Wednesday, February 18, 2009

NHS: Saying NO

The government bureaucracy of UK's National Health Service is known for it enormity, inefficiency and waste. First, there are six "trusts" including the acute trust, the ambulance trust, mental health trust and the primary care trust (PTC). Within the PTC, there are something like 300 different job titles, and "There are now more PCT managers than primary care doctors in many areas."

Next, here is a detailed,
38-page list of what the PCT is NOT prepared to pay for, courtesy of Dr. John Crippen, a family doctor who has worked for over 20 years in the NHS. He writes about "The trials and tribulations, the pleasures and pitfalls of family medicine in the modern British National Health Service" on his blog NHS Blog Doctor.

He says this about the list:

A line has to be drawn and there are many treatments listed that few would say the taxpayer should pay for. Drawing lines is not easy, but it seems to me to be cruel that if we are to fund sex-change operations and pay for removal of a penis, that we will not also fund breast augmentation.

The main thing that strikes me, as so often with this government, is the huge bureaucracy that has developed to police these exceptions. In one of the most telling medical blogs of the year, the Ferret revealed the enormity of a PCT payroll. We can expect the list to lengthen further as yet more commissars, this time tasked with preventing people from accessing health care, are appointed. Saying "no" may be important, but the process of saying "no" is in danger of turning out to be more expensive than the health care it is denying.


At 2/18/2009 10:58 AM, Blogger spencer said...

How does this compare to the private sector insurance bureaucracy in the US that does essentially the same thing?

At 2/18/2009 12:27 PM, Anonymous Anonymous said...

Well, Spencer, how do YOU think this compares to the American insurance system? I have seen this form of "discussion" as the bog standard, fookin' mechanical tactic of mindless question after question after question to the end point "questions remain." Bull. You are just intellectually lazy.

Let me contribute this telling difference between the Brit and American systems. The American system would not provide a supportive environment for the likes of Dr. Shipman. The American and Brit systems are in no way doing "essentially the same thing."

At 2/18/2009 12:55 PM, Blogger misterjosh said...

"Anonymous" calling somebody else intellectually lazy? pshaw!

and... who in the hell is Dr. Shipman? and define "supportive environment"

At 2/18/2009 2:43 PM, Blogger QT said...

In all fairness to NHS, only 5 pages list treatments not covered. The rest of the document outlines rational, appeals procedure, etc.

Although many are optional cosmetic procedures (ie. breast reduction, dental implants, liposuction, dermabrasion, removal of tatoos), other treatments do not seem unreasonable ie. cochlear or hearing implants, treatment of hyperpigmentation, treatment of scars, extraction of wisdom teeth (unless it meets NICE're guess is as good as mine) and surgical treatment of varicose veins.


Can only comment on dental insurance in Canada. Dental implants are definitely not covered by private insurance here although most other procedures are covered in part depending upon the plan (ie. root canal, extraction, partial dentures, bridges, caps, scaling, etc.).

At 2/18/2009 2:51 PM, Blogger QT said...


I'm afraid someone is tweaking your nose. More on the infamous Dr. Shipman

Found him in less than a minute using Google advanced search (allows use of an exact phrase which you can cross-reference to other words).

Keep your stick on the ice.

At 2/18/2009 4:50 PM, Anonymous Anonymous said...

The American health-care system may be a crazy mess, but it is the prime mover in the global ecology of medical treatment, creating the world’s biggest market for new drugs and devices. Even as we argue about whether or how our health-care system should change, most Americans take for granted our access to the best available cancer treatments—including the one that arguably saved my life.

Not everyone in similarly rich countries is so lucky—something to remember the next time you hear a call to “tame runaway medical spending.” Consider New Zealand. There, a government agency called Pharmac evaluates the efficacy of new drugs, decides which drugs are cost-effective, and negotiates the prices to be paid by the national health-care system. These functions are separate in most countries, but thanks to this integrated approach, Pharmac has indeed tamed the national drug budget. New Zealand spent $303 per capita on drugs in 2006, compared with $843 in the United States. Unfortunately for patients, Pharmac gets those impressive results by saying no to new treatments. New Zealand “is a good tourist destination, but options for cancer treatment are not so attractive there right now,” Richard Isaacs, an oncologist in Palmerston North, on New Zealand’s North Island, told me in October.

A more centralized U.S. health-care system might reap some one-time administrative savings, but over the long term, cutting costs requires the kinds of controls that make Americans hate managed care. You have to deny patients some of the things they want, including cancer drugs that are promising but expensive. Policy wonks dream of objective technocrats (perhaps at the “independent institute to guide reviews and research on comparative effectiveness” proposed by Barack Obama) who will rationally “scrutinize new treatments for effectiveness,” as The New Republic’s Jonathan Cohn puts it. But neither science nor liberal democracy works quite so neatly.

That surely accounts for the most damning inconsistency in New Zealand’s policy. When Pharmac was denying Herceptin to early-stage patients, it was fully funding the drug, without limitations, for women with advanced metastatic cancer, who are just buying time. A purely rational calculation would suggest the opposite course: letting patients with advanced cancer die while shifting the money to early-stage patients who, if treated, might survive for decades. But once a treatment has become standard practice, taking it away is hard.

Read it all

At 2/18/2009 4:54 PM, Anonymous Anonymous said...

Imagine a country where the government regularly checks the waistlines of citizens over age 40. Anyone deemed too fat would be required to undergo diet counseling. Those who fail to lose sufficient weight could face further "reeducation" and their communities subject to stiff fines.

Is this some nightmarish dystopia?

No, this is contemporary Japan.

The Japanese government argues that it must regulate citizens' lifestyles because it is paying their health costs. This highlights one of the greatly underappreciated dangers of "universal healthcare." Any government that attempts to guarantee healthcare must also control its costs. The inevitable next step will be to seek to control citizens' health and their behavior. Hence, Americans should beware that if we adopt universal healthcare, we also risk creating a "nanny state on steroids" antithetical to core American principles.


At 2/18/2009 4:59 PM, Anonymous Anonymous said...

The National Institute for Health and Clinical Guidelines (Nice) has ruled for the first time that saving a life cannot be justified at any cost, in a review of its ethical guidelines.

The ruling - made by the board of the controversial organisation - contradicts advice it received from its own 'Citizens Council' which offers advice from a representative sample of the general public.

Nice is facing growing criticism over the number of drugs it is now rejecting which are available throughout Europe and in America. Last week, it refused to sanction four kidney cancer drugs which can double life expectancy.

It has now rejected the so-called "rule of rescue" which stipulates that people facing death should be treated regardless of the costs. The rule is based on the natural impulse to aid individuals in trouble.


At 2/18/2009 5:03 PM, Anonymous Anonymous said...

In the latest jarring illustration of the country's doctor shortage, a family physician in Northern Ontario has used a lottery to determine which patients would be ejected from his overloaded practice.

Dr. Ken Runciman says he reluctantly eliminated about 100 patients in two separate draws to avoid having to provide assembly-line service or extend already onerous work hours, and admits the move has divided the close-knit community of Powassan.

Yet it was not the first time such methods have been employed to determine medical service. A new family practice in Newfoundland held a lottery last month to pick its caseload from among thousands of applicants. An Edmonton doctor selected names randomly earlier this year to pare 500 people from his heavy caseload. And in Ontario, regulators have heard reports of a number of other physicians also using draws to choose, or remove, patients.

... A paucity of medical professionals has left an estimated five million Canadians without a family doctor.


At 2/18/2009 5:07 PM, Anonymous Anonymous said...

Shona Robertson-Holmes was a mess. She had crushing headaches, insomnia and adrenaline levels so high that she constantly felt as if she had just stepped in front of a speeding bus. And that’s not to mention her rapidly deteriorating eyesight.

She headed to her family doctor, who recommended that she see two specialists.

But Robertson-Holmes is Canadian, and her state-provided health care gave her a wait time of four months to see a neurologist and six months to see an endocrinologist. Unable to get an expedited appointment, and with her eyesight worsening, Robertson-Holmes called the Mayo Clinic in Arizona and went in for tests and a diagnosis within a week.

The doctors there told her she had a four-to-six-week window to have a marble-sized tumor on her pituitary gland removed before her vision loss would be irreversible.

Returning home with the diagnosis, the Ontario native was still unable to expedite the surgery. Three weeks later, she came back to Mayo for brain surgery. And she took out a second mortgage to pay for the $100,000 ordeal.


At 2/18/2009 5:10 PM, Anonymous Anonymous said...

At least 30,000 patients were left starving on NHS wards last year, despite ministers’ pledges to make proper nutrition in hospitals a priority.

Last year, Health Minister Ivan Lewis admitted that some patients were given a single scoop of mash as a meal.

Others were ‘tortured’ with trays of food placed just beyond their reach while nurses said they were too busy to help them eat.


At 2/18/2009 5:15 PM, Anonymous Anonymous said...

As this presidential campaign continues, the candidates' comments about health care will continue to include stories of their own experiences and anecdotes of people across the country: the uninsured woman in Ohio, the diabetic in Detroit, the overworked doctor in Orlando, to name a few.

But no one will mention Claude Castonguay — perhaps not surprising because this statesman isn't an American and hasn't held office in over three decades.

Castonguay's evolving view of Canadian health care, however, should weigh heavily on how the candidates think about the issue in this country.

Back in the 1960s, Castonguay chaired a Canadian government committee studying health reform and recommended that his home province of Quebec — then the largest and most affluent in the country — adopt government-administered health care, covering all citizens through tax levies.

The government followed his advice, leading to his modern-day moniker: "the father of Quebec medicare." Even this title seems modest; Castonguay's work triggered a domino effect across the country, until eventually his ideas were implemented from coast to coast.

Four decades later, as the chairman of a government committee reviewing Quebec health care this year, Castonguay concluded that the system is in "crisis."

"We thought we could resolve the system's problems by rationing services or injecting massive amounts of new money into it," says Castonguay. But now he prescribes a radical overhaul: "We are proposing to give a greater role to the private sector so that people can exercise freedom of choice."


At 2/19/2009 10:27 PM, Blogger OBloodyHell said...

> Crippen

... and everyone should "remember Crippen"



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