Saturday, June 16, 2007

NHS: Go blind, you peasants! We've got clerks to pay!

It's much more important to pay the vast army of NHS bureaucrats than give the sick the drugs they need. The NHS has 1.3 million employees, of whom less than 70,000 are doctors. Bureaucrats don't stop people going blind but the latest medications might. So what is the NHS for, exactly?

Thousands of people face severe loss of sight after a decision by the health watchdog to deny two leading treatments to NHS patients. The drugs Lucentis and Macugen have been shown to be the most effective means of halting the onset of wet age-related macular degeneration (AMD), the only treatable form of the most common cause of blindness in Britain. The condition affects about 250,000 people and claims 26,000 new sufferers each year. It damages the central part of the retina called the macula and leaves one in ten sufferers blind.

The National Institute for Health and Clinical Excellence has been under intense pressure to approve the drugs. Its draft guidance recommends that Macugen should not be used at all on the NHS in England and Wales, while Lucentis is recommended only for a small group of patients who have already gone blind in one eye and whose disease is progressing in their second. The guidance is open to consultation but is based on NICE’s appraisal of cost-effectiveness, which is rarely overturned.

Campaigners said that the decision was “cruel” and “appalling” and added that they hoped the watchdog would reconsider its position for a final ruling, which is expected in September. Patients in Scotland can already get both drugs after rulings by the Scottish Medicines Consortium, although there is concern that this will be overturned in light of NICE’s decision.

Thousands of patients who need urgent treatment to save their sight say that they have already been let down by local health authorities refusing to fund the drugs, known as antiVEGF treatments, on the ground of cost. Lucentis, the most effective, can cost up to 28,000 pounds for a course of 14 monthly injections, while Macugen costs 4,000 a year.

A study, published in the New England Journal of Medicine and reported by The Times in October, found that Lucentis can prevent vision loss and even improve sight in nine out of ten patients. The total cost to the NHS of treating all newly diagnosed patients with the drug would be about 400 million, experts say.

Andrew Dillon, chief executive of NICE, said: “When treatments are very expensive we have to use them where they give most benefit to patients. “Most people with AMD only seek help once the disease is beginning to affect their second eye. “Because of this, and based on the evidence they have seen, our independent advisory committee believes the right thing to do is to treat and try to save as much sight as possible in the better-seeing eye.”

The Royal National Institute of Blind People (RNIB) said that it was “outraged” by the guidance, which meant that patients would be treated only once they had irrevocable loss of vision. Steve Winyard, head of campaigns, said: “This preliminary guidance is worse than we ever imagined it could be. It is simply unacceptable that NICE is recommending that only a small minority of patients within England and Wales will benefit from these ground-breaking treatments.” The Macular Disease Society, along with the RNIB, will be submitting a response to NICE “to encourage a reanalysis”.


Australia: Call for surgeon report cards

Long overdue. If the profession refuses to police itself, information should at least be made available, imperfect though it may be

REPORT cards for surgeons showing patient death rates should be introduced to help people make decisions about which doctor to choose for an operation. The recommendation from bioethics expert Justin Oakley includes making mortality rates available to the public on an internet database that lists every surgeon and hospital in Australia.

Professor Oakley, from Melbourne's Monash University, has called on federal and state governments to help fund the development of a public reporting system following the Bundaberg Hospital scandal, in which Jayant Patel was linked to at least a dozen deaths and dozens of injuries through incompetence. Professor Oakley said the national database should start with report cards for cardiac surgeons, a system that has recently been set up in Britain. It should then be expanded to include all surgeons. He said the report cards, which could also include surgery complication rates, would keep surgeons more accountable to the public. "The mortality rates of each surgeon should be made available to patients so they have a better idea of their surgeon's track record," Professor Oakley said. "It also improves the safety and quality of care. If surgeons know their performance will be seen by the community, that is a powerful incentive for surgeons to maintain their performance."

The Patel scandal at Bundaberg Hospital had shown that internal peer review was not enough to keep the profession accountable, he said. Professor Oakley, who heads Monash's Centre of Human Bioethics, said any mortality rate for surgeons would have to be adjusted based on the risk of the operation. "They would adjust the mortality rate depending on the mixture of patients," he said. "It would take into account patient profile. If a surgeon performs on a lot of patients that are high risk, like those that are a bit sicker or older, that is factored in to the rate."

Professor Oakley, who has co-edited a book on the subject due out in August, said governments would need to invest significant resources to make a report card system viable and it should be set up sooner rather than later. "I don't think we should wait for a scandal to occur to allow patients to get access to the track records of surgeons," he said.

However, Royal Australasian College of Surgeons president Andrew Sutherland said there were immense practical difficulties in implementing report cards, calculating a mortality rate and making risk adjustment. "It's a terrific idea but the risk assessment (of mortality rates) is very difficult," he said. Factors such as high-risk operations would make it almost impossible to determine a fair rating. "We are totally against report cards because there is so much opportunity for unfairness," Dr Sutherland said. "The practicalities are not possible at this time."

Dr Sutherland said the college had started conducting audits of surgery deaths in some states and said there were plans to expand the program nationally. Deaths were reviewed by specialists with the aim of trying to prevent problems from recurring, but the findings were not made public, he said. "Pretty soon we'll have an audit of surgical mortality in every state."



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

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