Tuesday, October 20, 2009

British hospital trusts launch 'sinister' bid to reduce funding for more than 100 life-saving drugs

Health trusts are trying to reduce the number of life-saving drugs pioneered on the NHS, it was claimed yesterday. A number have joined a lobby group suspected of seeking to influence the type of treatments endorsed by rationing body NICE. The lobby group, the Commissioning Support Appraisals Service, is urging primary care trusts to sign up because they are under the pressure of 'tightening budgets'. It points out that they have to fund new drugs out of existing reserves, possibly at the expense of existing treatments. A promotional letter sent to the top managers of every primary trust suggests that more than 100 life-saving cancer drugs are in the pipeline.

The lobby group's actions are controversial because NICE is supposed to be independent of the Health Service and government. Health campaigners said it was wrong to waste public money on 'sinister' lobbying activities. Kate Spall, head of the Pamela Northcott Fund, which campaigns on cancer drugs, said: 'The subtext of the organisation seems to be to lobby NICE to ensure less cancer treatments are approved nationally. 'But believe me, NICE needs no encouragement to deny cancer treatments - they're doing a great job doing just that. 'Why aren't the managers lobbying the Government for extra funding for cancer treatments instead of fighting to ensure they are not approved? 'No wonder we have the worst access to treatment in Europe.'

Andrew Lansley, Tory health spokesman, said: 'It is extremely concerning that the Government has allowed NHS bodies to band together to spend taxpayers' money on a group whose intention seems to be to stop patients getting the life-saving drugs they need. 'It is utterly perverse when this money should be being spent on treating patients. 'The job of NICE is to undertake appraisals and offer advice on the basis of evidence not on the basis of lobbying. 'The last thing I want to see is primary care trusts using scarce NHS money to try and influence NICE appraisals into turning down what could be life-saving drugs. 'If they have clinical evidence to offer that is one thing, but if not they should stick to their job of providing services and treatments to the patients that need them.'

Professor Karol Sikora, a cancer specialist, said: 'The real tragedy is that we are so far behind Europe already that to put more restrictions on cancer drugs will make us fall even further behind. 'It's a crazy system of rationing, especially when PCTs have to fund newly-approved drugs out of existing budgets. 'But they should be pushing for more money - not trying to make the system work better for them.'

Andrew Wilson-Webb of the Rarer Cancers Forum said: 'NICE's job is to provide independent advice to the NHS. 'It is outrageous if NHS bodies try to influence this process by stealth.'

A spokesman for the Department of Health said: 'NICE invites patients, clinicians, manufacturers and primary care trusts to take part in consultations as it develops technology appraisal guidance. 'It is important that all these stakeholders engage in the process to ensure that the best possible decisions are made. The Commissioning Support Appraisals Service exists to help primary care trusts do this. 'NICE is an independent body which follows rigorous and transparent processes to consider all the available evidence and make the final decision on its guidance.' NICE declined to comment.


Staffing shortages compromising patient care, warn British nurses

More than half of the RCN's members, 55 per cent, find they cannot provide the level of care they want to because they are so busy and the same number say there aren't enough staff to meet patient needs. And two thirds, 61 per cent, of NHS nurses say their workload is too heavy and they are under too much pressure.

The RCN is today calling for all political parties to commit to guaranteeing safe staffing levels for all nursing shifts. They are issuing a manifesto, ahead of the coming general election, with a series of demands including giving nurses time to train, regulating the drinks industry and improving care for those with long-term health conditions.

Dr Peter Carter, head of the RCN, said: ''Today's report shows that nurses and healthcare assistants feel up against it; worn down and exhausted by the pressure to make efficiencies and frustrated by being prevented from delivering the quality of care they want to be providing. Staff are concerned that they are delivering the basics but are unable to provide the full range of quality care they would like. ''With an average of 1,800 nurses and health care assistants in each constituency, politicians of all parties must pay attention to our call for safer staffing levels and sustained investment in the NHS.''

The RCN's annual survey of nurses also found that with 200,000 nurses expected to retire in the next ten years and fewer nurses entering training the number of trained nurses available in the UK could fall.

Dr Carter said: ''The nursing workforce has grown in recent years but only just enough to keep up with rising demands on healthcare. We expect the next few years will be the most challenging for staff levels in decades, especially with the drive to provide more services in the community. ''There is considerable pressure to focus on short-term funding constraints and cut staff numbers without taking patient needs into consideration. However, policy makers must look at workforce in conjunction with ability to deliver high quality and safe care. As we've seen too often, where there are not enough nurses, patient care suffers.''


Majorcan hospitals a surprise for the English

What a difference extensive private medicine makes! Majorca (Mallorca) is a Spanish island in the Mediterranean which has a huge tourist industry

My son’s headmaster was on the blower. It was a Friday afternoon and the prognosis wasn’t great. Ollie had fallen during a sports lesson and his ankle had apparently swollen to the size of a tennis ball. We whizzed off to the school, stopping en route at the airport to pick up Sarah, a friend staying for the weekend, who happens to be a nurse. Palma has more hospitals than you can shake a thermometer at and since we’re entitled to use both state and private healthcare, we’re spoilt for choice.

Many Majorcans, even those on modest incomes, like to have state and private health care and at about half the cost of the UK or less, going private is a very affordable option.

We decided on the nearest hospital to our location and dashed in to paediatric accident and emergency. A smiling receptionist led us over to a state of the art children’s game consul and play area where she asked Ollie to wait until the doctor came. Only a few other patients were sitting in the palatial, marble tiled waiting zone.

A few minutes later a nurse arrived and carefully examined Ollie’s foot in a spotlessly clean surgery. She suggested x-rays. A charming young doctor arrived, had a chirpy conversation with Ollie about football and began examining him from head to toe. He wanted to check he hadn’t hurt his head in the fall. Two radiographers appeared with an English interpreter – just in case our Spanish wasn’t up to medical phraseology – and finally another doctor to give his verdict post the x-rays, and a prescription. A motherly nurse then bandaged up Ollie’s foot, pinching his cheek and telling him he’d be back on the playing field before he knew it. In just 45 minutes Ollie was x-rayed, diagnosed and treated.

As always we took this exemplary service in our stride but Sarah, a nurse at a busy NHS teaching hospital in London, was in some shock. “Am I dreaming?” she asked at least twice. We took her to the hospital out-patient canteen to recover. “I think I’ll have a red wine since it’s a Friday night,” my husband said cheerfully. The counter staff shared a joke with him and then asked politely whether he’d like his wine at room temperature or chilled. “You’d be lucky to get a cup of tepid tea in our hospital,” Sarah said.

On a roll, the next day we popped by out local state run medical centre in Sóller which offers a 24/7 service to its patients. We wanted to show Sarah a typical Majorcan local surgery. The receptionist chuckled when he saw Ollie’s bandaged foot. “What have you been up to my Ronaldo, too much football?” One of the doctors we know walked by, stopped and came back to shake our hands. “Do you need to see me?” he asked with some concern. “We’ve only got a few patients in the waiting room if you can hang on ten minutes.”

We explained that we’d already been to a hospital in Palma but wanted to show our friend around the clinic. “Be my guest,” he beamed. “We’re a humble clinic but we offer the best we can and it’s rare to wait longer than fifteen minutes for an appointment.”

Sarah wanted to know if the clinic had x-ray equipment. The doctor explained that if x-rays were needed an ambulance was called immediately to take patients to the nearest hospital. “It’s all part of the service,” he said. “We also have multi-lingual staff to deal with expat residents.”

She left the clinic reeling. “How,” she asked, “have the Majorcans got it so right?”


Gag Order Admission

Humana gets a slap on the wrist for disseminating TRUE information

There's nothing like a Friday evening news release to hide a Washington embarrassment. In last week's episode, President Obama's health appointees lifted their outrageous gag order against health insurers for the sin of informing their customers about how ObamaCare would affect their insurance.

In September, Humana Inc. sent a mailer to some 900,000 enrollees in its Medicare Advantage plans, the program that gives seniors a choice of private insurance options, warning that spending cuts would result in reduced benefits and some people losing their coverage. The Congressional Budget Office has said the same thing, but the Obama apparat went nuclear. At the behest of Senate Finance Chairman Max Baucus, Medicare's administrators menaced Humana with fines and regulatory punishments, and even told all insurers participating in Advantage to shut up too—or else.

In its Friday ruling, Medicare slapped Humana on the wrist for disseminating information that it claimed was "misleading to beneficiaries"—even though it was perfectly true—but also lifted the gag order. Insurers will be allowed to communicate with enrollees, provided they get permission. This is basically a concession that the critics are right, especially considering that Health and Human Services Secretary Kathleen Sebelius defended the policy as recently as two weeks ago while refusing to answer questions about this raw political coercion from a supposedly impartial federal bureaucracy.

Meanwhile, the Administration is now threatening to strip the insurance industry of its decades-long exemption from antitrust law. This would blow a hole in the industry's profitability, as would ObamaCare for different reasons. The industry now faces a choice of playing ball with Democrats and getting punished, or trying to defeat the bill and being brutalized as an act of political revenge. This is the industry's reward for spending millions to promote "reform" in the hopes of not becoming a political target. It's still a target, and now it's poised to lose the policy fight too.


'Expert Panels' Won't Improve Health Care

Government reliance on medical studies will make it harder to discard false prophecies and dogmas, says Dr. NORBERT GLEICHER. If only people in general knew how poor the quality of medical expertise really is and how common false prophecies and dogmas really are. For regular coverage of the nonsense that passes as medical wisdom, see FOOD & HEALTH SKEPTIC -- JR

At a town-hall meeting in New Hampshire this summer, President Barack Obama explained why government "expert panels" are an essential part to overhauling the health-care system. Right now the United States spends $6,000 more per person each year than other advanced nations and isn't healthier for it. He said these panels would reduce wasteful spending by providing "guidelines" for doctors on which procedures to perform.

His panels are now part of legislation moving in Congress. But the idea of inserting a government panel between patients and physicians remains contentious and with good reason. Inevitably, the panels' guidelines will come to be seen as the industry's "best practices" and would therefore be adopted as a blueprint for which procedures health insurance should cover.

The idea of creating expert panels has a certain logic to it. After all, who is better qualified to determine best medical practices than medical experts? The medical field itself has been edging toward a similar approach in recent years with "evidence based medicine," an approach that assumes it is possible to determine what works and what doesn't by reviewing published medical literature.

Evidence-based medicine has some value, but it can provide misleading information. Determining which studies to review, for example, can introduce biases. Whether investigators accept published data at face value or repeat primary data analyses also matters. If the data in a published study were poorly analyzed or, for argument's sake, completely invented, relying on it can lead to faulty conclusions. It's an unfortunate reality, but our medical literature is significantly contaminated by poorly conducted studies, inappropriate statistical methodologies, and sometimes scientific fraud.

Of course evidence-based data can be useful. But I have seen firsthand how it can be dangerous.

Several years ago I grew concerned about my postmenopausal mother's risk of osteoporosis. I tried to convince her to initiate hormone replacement therapy. She didn't listen to me. Instead, she spoke with her gynecologist, who —contrary to best medical evidence at the time— recommended against such treatment. I would eventually be thankful my mother listened to the gynecologist who had known her for decades instead of me and the published medical reviews I was relying on. Some years later my mother was diagnosed with early breast cancer. Had she been on estrogen replacement, it is likely that her tumor would have progressed more rapidly. The gynecologist likely saved my mother's life.

Studies published in the medical literature are mostly produced by academics who face an imperative to publish or watch their careers perish. These academics aren't basing their careers on their clinical skills and experiences. Paradoxically, if we allow the academic literature to set guidelines for accepted practices, we are allowing those who are often academics first and clinicians second to determine what clinical care is appropriate.

Consciously or not, those who provide the peer review for medical journals are influenced by whether the work they are reviewing will impact their standing in the medical community. This is a dilemma. The experts who serve as reviewers compete with the work they are reviewing. Leaders in every community, therefore, exert disproportional influence on what gets published. We expect reviewers to be objective and free of conflicts, but in truth, only rarely is that the case.

Albert Einstein once noted that "a foolish faith in authority is the worst enemy of truth." At the moment, there isn't an overreliance on expert panels in health care. Our system can therefore self-correct when experts lead us astray. This has given us the best medical care in the world, which is still envied by people from all over the world who face much more rigid, government-driven health care.

This does not mean that our system should not be improved. It is far from perfect. The country needs universal health-care coverage, must do away with exclusions for pre-existing conditions, and must make insurance a portable benefit. But expert panels would only slow medical progress and delay rejection of false prophecies and dogmas. These panels would interrupt a well working free market of ideas in health care, where effective therapies can rise to the surface and win out.


The Massachusetts lesson: Diminished choice for patients already in the offing

The state’s ambitious plan to shake up how providers are paid could have a hidden price for patients: Controlling Massachusetts’ soaring medical costs, many health care leaders believe, may require residents to give up their nearly unlimited freedom to go to any hospital and specialist they want.

Efforts to keep patients in a defined provider network, or direct them to lower-cost hospitals could be unpopular, especially in a state where more than 40 percent of hospital care is provided in expensive academic medical centers and where many insurance policies allow patients access to large numbers of providers.

But a growing number of hospital officials and physician leaders warn that the new payment system proposed by a state commission would not work without restrictions on where patients receive care - an issue some providers say the commission and the Patrick administration have glossed over.

“You can’t reap these savings without limiting patients’ choices in some way,’’ said Paul Levy, chief executive of Beth Israel Deaconess Medical Center. “It’s a huge issue, it’s huge.’’ Dr. James Mongan, president of Partners HealthCare, a Beth Israel Deaconess competitor, agreed that it wouldn’t “work without some restriction on choice.’’

A state commission recommended in July that insurers largely scrap the current fee-for-service system - in which insurers pay doctors, hospitals, and other providers a negotiated fee for each procedure and visit - and instead pay providers a per-patient annual fee to cover all of the patient’s medical care.

This new system of “global payments’’ would discourage overuse of expensive medical services, force providers to live within a budget, and improve coordination of care for patients, supporters argue.

There is little doubt that the state’s current system of broad choice and sometimes unco-ordinated care has helped push Massachusetts health care costs above the national average. It can lead to unnecessary duplication of medical tests, when patients see multiple providers, each often unaware of what the others have done. And thousands of residents get knee replacement surgery, have babies at teaching hospitals, or other care, when often a less-expensive hospital would be more economical and provide good-quality care.

In 1990, 36 percent of Massachusetts hospital patients were treated at teaching hospitals, but by 2007 the percentage climbed to 44 percent - more than twice the national average of 19 percent. The percentage of Massachusetts births at teaching hospitals also has increased. Some of this expanded use of teaching hospitals is understandable, because for many Boston residents academic medical centers in their neighborhoods are their community hospitals. In other cases, residents bypass less-expensive community hospitals, but this is a freedom many patients desire.

The Massachusetts proposal would involve a more ambitious restructuring of health care than any of the cost-cutting ideas being discussed in Washington. Under a global payment system, doctors, hospitals, nursing homes, and other providers would form large networks, called accountable care organizations, that would provide most of the care for individual patients and divvy up the payments. Doctors would try to coordinate patients’ care within these networks, which would share electronic medical records and treatment plans. And to manage costs, they would try to direct patients to the hospital within the network that could provide good-quality care at the lowest cost, while generally using teaching hospitals for advanced care.

The release of the report sparked a lobbying campaign by Massachusetts health care executives, who are urging Governor Deval Patrick’s administration and state legislators to move cautiously because they fear a new payment system could bankrupt some providers and compromise patient care. Many changes recommended by the commission would have to be approved by the Legislature before being put in place.

In its report, the commission, which includes high-ranking Patrick administration officials and legislators, said patients wouldn’t necessarily be restricted to providers within their primary care doctor’s accountable care organization. And, during a hearing at the State House Thursday, Dr. JudyAnn Bigby, secretary of Health and Human Services, said “the people benefiting from the new system should not even notice it.’’

Writing in the New England Journal of Medicine last month, staff writer Dr. Robert Steinbrook said the state commission failed to address the choice issue head-on. Global payments would save money only if networks “limited the volume of services, and denied certain requests from patients and providers,’’ among other measures, he wrote. “Since patient choice is such a sensitive issue, the commission waffled.’’

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