Wednesday, September 16, 2009

More NHS arrogance and negligence

Treatment was "negative, unhelpful, almost inhuman"

Two devastating strokes had left him paralysed and barely able to speak, let alone feed himself. Following surgery to stop further bleeding on the brain, pop star Edwyn Collins also developed an MRSA infection. There was no denying he was desperately unwell - yet, once he was out of intensive care, he found his problems had only just begun.

The singer, who'd written the global hit A Girl Like You, spent six months in hospital. And while his family have nothing but praise for the emergency health care he received, they were alarmed and frightened by the neglect he and other chronically ill patients suffered on the wards afterwards.

'I'd come in at the beginning of visiting hours and Ed would be filthy, with an oozing head wound that was encrusted with muck, and then I'd find he hadn't been given his antibiotic,' recalls Grace Maxwell, Edwyn's partner and manager for more than 20 years. 'We saw the NHS at its brilliant best when Ed's life was in danger. But the less-glamorous, long-term therapeutic care was scarily inconsistent. And when I tried to step in and help, the nurses' response was: "Don't tell us how to do our job."

When she tried to find out more about Edwyn's treatment, the clinicians also seemed to take it as a challenge to their authority. Doctors were 'aloof, imperious, brusque - you had to screw up all your courage to persist with your questions, to face them down' - while nurses routinely treated her 'as a nuisance, as though I was making trouble for the sake of it,' she says.

In particular, no one seemed interested in treating Edwyn's aphasia, a relatively common stroke-related condition that left him unable to use or understand language. 'I have read the so-called "evidence" that people with aphasia almost never improve after the first six months,' says Grace. 'Yet no one seems to ask the question: why? What sort of therapy were these people getting? Were they feeling marginalised and withdrawn? Is that why they made no progress?'

Faced with a beloved partner apparently consigned to the scrap heap, Grace felt she had no choice but to quickly learn to play the system, using a mixture of heavy-handed buttering-up of ward staff, along with occasionally 'blowing my stack' to ensure that Edwyn's care was adequate.

Once, when Edwyn managed to yank out his much-hated feeding tube late on a Friday afternoon, it was Grace who discovered he was being put at the end of a queue to get it replaced with specialist equipment - and that if he wasn't seen quickly, he faced the risk of a weekend without food, water or drugs.

Unable to convince the junior doctor of the urgency of the situation, she recalls: 'I hauled that doctor into the corridor and threatened to go up like a rocket in a way that would completely spoil his boss's weekend.'

And when she found there was no prospect of Edwyn getting speech and language therapy for his aphasia on the stroke unit, Grace sweet-talked the ward sister to allow her to bring in a private therapist every week.

Then when another ward sister on the rehabilitation unit told her there was no possibility of switching off the heating on a boiling hot May day 'even though all the patients would soon be on drips for dehydration', Grace phoned the hospital press office and threatened to call the media. 'Heat off by close of play. Staff amazed,' she noted in her diary.

Yet she didn't always win. The rehabilitation ward's 'seemingly arbitrary' ban on visitors until 4pm was intractable because of the 'intensive' rehabilitation patients were undergoing - even though this turned out to involve long periods of inactivity, with only one or two 45-minute therapy sessions a day. Indeed, by the time she arrived, Edwyn would be mentally 'climbing the walls', having been woken at 6.30am and then spending endless hours marooned in a wheelchair, prevented by his condition from reading or even switching on his Walkman to pass the time.

'If I hadn't been there, battling daily on his behalf, I can't help feeling Ed might not have survived,' Grace says. 'I had to use every trick in the book to make sure he was looked after properly, for ever biting my tongue to avoid a stand-off with staff. I'd see other families having fierce rows with ward staff often enough to know that it was the worst possible thing to do.'

This kind of exhausting tightrope act will be familiar to anyone whose loved one has spent a long time in hospital. Not only is there the stress and anxiety of their illness to deal with, but the feeling that, as far as many medics go, you're just an irritation.

In fact, this goes against the long-established principle that hospital patients recover faster when their loved ones are involved in their care. In the mid-Eighties a key study by the Harvard Medical School showed that people get better more quickly when they are treated as human beings 'with acknowledged social and emotional needs' - and central to this is the daily involvement of family and friends.

This is something experts in the UK acknowledge. 'Patients recover more rapidly when they are less anxious, and that's more likely to happen when their relatives are involved in their care,' says Jocelyn Cornwell, director of the Point of Care programme run by the NHS think-tank the King's Fund. 'We know that is true for children in long-term care in hospital as well as in obstetrics, intensive care and post-surgery. I believe the involvement of relatives is crucial to the wellbeing of all patients in long-term care.'

Dr Mike Dixon, chair of the NHS Alliance, agrees, adding: 'Hospital patients today need their relatives to be there for them both as advocates and as daily carers more than ever before. Yet this growing concern about poor nursing seems to be making hospital staff ever more defensive in the face of criticism from relatives.'

Sometimes, however, relatives are able to provide care for their loved one almost by default. Diana Jakubowska, 57, from Cambridge, was shocked by the poor standard of nursing care when she spent three months in hospital with Guillain-Barre syndrome. 'The nursing staff were simply not interested in looking after their patients, whether because they didn't have time or they didn't care,' she recalls.

Diana's sister visited every day after work, staying until the late evening, despite having three young children. 'Hearing my sister's heels clip-clopping along the corridor was the best noise in the world. These daily visits reminded me I was a human being with a wonderful life that was waiting for me. With my family, there was never any question that I would not get better - yet I never once got that feeling from the nurses.'

It wasn't just the psychological boost this provided, but the actual care she received from her sister that made all the difference. 'Without her help I sometimes wouldn't have had my teeth brushed or my body washed,' says Diana.

The King's Fund Point of Care programme is testing ways to encourage the involvement by patients' relatives. 'We know there are no easy solutions.' says Jocelyn Cornwell. 'Nurses already feel plagued by fielding constant telephone calls from relatives. And while each family is focused on getting the best care for their own loved one, the nurse has to juggle equally important demands from all the patients on the ward.'

The answer, she says, is for staff to learn to put themselves in the shoes of those families. 'It took decades of campaigning before parents of children were made welcome in long-stay paediatric wards. It mustn't take so long with equally vulnerable adults.'

For Grace Maxwell, it wasn't simply a case of being welcomed, but actually taking on elements of Edywn's care. 'The doctors were telling me there was no chance of him having any meaningful recovery. Of course, I didn't accept that for a minute.' She refused to believe that more couldn't be done to restore the man she'd met in the mid-Eighties when he'd been the idol of the pop scene, celebrated for his songs, dandy looks and scathing wit, as she puts it.

Grace worked with the speech and language therapist, bringing in a flask of ice to stimulate sensation on the right-hand side of Edwyn's face and showing flash cards. 'Mostly, I would talk to him lots and lots.' More practically, she developed a new competence in 'changing the sheets on a bed with an immobile 6ft 1in man still in it' and becoming 'an expert shaver of a man's face'.

She noted with delight his first whispered sentence - 'Be careful with William' - a reference to their son, now 19, and a signal that both Edwyn's language and sense of family was returning. But his recovery was far from easy. Despite her efforts, when he was discharged from hospital in September 2005, Edwyn appeared to have made little progress: he was still barely able to speak, couldn't walk read or write and was unable to recognise his own home from the outside.

And so Grace insisted on a regimented programme of 'stimulus overload all the way', including speech therapy, regular walks and daily reading lessons, starting with infant readers' material. And an extraordinary 18 months later, Edwyn was back on stage, at Camden Lock in North London, earning five-star reviews for singing favourites from his repertoire.

Four years after leaving hospital, he remains partly paralysed on his right side, but sufficiently mobile to tour with his band, reliant only an elegant silver-topped stick, with eight new songs already written and plans for the future.

He is lucky, says Grace, to have been able to afford extra therapy and to have the family and friends to provide the support. But she knows only too well that the plans for new songs and tours and the fact that 'these days, we walk in the sun' is largely down to her determination to be an effective partner in his longterm hospital care. 'We are grateful for Edwyn's treatment in hospital,' says Grace. 'But large parts of it were negative, unhelpful, almost inhuman. Without me to fight his corner, our lives would be incomparably worse today.'


Can Obama force you to buy health insurance?

Nothing in the Constitution allows the individual mandate he proposes

Many liberals lambasted the Bush administration on detention policy and warrantless surveillance, often arguing that they violated the Constitution. Now the Obama administration is pushing ahead with plans to require every American to purchase health insurance.

Doesn't that also violate the Constitution?

The Constitution created a federal government limited to its enumerated powers. Everything Congress is allowed to do is spelled out in Article I. The 10th Amendment makes it explicit: "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

Nothing in the Constitution authorizes any federal involvement in healthcare – yet Congress may soon require everyone in America to buy insurance.

Admittedly, the Supreme Court has ruled that the language empowering Congress to "regulate Commerce ... among the several States" applies to an ever-broadening range of activity. The "commerce" clause was originally intended to prohibit interstate tariffs, a supposed problem under the Articles of Confederation.

Ironically, consumers today cannot freely buy health insurance from across state lines. If there's any legitimate application of the "commerce" clause, it would be to overturn such restrictions. But the framers never gave Congress the general power to regulate industry.

In the 1935 case Schecter v. United States, involving farming regulations, the court unanimously struck down parts of the National Industrial Recovery Act for overstepping Congress's commerce power. Liberal Justice Louis Brandeis informed one of President Franklin Roosevelt's aides to "tell the president that we're not going to let this government centralize everything."

The next year, the court ruled in Butler v. United States that elements of the Agricultural Adjustment Act, which inflated food prices by restricting supply, violated the 10th Amendment.

After FDR threatened to pack the court with additional judges friendly to the New Deal, the court lost its spine. In 1937, it upheld the National Labor Relations Act – which greatly expanded the power of labor unions and greatly diminished the freedom of contract – under the "commerce" clause.

In Wickard v. Filburn (1942) the justices even upheld the conviction of a man for growing too much wheat on his farm. The court reasoned that even wheat grown solely for private consumption ultimately had an impact on the economy, turning the "commerce" clause into a regulatory rubber stamp.

The "commerce" clause is now interpreted very broadly. Although in United States v. Lopez (1995) the court struck down a firearms law that exceeded Congress's commerce power, it ruled 10 years later in Gonzales v. Raich that federal drug policy overrode California's medical marijuana laws, despite the 10th Amendment.

Justice Clarence Thomas dissented: "If the Federal Government can regulate growing a half-dozen cannabis plants for personal consumption (not because it is interstate commerce, but because it is inextricably bound up with interstate commerce), then Congress' Article I powers … have no meaningful limits." Indeed, practically nothing is beyond the pale anymore.

Then there is the privacy issue. In Griswold v. Connecticut (1965), Roe v. Wade (1973), and Planned Parenthood v. Casey (1992) the court found reproductive freedom to be guaranteed as an implicit right to privacy. In Casey, the court reasoned that abortion entailed "the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy," and that such choices are "central to the liberty protected by the 14th Amendment."

Why wouldn't this apply to the right to decide whether to buy health insurance?

Other constitutional concerns emerge. The mass collection of medical data likely to occur under proposed reforms threatens the Fourth Amendment's "right of the people to be secure in their persons, houses, papers, and effects." Making it a crime not to buy insurance, and then forcing people to show they have not bought it, arguably clashes with the Fifth Amendment's protection against self-incrimination.

The Ninth Amendment reserves to individuals all rights not expressly denied by the Constitution. Nothing in the document curtails our right not to purchase health insurance. And being forced to fill out forms to apply for insurance is in tension with the 13th Amendment's prohibition of "involuntary servitude."

The quality we could expect from government care may also raise constitutional questions. In early August, a federal panel ordered California to release 40,000 inmates because the health services were so strained, causing one unnecessary prisoner death per week, so as to render the treatment "unconstitutional." If we all become captive consumers under federal mandate, could we not similarly argue that any shoddiness in our mandated health services is an unconstitutional burden?

Those who find such constitutional arguments unconvincing are often quick to invoke them against policies they oppose. Similarly, some of today's critics of President Obama and national healthcare brandish the Constitution as a holy document, but were silent when President George W.Bush trampled its many limitations on executive power, and even signed an expansion of Medicare.

A newfound, consistent, and lasting respect for the Constitution, across the ideological spectrum, would renew the health of our republic like nothing else.


Compulsive Disorder

During the Democratic presidential primaries, Barack Obama argued against forcing people to buy health insurance. But on Wednesday night, he flip-flopped and endorsed the idea.

President Obama argued that people who do not have insurance raise the premiums of those who do. But careful analyses of this effect — notably that of the Democrat-controlled Congressional Budget Office — suggest that it is minuscule. (Some of the uninsured, by paying out of pocket for medical expenses, actually subsidize the rest of us.) Obama’s solution to this modest cost shifting would increase premiums far more than ignoring it, for requiring everyone to purchase health insurance would lead to a lobbying free-for-all. The experience of state regulation strongly suggests that producer interests would overwhelm consumer interests: People would pay high premiums for coverage they may not need or want, such as coverage for drug abuse.

The effect would be a tax increase for millions of people. People who have turned down their employer’s offer of health coverage in favor of higher wages would be forced to take a pay cut. Because of the predictable effects of lobbying, even those who already have insurance would be forced to part with more and more money to pay for more expensive insurance.

The president has another reason for favoring compulsion. He seeks regulations on the insurance industry that will not work unless people are forced to buy its products. If insurers have to charge the same price to all comers regardless of their health status, healthy people will have no reason to sign up. They will instead wait until they get sick and get charged the same rate. But if only sick people buy insurance, premiums will skyrocket. Insurance markets will collapse.

An order for all people to buy insurance would not so much prevent that collapse as disguise it. Once insurance companies have to sell policies to sick people and healthy people at the same rates — or to put it another way, once people are no longer allowed to buy insurance policies that give them a discount for being healthy — those policies are no longer insurance against the risk of getting sick. What “insurance companies” would instead be selling is a share of the nation’s medical resources. Viewed from this angle, the same need for compulsion presents itself. If you think that you are likely to cost less than your share of the nation’s medical expenses, and you have freedom, you may reject this bad deal. But if only the people who expect they will have higher than average medical expenses take the deal, again, the system becomes untenable. The president wants insurance to be structured in a way that cannot arise in conditions of freedom. Hence those conditions must be revoked.

Obama drew an analogy between compulsory health insurance and compulsory auto insurance. But never before has the federal government required the purchase of a product as a condition for lawful residence in this country. (No state actually forces anyone to buy a car.) An individual mandate would be an extension of federal power that raises serious constitutional issues. It may even be said that while the “public option” — the proposal, that is, for a government-run insurance program — has caused the most controversy for its socialistic aspects, it is the mandate that most clearly exposes the coercive nature of the liberal version of health-care reform.

It is not as though we had no alternative. If we want to reduce the tiny amount of cost shifting that the federal government’s requirement that all people be able to get emergency care entails, we could enable young and healthy people to purchase cheap policies to insure them against catastrophic events. Obama prefers to mulct them in order to advance his ideological agenda. There is no reason for the rest of us to share this preference.

Obama’s opposition to a mandate in 2008 did not keep him from winning majorities among Democratic voters, who make up the portion of the electorate most enthusiastic about health regulation. Congressmen and senators can oppose this coercion without any fear of adverse political consequences, and should. Republicans, in particular, have in the past voted unanimously against tax increases much less egregious than this one. If the administration has to give up the “public option,” it will merely have to settle for socialized medicine on a longer time frame. Abandoning the individual mandate would truly force it to scrap its plan and start over, as the country seems to want and the public interest requires.


Listening to a Liar (again)

By Thomas Sowell

"Hubris-laden charlatans" was the way a recent e-mail from a reader characterized the Obama administration. That phrase seems especially appropriate for the Charlatan-in-Chief, Barack Obama, whose speech to a joint session of Congress was both a masterpiece of rhetoric and a shameless fraud.

To tell us, with a straight face, that he can insure millions more people without adding to the already skyrocketing deficit, is world-class chutzpa and an insult to anyone's intelligence. To do so after an analysis by the Congressional Budget Office has already showed this to be impossible reveals the depths of moral bankruptcy behind the glittering words.

Did we really need CBO experts to tell us that there is no free lunch? Some people probably did and the true believers in the Obama cult may still believe the President, instead of believing either common sense or budget experts.

Even those who can believe that Obama can conjure up the money through eliminating "waste, fraud and abuse" should ask themselves where he is going to conjure up the additional doctors, nurses, and hospitals needed to take care of millions more patients.

If he can't pull off that miracle, then government-run medical care in the United States can be expected to produce what government-run medical care in Canada, Britain, and other countries has produced-- delays of weeks or months to get many treatments, not to mention arbitrary rationing decisions by bureaucrats.

Obama can deny it in words but what matters are deeds-- and no one's words have been more repeatedly the direct opposite of his deeds-- whether talking about how his election campaign would be financed, how he would not rush legislation through Congress, or how his administration was not going to go after CIA agents for their past efforts to extract information from captured terrorists.

President Obama has also declared emphatically that he will not interfere in the internal affairs of other nations-- while telling the Israelis where they can and cannot build settlements and telling the Hondurans whom they should and should not choose to be their president.

One of the secrets of being a glib talker is not getting hung up over whether what you are saying is true, and instead giving your full attention to what is required by the audience and the circumstances of the moment, without letting facts get in your way and cramp your style. Obama has mastered that art.

Con men understand that their job is not to use facts to convince skeptics but to use words to help the gullible to believe what they want to believe. No message has been more welcomed by the gullible, in countries around the world, than the promise of something for nothing. That is the core of Barack Obama's medical care plan.

President Obama tells us that he will impose various mandates on insurance companies but will not interfere with our free choice between being insured by these companies or by the government. But if he can drive up the cost of private insurance with mandates and subsidize government insurance with the taxpayers' money, how long do you think it will be before we have the "single payer" system has he has advocated in the past?

Mandates by politicians are what have driven up the cost of insurance already. Politicians love to play Santa Claus and leave it to others to raise prices to cover the inevitable costs.

Politicians have driven privately owned municipal transit systems out of business in many cities, by simply imposing costs and restricting the fare increases needed to cover those costs. The federal government can drive out private insurance the same way that local politicians have driven out private municipal transit and replaced it with government-run transit systems.

Barack Obama's insistence that various dangerous policies are not in the legislation he proposes sounds good but means nothing. Unbridled power is a blank check, no matter what its rationale may be. No law gave the President of the United States the power to fire the head of General Motors, but TARP money did.

When there are "advisory" panels on what treatments to approve and the White House's existing medical advisor has complained of Americans' "over-utilization" of medical care, what does it take to connect the dots?


International Health Care Comparisons: The WHO Numbers

In the course of the healthcare debate, supporters of change along the lines proposed by the administration have called attention to a World Health Organization study ranking the health care systems of 192 nations. A common claim is that the U.S., despite spending more per capita than any other country, still ranks only 37, behind most developed countries.

That version of the claim is at best misleading. There is a measure, "Overall Health System Performance," on which the U.S. ranks 37. But it is a measure that takes expenditure into account, downrating the U.S. precisely because it spends so much. The rank is 37 not in spite of the level of expenditure but because of it.

There is another measure, "Overall Goal Attainment," which does not take account of expenditure; on that the U.S. ranks 15, still behind a fair number of other countries but not nearly as many. So a more accurate claim would be that the U.S. ranks 15 despite its large expenditures.

Even that is misleading, however, because if one actually read the notes explaining how the numbers are calculated it turns out that "Goal Attainment" is based on five different characteristics of a health care system, only one of which is an (imperfect) measure of how much health care the system provides.

That one, "Health level," is average life expectancy, adjusted to make a disabled year count for less than a healthy year. It is an imperfect measure because life expectancy depends not only on health care but on lifestyle variables such as smoking or obesity and on factors such as the death rate from murders and traffic accidents. And even to the extent that it depends on health, health is not entirely a matter of health care; some environments are more unhealthy than others.

A second variable, responsiveness, measures how good people in each country think their health care system is, as determined by questionaires. On that one, interestingly enough, the U.S. comes in first —a fact that ought to worry the President. If Americans think the current system works better than any existing alternative, as they apparently do, they may not look favorably on changes to it.

The other variables all have to do with distribution. "Health distribution" purports to measure how unequal the distribution of health care in each country is. The authors wanted to use distribution of life expectancy but didn't have the data to do it. Instead they used a measure, never clearly explained, of the distribution of infant survival, apparently of how many infants die at what point in their first five years. Even for that, the relevant data existed for only a minority of countries; for the rest the report substituted an estimate based on variables such as poverty level.

"Responsiveness distribution" was calculated from questionaires and apparently designed to measure the degree to which respondents believed that various groups in their country were disadvantaged with regard to health care.

Finally, we have "fairness in financial contribution," defined as how nearly health costs are distributed in proportion to income minus the cost of food. That measure is obviously biased in favor of state run health care plans, since in order for both health care and its cost to be distributed in the way the authors of the report want there has to be a sizable redistribution of cost from poorer families getting health care to richer families paying for it.

My conclusion is that the numbers produced by the report are very nearly useless for purposes other than propaganda, since they do not provide much information on how good the health care systems of different countries are at delivering health care.

In fairness, I should add that I don't have any proposal for doing a much better job of comparing international health care systems, given the data limitations when trying to look at 192 different countries. Ideally, one would want a value added measure, something like the difference between actual life expectancy in a country and what life expectancy would be if there were no health care system at all. But I don't see any practical way of generating such numbers. One could simply use life expectancy, but that has the problems I have already described. One can try to look at particular outcomes heavily dependent on health care; the U.S. apparently does very well measured by cancer survival rates. But neither approach really tells you what you want to know.


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