Dozens of NHS patients left to repeat surgery after botched work by Swedish doctors

An interesting commentary on the quality of treatment Swedes receive from THEIR socialized medicine system

Dozens of elderly people were left in pain and requiring further surgery after botched work by Scandinavian surgeons brought in to reduce NHS waiting lists, an investigation has found. An audit of hundreds of patients sent to the "flying doctors" for knee operations found that one in three suffered a poor outcome, with one in five cases so bad that the operation needed to be redone.

Lawyers are considering at least six cases involving patients treated at a centre in Weston-super-Mare, Somerset, which hired surgeons from Sweden, Denmark and Finland and to cut waiting times for orthopaedic procedures.

The review of their treatment comes amid increasing concern about the risks posed by EU laws which allow medics to work in any member state, without checks on their competence or language skills. Earlier this month, the case emerged of a [black] German doctor who killed a Cambridgeshire pensioner by administering ten times the required dose of painkillers. Dr Daniel Ubani said he was not familiar with diamorphine, a drug commonly used by GPs in this country.

Under an EU directive passed in 2004, doctors can work in any member state without tests of their language skills or clinical competence. Since then, the number of EU doctors registered to work in Britain has risen by 4,000 – an increase of 24 per cent – at a time when the number of UK-trained doctors fell. Meanwhile, the amount of serious disciplinary action taken against European medics by the General Medical Council has doubled.

Last year, 30 were struck off, suspended, given a warning or had conditions imposed on their practice, compared to 15 cases in 2005. But under current rules the GMC is unable to demand information from its counterparts abroad showing whether a doctor has been previously disciplined or struck off in another country.

The Somerset treatment centre, run by Weston Area Health Trust, hired surgeons from Scandinavia in order to cut local waiting lists, and boost the trust's income by attracting patients who faced long delays elsewhere. Patients from Wales were among those encouraged to travel to the centre, despite concerns from local orthopaedic specialists that they could not guarantee the quality of the doctors, who had been contracted from a private company in Sussex.

Now, an audit of more than 200 patients who underwent knee surgery between 2004 and 2006 has revealed that the number of operations which were botched was ten times the national average.

The paper, published in the Journal of Bone and Joint Surgery, found that 37 per cent of the knee operations carried out on 224 patients had an unsatisfactory result, with dozens of patients left in pain. Twenty two per cent of the operations to replace knees were so bad that they had to be redone – a rate ten times the normal figure in NHS hospitals – while the review warns that yet more patients might need surgery redone in the future.

Orthopaedic surgeon Stephen Cannon, former president of the British Orthopaedic Association, attacked the Government's use of foreign doctors to fill gaps in locum services, and achieve waiting targets. "These guys were brought in as carpenters," he said. "They didn't see their patients postoperatively. They flew in to do the operations, and the doctors in South Wales were left to pick up the pieces."

South West Strategic Health Authority is due to publish a review of the outcomes at the centre, which is no longer staffed by doctors from Scandinavia. The inquiry, ordered in January 2007, will compare results for all patients sent to the centre with national data on outcomes.

Dr Paul Callaghan, medical director of Scanloc, the recruitment company which provided the surgeons, said it examined their surgical outcomes in their own countries before they were hired, and found results similar to those in this country. "We are a recruitment bureau, and we were not responsible for how the centre was set up. The doctors were experienced knee surgeons who had shown good results when they came to us."

Mr Cannon attacked the legislation giving "equivalence" to medical qualifications from 27 EU member states, despite the fact each country's medical education is tailored to its health care system. "The systems are very different in each country – for example, there are countries like Italy where doctors qualify while barely seeing a patient," he said.

An amendment making it mandatory for countries to share information will be put to the European Parliament next month, but the British Government plans to block the move. Professor Sir Donald Irvine, former president of the GMC said a "gaping hole" had now been revealed in the protection of patients. He criticised the Government for failing either to block the original EU laws which had created dangers to the public, or adapt British regulation systems to ensure more rigorous assessment for every doctor before they were allowed to work.

Sir Donald said: "This is an unsafe system; the holes in it are gaping. The problem is the starting point always seems to be 'What do the lawyers say?' – not 'What is best for patients?'"

The Department of Health said it did not believe the legislation being discussed next month, covering the rights of patients in Europe, was an "appropriate mechanism" to introduce changes making information sharing between regulators mandatory. A spokesman said the Government had no plans to press for changes by any other route, and said a voluntary scheme was already in existence.

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The Obamacare to come

Drip by painful drip, the details of the Democratic health-care-reform plan have been leaking out. And from what we can see so far, it looks like bad news for American taxpayers, health-care providers, and, most important, patients.

The plan would not initially create a government-run, single-payer system such as those in Canada and Britain. Private insurance would still exist, at least for a time. But it would be reduced to little more than a public utility, operating much like the electric company, with the government regulating every aspect of its operation.

It would be mandated both that employers offer coverage and that individuals buy it. A government-run plan, similar to Medicare, would be set up to compete with private insurers. The government would undertake comparative-effectiveness and cost-effectiveness research, and use the results to impose practice guidelines on providers. Private insurance would face a host of new regulations, including a requirement to insure all applicants and a prohibition on pricing premiums on the basis of risk. Subsidies would be extended to help middle earners purchase insurance. And the government would subsidize and manage the development of a national system of electronic medical records.

The net result would be an unprecedented level of government control over one-sixth of the U.S. economy, and over some of the most important, personal, and private decisions in Americans' lives. Let's look at some of the most troubling ideas in detail.

An employer mandate. Employers would be required to insure their workers through a "pay or play" mandate. Those who did not provide "meaningful coverage" for their workers would pay a penalty, equal to some percentage of their payroll, into a national fund that would provide insurance to uncovered workers. Such a mandate is, of course, simply a disguised tax on employment. As Princeton University professor Uwe Reinhardt, the dean of health-care economists, points out, "[That] the fiscal flows triggered by mandate would not flow directly through the public budgets does not detract from the measure's status of a bona fide tax." Estimates suggest that an employer mandate could cost 1.6 million jobs over the first five years.

An individual mandate. As is the case with an employer mandate, an individual mandate is essentially a disguised tax. It is also the first in a series of dominoes that will lead to greater government control of the health-care system.

To implement an insurance mandate, the government will have to define what sort of insurance fulfills it. As the CBO puts it, "an individual mandate . . . would require people to purchase a specific service that would have to be heavily regulated by the federal government." At the very least, deductible levels and lifetime caps will have to be specified, and a minimum-benefits package will likely be spelled out. This means the oft-repeated promise that "if you are happy with your current insurance, you can keep it" is untrue. Millions of Americans who are currently satisfied with their coverage will have to give it up and purchase the insurance the government wants them to have, even if the new insurance is more expensive or covers benefits the buyer does not want.

A "public option." The government would establish a new universal-health-care program, similar to Medicare, that would compete with private insurance. Regardless of how it is structured or administered, such a plan would have an inherent advantage in the marketplace because it would ultimately be subsidized by taxpayers. It could, for instance, keep its premiums artificially low or offer extra benefits, then turn to the U.S. Treasury to cover any shortfalls. Consumers would naturally be attracted to the lower-cost, higher-benefit government program.

A government program would also have an advantage because its tremendous market presence would allow it to impose much lower reimbursement rates on doctors and hospitals. Government plans such as Medicare and Medicaid traditionally reimburse providers at rates considerably below those of private insurance. Providers recoup the lost income by raising prices for those with private insurance. It is estimated that privately insured patients pay $89 billion annually in additional insurance costs because of cost-shifting from government programs. If the new public option would have similar reimbursement policies, it would result in additional cost-shifting of as much as $36.4 billion annually. Such cost-shifting would force insurers to raise their premiums, making them even less competitive with the taxpayer-subsidized public plan. Lewin Associates estimates that as many as 118.5 million Americans, nearly two out of every three people with insurance, would shift to the government program. The result would be a death spiral for private insurance.

Given that many of the most outspoken advocates of the "public option" have, in the past, supported a government-run single-payer system, it is reasonable to suspect they support a public option precisely because it would squeeze out private insurance and eventually lead to such a system. President Obama himself has said that if he were designing a health-care system from scratch, his preference would be a single-payer system "managed like Canada's." He has also said that, while his proposal is a less radical approach, "it may be that we end up transitioning to such a system."

Comparative- and cost-effectiveness research. In an attempt to control health-care costs, the government would undertake research to determine which health-care procedures and technologies are most effective and, more ominously, cost-effective. Of course, there is a great deal of waste in the U.S. health-care system, and if the government's goal were simply to provide better information there would be little cause for concern. But there is every reason to believe such research would be used to impose restrictions on how medicine is practiced. For example, some reform advocates have said that when an insurance company fails to comply with government practice guidelines, workers should no longer be able to exempt the value of that company's plans from their taxable income.

There is no doubt that other countries use comparative-effectiveness research as the basis for rationing. For example, in Great Britain, the National Institute on Clinical Effectiveness makes such decisions, including a controversial determination that certain cancer drugs are "too expensive." The U.K. government effectively puts a price tag on each citizen's life — about $44,305 (£30,000) per year, to be exact, under NICE's guidelines. That's just a baseline, of course, and, as NICE chairman Michael Rawlins points out, the agency has sometimes approved treatments costing as much as $70,887 (£48,000) per year of extended life. But such treatments are approved only if it can be shown they extend life by at least three months and are used for illnesses that affect fewer than 7,000 new patients per year.

The final health-care-reform bill is likely to include a number of other bad ideas: a host of new insurance regulations that will drive up costs and limit consumer choice (under one leaked proposal, Americans would be limited to a choice of four standardized insurance plans); subsidies for middle-class families (a family of four earning as much as $83,000 per year would receive subsidized care under one proposal); and government preemption of private investment and research into health IT. All of this would come at a cost to taxpayers of at least $1.5 trillion over the next ten years.

The American people are right to demand health-care reform. The current system is broken. But taken individually, most of the ideas currently being considered by Congress would make the problems we face even worse. Taken together, they amount to a complete government takeover of the American health-care system. That is not the type of reform most Americans seek.

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