Sunday, August 23, 2009

The NHS is deeply and irrevocably flawed

Story from a disillusioned Brit excerpted below:

A simple thing. Another blood test, some more investigations into whatever flawed gene or missing protein might be the cause of my daughter's troubled life, with her terrible seizures, her blindness, her inability to walk or talk or eat unaided. Over the past 15 years, there have been many such attempts to identify her condition. One year later, we asked the doctor, a top geneticist at one of the world's most famous hospitals, what had happened to the results.

His office told us a rambling story about financial restrictions and the need to send such tests to a laboratory in Germany. They said there was little he could do, but promised to pursue our case. It was a bare-faced lie. The precious vial of blood had been dumped in storage and forgotten. The following day it was dispatched to a laboratory in Wales and 40 days later the specialists came up trumps. They identified her condition, an obscure genetic mutation called CDKL5.

The breakthrough was rather mind-blowing, giving us some peace of mind and the chance to talk to families of the hundred or so other children worldwide identified with the condition. It was also life-changing, since it means our other child and close relatives are in no danger of passing on the condition. Indeed, had we known sooner we might have even tried for more children.

But the most shocking thing was not the lying. Nor even the incompetence. It was our total lack of surprise at the turn of events, since after 15 years suffering from the failings of the National Health Service, we are prepared for almost any ineptitude.

Of course, everyone loves the NHS now. It is officially sacrosanct. Our doctors are deities, our health care the envy of the world. And anyone who says anything different is an unpatriotic schmuck who should go and join those losers in the United States. (Although American doctors terrified of litigation would have done all the tests possible on my daughter if I had sufficient insurance, and would think twice about lying to patients.)

So forgive a harsh dose of reality. I used to share these delusional views, wrapped in a comforting blanket of national pride over Aneurin Bevan's legacy. But that was before the birth of our daughter sent us hurtling into the hell of our health service. Since then, hours and days and months and years have been spent battling bureaucracy, fighting lethargy and observing inefficiency while all the time guarding against the latest outbreak of incompetence.

Despite my daughter being under palliative care, my wife spends two hours a day struggling against the system, to say nothing of the endless appointments that go with being primary carer of a severely disabled child. Right now, following some dramatic hormonal and physical changes, we are waiting to talk to one of our daughter's doctors: the first call went in three weeks ago, followed by three more phone calls and one email. No reply yet.

Or take the request for a bigger size of nappies [diapers], urgently needed because of our daughter's sudden weight spurt. A simple thing to sort, you might think. Not in the parallel universe of the NHS. It has taken four weeks, three phone calls, two home visits from community nurses to assess our needs and fill in the requisite forms - and still looks like being one more week before there is any hope of delivery.

It might seem comical, but the result is a distressed child and endless extra laundry. The warning signs of what lay ahead came on our first visit to Great Ormond Street, when there was a young couple who had travelled down from the North-East of England in front of us, their tiny sick baby almost lost in its blankets. 'Didn't anyone tell you - your appointment's been cancelled?' the receptionist told them breezily. They looked at each other despairingly.

Such insensitivity is typical. When my daughter was seven, she underwent a major review at a specialised unit in Surrey, spending three days and nights with sensors connected to brainscanning devices glued to her head, under constant video surveillance while my exhausted wife comforted her and stopped her ripping off the electronic pads. A huge strain, but worth it given the hope of a breakthrough. When we went to get the results a few weeks later, there was the usual wait.

After eventually summoning us, the neurologist asked why we were there. Then she opened our daughter's notes and asked what was wrong with her. Then she couldn't find the results. We stormed out, me in fury, my wife in tears.

There are countless other examples. The celebrated neurologist who measured our heads before blithely asserting that our daughter - suffering up to 30 fits a day - would just have a slightly lower IQ than the average person. The GP who gave her an MMR injection against our wishes, despite warnings it might prove fatal. The nurse who, having been told our daughter was blind, asked if she would like to watch a video.

And that is to say nothing of the endless minor irritations: the overcrowded waiting rooms, the blase receptionists, the unanswered emails, the blinkered attitudes to people with disabilities.....

Unfortunately, it is equally clear that billions have been wasted, poured into a centralised monopoly that focuses on the manipulation of a target culture rather than delivery and innovation. It was little surprise to learn that more managers than doctors were hired last year. And all too often these managers seem to reinforce rather than challenge the patronising attitudes that often predominate, while failing to tackle glaring waste....

Clearly there is systemic failure. And it is a question of management, not money...

More here

Australia: Another ambulance bungle -- man dies

(Ambulances are part of the public health bureaucracy in Queensland)

The widow of a Queensland man said his last act was to trust the ambulance service that ultimately bungled the response to his fatal heart attack. Karen Howlett has recalled how her husband Peter, 44, urged her to call an ambulance when he began to feel the effects of a heart attack in his Mackay home. But a series of communication miscues in the Queensland Ambulance Service were highlighted after Mr Howlett died in front of his three young children before an ambulance arrived.

The ambulance – leaving from a station about 15 minutes' drive away – got lost and arrived almost one hour after the initial Triple 0 call. "He was the one who asked me to call an ambulance. He had faith they would come in time," Mrs Howlett said. "But they didn't and a good man lost his life."

Mr Howlett's death in April 2006 remains the subject of a coronial inquest which has heard QAS admissions that it made several errors in responding to the callout. These include the incorrect prioritising of the call which, the inquest heard, was among factors that led to paramedics making a cup of tea before they headed out.

The incident has been one of many researched by The Courier-Mail as part of a special investigation into the QAS since its 2007 overhaul. The series, from Monday, will look at the QAS's dispatch process, spending and workplace culture.

Mr Howlett's emergency occurred at 7.22am on April 21, 2006, in clear weather at Farleigh, an historic community just off the Bruce Hwy northwest of Mackay. The street and address of the family home, built in the 1980s, were clearly marked. Mrs Howlett called Triple 0 three times while her husband's condition worsened. After her second call, she received a call from the ambulance seeking directions and had to go outside with the phone. "I couldn't hear because Peter was screaming in pain," she said.

Mrs Howlett returned to the room to find her husband "turning purple" and then gave him CPR. "He had his children – who were 8, 6, and 2 at the time – watching this. It was very, very traumatic," Mrs Howlett said.

Mrs Howlett doesn't blame the paramedic, who was new to the area and worked frantically on her husband, or his assistant on her first day on the job. But she has lost confidence in QAS management. "I could never rely on an ambulance again. I would put my family in the car and drive," she said. "It's a shame really. I think about that every day."

Mrs Howlett was angry a tape of the call revealed an ambulance dispatcher felt she was a "stroppy little thing".

The inquest has heard that the call was not given the highest emergency code because of a misunderstanding at the QAS communications centre.

After her husband's death, Mrs Howlett expected an apology and explanation from QAS managers. There was nothing but silence until her brother-in-law complained and a general apology was made. "It seemed all hush-hush to me. My feeling was if we hadn't initiated contact, I don't know that we would have heard anything. They did an investigation but I wasn't asked anything," Mrs Howlett said. "My husband died a very painful death without any medical assistance. I would have appreciated some feedback."

QAS medical director Dr Stephen Rashford told the inquest that mistakes were made and that "this was not a good case for us". The ambulance lacked a backup GPS that could have assisted the paramedic, who had only worked in Mackay for two months.


Paging Dr. Reform

A view from the more moderate Left

Reading the transcripts of President Obama's "town hall meetings" this month on heath-care reform is painful. He's preaching the right gospel, but the parishioners are getting restless. The harder he tries to sell his program, the louder and angrier the debate gets -- and the more the general public tunes out the politicians.

It reminds me of the polarizing Iraq debate of several years ago. Forgive the analogy between war and health care, but maybe Obama needs the medical equivalent of a Gen. David Petraeus -- that is, a professional who can break through the political chaff and describe a strategy for reform that can unite the country.

I have a nomination for the medical commander role, and it won't surprise anyone who follows this issue: Dr. Denis Cortese, the chief executive of the Mayo Clinic. He's already doing what the nation needs -- that is, providing high-quality health care at relatively low cost. Every time I listen to Cortese explain what's wrong with the system, I have the same reaction: Let him and other smart health professionals lead us out of the political morass.

Talking to Cortese this week, I heard two themes that cut to the heart of the debate. First, he thinks Obama has made a mistake in moving toward the narrower goal of "health insurance reform" when what the country truly needs is health system reform. Imposing a mandate for universal insurance will only make things worse if we don't change the process so that it becomes more efficient and less costly. The system we have is gradually bankrupting the country; expanding that system without changing the internal dynamics is folly.

Second, Cortese argues that reformers should stop obsessing over whether there's a "public option" in the plan. Yes, we need a yardstick for measuring costs and effectiveness. But we should start by fixing the public options we already have.

Cortese counts six existing public options that should be laboratories for reform: Medicare, with its 45 million patients and a fee-for-service structure that all but guarantees bad medicine; Medicaid, with an additional 34 million beneficiaries; military medicine, through which government doctors deliver state-of-the-art care; the Department of Veterans Affairs, which has improved performance at its hospitals by embracing new technology; the "Tricare" insurance plan for military retirees; and the Federal Employees Health Benefits Program.

Adding a new public option for insurance, as congressional reformers are demanding, would be useful. But it's not necessary now, and it is creating a poisonous debate that's undermining the more important reforms -- which are in the delivery system, not insurance.

If liberals really want to show they are serious, they should begin with our existing single-payer behemoths, Medicare and Medicaid. Cortese argues that the White House should mandate that, within three years, these programs will shift from the current fee-for-service approach to a system that pays for value -- that is, for delivering low-cost, high-quality care. If doctors performed unnecessary tests that ballooned costs, their compensation would be reduced. And doctors would be compensated by regional formulas, to encourage them to work cooperatively in local networks where they could all make more money by practicing better medicine.

What difference would such Medicare reform make? Take a look at estimates prepared by the Dartmouth Institute for Health Policy and Clinical Practice (which developed the national "health atlas" that was the basis for the widely read New Yorker article by Dr. Atul Gawande). At current spending rates, Medicare will run a $660 billion deficit by 2023. But by cutting the annual growth in per-capita spending from the current national average of 3.5 percent to 2.4 percent (the rate in San Francisco, for example), Medicare could save $1.42 trillion and post a big surplus.

This "pay for value" approach would amount to a cultural revolution in American health care. It would take our bloated system and make it cheaper and better. The adjustments wouldn't be easy, and the medical profession would balk unless respected doctors such as Cortese led the way.

Obama has been campaigning furiously in this crazy summer of bogus debates about "death panels," but he's losing traction. Reformers aren't helping by drawing a false line in the sand over a "public option" when we already have one, in Medicare, that provides a laboratory for systemic change. I hope that Obama understands that his health plan is in mortal danger -- and that it's time to call for the doctor.


Reid: ObamaCare "By Any Legislative Means Necessary"

Harry Reid has delivered his ultimatum to Republicans in the Senate. And it is nothing short of a coup of representative government. Either Republicans bow to the demands of Senate leadership and pass a "bipartisan" bill, or he'll invoke a process known as "reconciliation," whereby only 51 votes would be needed to pass the bill.

Reid's problem is that he doesn't have enough Senate Democrats to break a filibuster—which requires 60 votes. And so, he's rolling the dice, gambling that the Senate parliamentarian will go along with his blatant breach of procedure and that his thuggish threats will cause Senate Republicans to capitulate to his demands.

The truth is, however, this may be the only way Barack Obama's takeover of the nation's entire health care system will be passed this year or any year. The so-called public "option"—which is not at all optional—cannot clear the 60 votes needed in the Senate. And a bill in the House without the public "option" cannot pass either because of demands by the so-called "progressive" caucus.

All of which leaves Reid, Pelosi, and Obama with but one option: to change the rules and eliminate the filibuster in a sharp departure from more than 200 years of parliamentary history.

According to Reid spokesman Jim Manley, "The White House and the Senate Democratic leadership still prefer a bipartisan bill. However, patience is not unlimited, and we are determined to get something done this year by any legislative means necessary."

That's right. "By any legislative means necessary." Attila the Hun would be proud.

To make matters worse, Reid's dictatorial move is a definite shift to a "Senate-first" strategy to pass ObamaCare. In this scenario, Senate Democrats would pass the legislation through the "reconciliation" process and send the bill(s) directly to the House for a vote. Then, there wouldn't be a conference bill, which would still need 60 votes in the Senate to get cloture.

Instead, it would just get rubber-stamped against the express wishes of the American people.

And don't be surprised if Reid and his cabal surreptitiously insert the force "option" into the bill. According to the Wall Street Journal, "In recent days, Democratic leaders have concluded they can pack more of their health overhaul plans under this procedure, congressional aides said. They might even be able to include a public insurance plan to compete with private insurers, a key demand of the party's liberal wing, but that remains uncertain."

But then again, Reid is committed to getting this done "by any legislative means necessary." And that certainly includes ignoring the intent and spirit of the reconciliation rule—which is only supposed to deal with budget resolutions.

As a result, the normal rules are likely to be circumvented, and Congress will try any underhanded, backroom maneuver possible to get government-run health care without any opportunity for a filibuster.

The worst part is, there may not be a thing that Senators opposed will be able to do to stop it.

That is, unless the American people make their voices heard and let members of Congress know that it is they who will be rolling the dice with their political careers should they go along with this subversion of the time-honored filibuster.

Concerned Americans need to specifically let Senate Republicans know they must not cave into Harry Reid's ultimatum and sign on to any mealy-mouthed compromise. If they hold the line, it is Reid and his caucus who will pay the price for this coup, and not they.


Health Care Rationing: Its No Myth!

By Victor Morawski

I awoke one morning last week, as I often do, with my clock radio playing The Wall Street Journal Report. A representative of the AARP was being interviewed. When asked whether his organization had concerns about rationing of health care to senior citizens, he assured the reporter that rationing is just a myth being perpetrated by the opponents of health care reform.

This, of course, does not fit other analyses I have read on the issue. Nor, I might add, does it fit the truth. Reading the bill carefully (something one or two members of Congress might consider doing) makes it clear to me that, if a public option is out there, health care rationing is no myth. And senior citizens better beware.

Rationing decisions, like those made within Britain’s National Health Service, are made within a system that both guides and ethically justifies them. So, let’s take a quick look at two such rationing systems. The first is currently in use in Great Britain and was recently defended by Obama Health Care Team member Dr. Peter Singer. The second was proposed by Dr. Ezekiel Emanuel, Obama’s top health care advisors.

What will become unmistakably clear is just how heavily these two systems are weighted against the interests of the elderly.

1. The QALY System

Peter Singer, in his New York Times Magazine article “Why We Must Ration Health Care” (July 19, 2009) has boldly claimed: “The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?”

Now, one might think that the chief good promoted by health care is the saving of lives---a good that we could easily measure in terms of the number of lives saved. If this were so, then presumably saving the life of an 85-year-old would count as much as saving the life of a teenager, both reflecting an instance of a life saved.

But this way of looking at things is “too crude” for both Singer and the British NHS [National Health Service] because it doesn’t reflect our basic intuition that the death of a teenager is a greater tragedy than the death of an 85-year-old. What government should really aim for, Singer and his ilk contend, is not saving lives, but life-years.

If we save the life of a teenager who could normally be expected to live another 70 years then we have saved 70 life-years. On the other hand, if we save the life of an 85-year-old, who could normally be expected to live only another five years, then we have saved only five life-years. “That suggests,” says Singer, “that saving one teenager is equivalent to saving fourteen 85-year-olds.” A perspective, which obviously gives the elderly little chance when it comes to the allocation of health care Singer and Obama advocate.

2. The Complete Lives System

As chilling as Singers’s views are, those of top Obama health care advisor, Ezekial Emanuel, may be even more devastating. In a Lancet article entitled “Principles for allocation of scarce medical interventions” Emanuel proposes what he and his colleagues call “the complete lives system.”

The only problem is: it empowers those in government to decide who lives and who dies by determining who is really living – or, could yet live -- what they determine is a “complete life.” And by “complete,” they mean both the quality of life and the length of years.

Emanuel and his co-authors concede that their system “prioritizes younger people who have not yet lived a complete life and will be unlikely to do so without aid.” And they make no apology for this. While some things might constitute ageism---treating the elderly “differently because of stereotypes or falsehoods”…“treating them differently because they have already had more life years” would not.

So, there you have it. And so, really, does AARP – though they will likely never admit it. Both Barack Obama’s top health care advisor, Ezekiel Emanuel (who also happens to be the brother of Obama’s Chief of Staff) and one of his foremost Health Care Team members, Peter Singer, have come our foursquare for rationing health care. Perhaps the only silver lining for the elderly is that if the bill passes in its present form, you won’t have to worry about it – for long.


Catch me if you can

Last week, Barack Obama treated us to a traveling road show crusading for his heath care overhaul plan. But what he actually said at those staged, orchestrated, town halls packed with his fervent supporters was so unhinged from the reality of the Congressional legislation he is supporting that he must have consciously decided to challenge us all with the dare: "Catch me if you can."

President Obama keeps repeating over and over that his plan does not include any cuts in Medicare. But the legislation he is supporting specifies $500 billion in reduced funding for Medicare, scored by CBO. When arguing that his health overhaul is paid for, he wants credit for these cuts. But when challenged, he wants to deny before the whole country in broad daylight that he is doing it. I can't recall any precedent for such a Presidential disconnect from reality.

In trying to deny these Medicare cuts, President Obama said at one town hall that AARP had endorsed his plan. He said, "AARP would not be endorsing a bill if it was undermining Medicare, okay?" But just the night before, AARP was on national television denying that it had endorsed the Obama health plan. It issued a press release saying the same just after Obama's town hall misstatement.

President Obama also repeats over and over in these town halls that his health plan will reduce health costs, thereby reducing federal spending and deficits. But CBO, which is now in complete control of the Democrat Congressional majorities, says just the opposite. It says the Obama health overhaul plan will increase federal spending by close to a trillion dollars or more, and increase the federal deficit by hundreds of billions. On health costs, CBO Director Doug Elmendorf told Congress,

In the legislation that has been reported we don't see the sort of fundamental changes that would be necessary to reduce the trajectory of federal spending by a significant amount…[O]n the contrary, the legislation significantly expands the federal responsibility for health costs….[The government public option for health insurance] raises the amount of [spending] that is growing at this unsustainable rate.

And here's a dirty little secret. The CBO surely underestimates the costs of the Obama health plan, just as it regularly does for new government programs, health programs in particular. The official government estimates for Medicare when it was adopted in 1965 projected that the program would cost only $12 billion by 1990. But the actual costs of the program by that year were $109.7 billion, nine times larger than the original estimate.

Independent private estimates have ranged far higher than what CBO projects. HSI Network used its proprietary ARCOLA simulation model to estimate that the House bill would cost $3.5 trillion in additional federal spending alone over 10 years. HSI estimates that the Senate bill would cost $4.1 trillion over 10 years. These estimates seem far more realistic than the CBO estimates. In my study of the Obama health plan for the Heartland Institute, I explain in thorough detail how and why the Obama health overhaul will raise rather than lower health costs.

But in the town halls, President Obama just goes from bad to worse. In Colorado on Saturday, President Obama even suggested that his health overhaul scheme would "bend the cost curve," reducing "health care inflation" so much that the enormous long-term deficit of Medicare (unfunded liability: $89 trillion) would be eliminated! He said that without his health overhaul plan, "We'll either have to cut Medicare, in which case seniors then will bear the brunt of it, or we'll have to raise taxes, which nobody likes." But the CBO has never ever come anywhere near to confirming anything like this. This is just abusive…

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