has not directly disputed his figures, and admits much needs to be done. The argument now is about how to do it, and that is why Dr. Lazzari is right to try to shock the public out of its apathy and acceptance.

He says there are 500 deaths each year on waiting lists, 250 of which are avoidable. The government's own figures, revealed under Freedom of Information laws, show this could be a realistic assessment. He further claims that overcrowded hospitals cause another 250 unnecessary deaths each year. Again, government figures show hospitals are short 550 beds, and although Dr. Lazzari cannot prove overcrowding kills 250, it is reasonable to assume that as a representative of doctors in the system he has a fair idea what is going on.

Of course the government does not want such death. It has worked hard to improve the system, but now in the face of such an appalling statistic it is defensive and secretive because it knows health is a dangerous political issue. Much of what official information is available has been dragged out through FOI laws. Now, rather than encouraging an all-in debate that might throw up ideas and save lives the government prefers chanting politically targeted statistics designed to confuse.

The acting Health Minister Gavin Jennings finally recognized reality, admitting that the government had to take responsibility for the 500 deaths and for ``continued suffering'' on waiting lists. But the minister's spokesman offered this: ``The Government is proud of its record in health. This year Victorian hospitals will treat around 300,000 more people than they did when the government was elected. We have employed 6035 extra nurses and 1365 extra doctors.'' Perhaps that is true, but it is little consolation to the families of the 500 dead who need not be dead. Quoting staff numbers and dollars spent only proves the depth of the problem, because it is still not fixed. What is urgently needed in this are facts, ideas, and less political spin.

The Government needs to put aside political sensitivity and the State Opposition needs to allow them the breathing space to do it. Accurate and detailed figures on waiting lists and bed shortages need to be released, not dragged out through FOI. For example, we need to know how many patients on the lists are being reclassified as their health worsens. We need to know whether official waiting lists include those waiting to see a specialist and if not how many are waiting. We need to know how many patients wait so long they are deemed unfit for surgery by the time their case is at the front of the queue. And we need to know whether Dr. Lazzari is right and how many died because they waited too long. Doctors, God bless them, would throw endless billions of dollars at the system because all they want to do is help people.

The country does not have endless billions of dollars to spend so instead we need co-operation, consultation, openness and ideas. Perhaps hospitals can work smarter, not leaner. Perhaps medical staff can be freed from bureaucratic duties so they can concentrate on medicine ahead of bean-counting.

Perhaps waiting lists can be better managed. Perhaps there are ideas that would allow specialists to see more patients. Perhaps we should ask why this country tolerates the expensive and ridiculous duplication of the system through state and federal bureaucracies that sit around getting fatter while frail people can't get a bed. It is unlikely there is a person working inside the health system without a view on how to make it better. Victoria must end the defensiveness and listen. The politicians must put aside point scoring and construct a bi-partisan think tank to chase solutions.

There will never be a zero avoidable death rate, just as the roads will always kill some people. But if the united community focus that has built around the road toll can be applied to hospitals, lives will be saved. Once, 1034 deaths on the roads were considered inevitable. Now that is unthinkable. Five hundred unnecessary deaths in the hospital system must today be considered equally atrocious.



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 Page is here or here.