Astroturf Grows in Britain

This is just in case anyone thought this was only an American pheonomenon. As reported by the Independent.

The rising tide of protest over the refusal by the NHS to provide expensive drugs for cancer and other conditions is being funded by the pharmaceutical industry, an investigation by The Independent has revealed.

Patient groups that have been among the most vocal in spearheading attacks on the National Institute for Clinical Excellence (Nice) over decisions to restrict access to drugs on the NHS depend for up to half of their income on drug companies, but details are often undisclosed.

Protests have been launched by charities including the National Kidney Federation, the Arthritis and Musculoskeletal Alliance, the National Rheumatoid Arthritis Society, Beating Bowel Cancer, the Royal National Institute for the Blind and the Alzheimer's Society. All of these charities received sums of up to six figures from drug companies in 2007.

The extent of the drug companies' support for the smaller charities has led to criticisms that supposedly grassroots patient organisations are puppets of the pharmaceutical industry, being used to bludgeon Nice into making the drugs available on the health service.

Yet none of the charities named has criticised the high prices charged by the pharmaceutical companies for their products in their recent campaigns.

The National Kidney Federation (NKF) accused Nice of taking a "barbaric, damaging and unacceptable" decision when it turned down four kidney cancer drugs for NHS use this year and pledged to campaign against the decision. It did not criticise the cost of the drugs, at more than £3,000 for a 30-tablet pack. Half the NKF's £300,000 budget comes from the pharmaceutical and renal industries.

The Arthritis and Musculoskeletal Alliance (Arma) organised a protest letter from 10 professors of rheumatology, published in The Sunday Times last month, over a recent Nice decision to restrict access to arthritis drugs. The letter made no mention of the cost of the drugs but Ros Meek, chief executive, admitted that "half, or more" of the charity's £147,000 income came from the drug industry.

The National Rheumatoid Arthritis Society described the same Nice decision as "another nail in the coffin" for arthritis treatment and launched an appeal against it this week, with Arma and three drug companies. The society received 49 per cent of its £300,000 budget from the pharmaceutical industry in 2005-06, reducing to 26 per cent of its £472,000 budget in 2006-07.

We have heard physicians and leaders of not-for-profit organizations funded by pharmaceutical companies and other commercial health care organizations protest again and again that their activities and decisions are uninfluenced by the source of their money. For example, we recently posted about the President of the US American College of Cardiology who revealed that this medical society receives 38% of its funds from the pharmaceutical industry, but has "firewalls" that prevent this sum of money from having any effect on how the organization operates. Yet, as the saying goes, "he who pays the piper calls the tune."

The current example, from the UK, highlights how organizations that get substantial commercial support never seem to manage to criticize the policies or actions of those who provide the support. One would think a charity devoted to the interests of patients with a particular disease might protest when drug companies charge outrageous prices for treatments for that disease, but as noted above, not one of the charities listed above did so.

So in the absence of transparency, accountability, and clear and enforced codes of ethics, those with health care goods or services to sell are more than happy to plow substantial funds into non-profit, "grassroots" organizations with the not unreasonable hope that such organizations will then promote the requisite marketing or policy agenda. Thus these supposed "grassroots" organizations are really astroturf, and allow their sponsors to engage in stealth health policy advocacy.

Hat tip to Ed Silverman on PharmaLot.

Post Title → Astroturf Grows in Britain

The UK "Superbug" Row: Echoes of US Problems

Here is a story from the UK which shows that that country too suffers from some of the problems with the leadership of health care organizations which plague the US. (I comment on this with some trepidation, lest I have misunderstood the UK context. UK readers are invited to comment and correct me, if needed.)

The background is that several UK hospitals have been having increasing problems with hospital-acquired infections such as those due to C. difficile. A recent report cited particular problems run by the Maidstone and Tunbridge Wells NHS Trust. As reported by the Telegraph,

The hospitals had filthy wards and vulnerable elderly patients were told to soil their beds because nurses were too busy to help them.

Targets and financial problems within the health service led to staff shortages and overcrowded wards which contributed to the spread of the infection, the report found.

Between April 2004 and September 2006, 1,176 patients contracted C.diff at the three hospitals and 345 died. Some patients with curable conditions died after contracting the bug.

The commission found the bug definitely or probably caused the deaths of 90 of them and was likely to have contribu ted to the deaths of another 255. In only 14 cases was it felt the bug had not been a factor in the death.

So what happened to the chief executive of the trust?

Rose Gibb left her job as chief executive of the Maidstone and Tunbridge Wells NHS Trust, in Kent, days before a damning report revealed at least 90 patients in its care had been directly killed by clostridium difficile.

Miss Gibb was allowed to leave her £150,000 post by "mutual agreement" last Friday, meaning she was eligible for £250,000 in severance pay....

It turned out that there were allegations that the chief executive had covered up this and other problems.

It has also emerged that Miss Gibb ... tried to cover up the extent of the C.diff outbreak.

Doctors at the Maidstone and Tunbridge Wells NHS Trust told The Daily Telegraph that Miss Gibb had deliberately withheld information about the extent of the outbreak, even from fellow board members.

Junior doctors were also allegedly ordered not to put clostridium difficile on death certificates.

The Telegraph has also learnt that Miss Gibb was blamed for allegedly failing to sort out dirty wards at two other hospitals and was involved in a secret pact to try to ensure her previous hospital was not blamed for failings in the 2000 case of Victoria Climbie, who died after appalling abuse at her home.

Miss Gibb was one of six signatories to a letter from health chiefs to Haringey council in which they allegedly agreed not to criticise each other over failures to spot the signs of abuse before the eight-year-old died, though Miss Gibb was not working at the hospital at the time of Victoria's death.

Several editorialists also suggested deeper systemic problems. Charles Moore wrote in the Telegraph.

We all complain about the "target culture" that made administrators in Maidstone ignore actual human suffering before their eyes. But if you have a top-down system of healthcare, targets are the inevitable response to whatever is the latest disaster.

In this case, one of the targets was to cut waiting times in Accident and Emergency to four hours .... In this world without choice, each claim of need jostles against another: either faster A&E, or cleaner bed-pans, but not both.

This is all, morally, wrong. It turns the patient from being the entity for which the service exists into a nuisance. Each new patient is just an added cost and each dead patient is an administrative convenience.

And Minette Martin wrote in the Times,

Government has almost overwhelmed the NHS with money, protocols, guidelines, employment procedures, information technology – much of it clearly disastrous and with perverse consequences. The whole point of this tyranny of inspection, infection control teams, recording, box-ticking and, above all, the imposition of targets, was to make things better in the health service.

Maidstone and Tunbridge Wells NHS Trust was obsessed with government waiting time targets and financial targets, to the neglect of infection control.

It all sounds too familiar to a US reader.

In the US, the large organizations that now run health care, including in this case, government agencies, managed care organizations and health insurers, and pharma/ biotech/ device manufacturers have also pushed "protocols, guidelines," and "information technology" which risk "perverse consequences." (See this post on the "pay for performance" movement, for example.) And we have worried that focus on a few easily measured targets will distract from the more important parts of medicine and health care.

In the US, it also seems true that there is no pay for performance for health care leaders. When misdeeds are discovered, it is the organization as a whole, rather than the leaders responsible, who pays the penalty (see this recent post). Inept leaders retire with huge golden parachutes.

Finally, it seems that health care leaders in both countries are too quick to hide their problems, and threaten any possible whistle-blowers.

The similarities are striking, even though the UK has a National Health Service, and the US has a mosaic of private and public health care.

So perhaps UK and US doctors ought to get together and discuss how to fix this mess.

Post Title → The UK "Superbug" Row: Echoes of US Problems

BLOGSCAN - Even European Pharma Execs Don't Like DTC Advertising

On BrandweekNRX is a fascinating post on the disdain European pharmaceutical executives have for direct to patient (DCT) pharma advertising. On UK executive even said "that American drug advertising was regarded as so excessive in the UK that it had actually nixed the chances of UK drug companies being allowed to conduct similar promotions."

And the post started with a link to Question Authority with Dr Peter Rost which cited a commentary in a left-wing Swedish newspaper in which a Swedish Pfizer executive called DTC advertising "a bad model for Sweden."

So why do American pharma executives swear by DTC advertising? Are they dumber than their European counterparts, or are American consumers more gullible than European consumers?

Post Title → BLOGSCAN - Even European Pharma Execs Don't Like DTC Advertising

UK Doctors Protest "Modernising Medical Careers"

We have posted several times, most recently here, about the controversy over the new system developed by the UK National Health Service (NHS) to select physicians for senior specialty training positions, part of the the new "Modernising Medical Careers" (MMC) program. Since the last post, criticism of the selection process, called the Medical Training Application Service (MTAS), has been growing. The Telegraph, which has been providing most of the coverage of this story, reported,

Prof John Bell, president of the Academy of Medical Sciences, and Prof Sir John Tooke, chairman of the Council of Heads of Medical Schools, criticised the scheme for undervaluing applicants' research experience and academic potential. In an open letter released yesterday, Prof Bell and Sir John said: 'Academic trainees - those doctors wishing to pursue careers which encompass research as well as patient care - have been particularly badly affected by the decision to anonymise applications and deprive the assessors of details of previous clinical and research experience. Without a scientifically informed and research-orientated medical workforce throughout the country, the Government's vision of the UK as a world-class centre for biomedical research and healthcare cannot be realised.'

Prof Ian Gilmore, the President of the Royal College of Physicians, added his voice to the criticism, saying the system was 'at the point of breaking down.'

Nine out of 10 doctors who have taken part in an online poll called for the resignation of those responsible for the MMC/MTAS debacle.

Meanwhile, The Lancet called for MTAS to be suspended and said the new system, combined with EU laws preventing junior doctors from working longer than 48 hours per week, would produce inexperienced consultants.

Many phases of the MTAS have been criticized. A Telegraph physician columnist, Dr Max Pemberton described his personal experience with the interview phase of the MTAS.

I am one of the lucky ones. I am here for one of the much coveted Medical Training Application Service (MTAS) interviews....

Any doctor awaiting an interview and hoping that the interview process will in some way be superior to the ludicrous, Kafkaesque application form should be warned: it isn't.

The grey man led me into a room filled with work stations manned by confused, bewildered looking interviewers. Some of them were doctors, some, I learned later, were not. None was properly introduced to me. It was clear they hadn't read my form and knew nothing about me. Each asked a series of formulaic questions to which I had a few minutes to provide equally formulaic answers.

There was no provision for me to discuss anything, to show my strengths and qualities, or to talk about the things that interest me. The bland questions were designed to elicit responses that could be ticked off on a form.

In all honesty, I wouldn't trust this system to select someone to water my plants, let alone look after me when I'm sick.

Dr Pemberton came to a clear realization what the larger problem is.

This is a clear attempt to undermine the medical profession; to ensure that we become compliant, unquestioning automatons in a system that can be presided over by managers and politicians.

He has hit the nail on the head. This seems to be the same problem that plagues us here in the US, and maybe plagues health care around the world.

When I interviewed physicians about what they thought was wrong with health care, many cited cases of bad decisions by, and conflicts of interest and outright corruption affecting health care leaders, who were often managers and politicians. Yet at the time, most of the physicians saw thess as their unique local problems, not as part of a largersystemic problem. Perhaps because physicians see the problems only as local, are too busy just trying to keep up with their patients' needs, or tend to be conflict-averse and apolitical, few physicians have protested the systemic problem. But maybe in the UK that is changing. Pemberton also wrote,

Doctors are notorious for being apathetic when it comes to fighting their corner. Not this time. We are so horrified by what is happening that there is now even talk of a strike.

In fact, doctors' protests were planned today in both London and Glasgow. The Telegraph reported on preparations for the London rally,

Speakers at the march in London and rally in Glasgow will call for the new online selection system, Medical Training Application Service (MTAS), to be suspended.

Andrew Lansley, shadow health spokesman, who will address the London march, says that MMC is 'an appalling shambles.'

'It risks undermining the morale and the future of the medical profession. What is the point of expanding medical school places and then destroying the career progression of juniors?'

'We cannot, we must not, abandon thousands of junior doctors; we must ensure that they can fulfil their vocation, for them and for our patients,' he said.

The junior doctors have increasingly been supported by senior doctors including some of the most eminent names in medicine.

The demonstrations have been organised by a grassroots doctors’ group, RemedyUK.

The BBC just reported that 200 doctors rallied in Glasgow today. And NHS Blog Doctor has a first report on the London march with some video. Maybe doctors in other countries should think about following their example. Grumbling to ourselves hasn't done much good.

Post Title → UK Doctors Protest "Modernising Medical Careers"

"Modernising Medical Careers" Goes into the [Trash] Bin

We have posted several times, most recently here, about the controversy over the new system developed by the UK National Health Service (NHS) to select physicians for senior specialty training positions, called "Modernising Medical Careers." Now, after having a spokesperson say "it would be irresponsible to halt the interview process at this late stage," the NHS has decided to cancel the whole new system and go back to the traditional method of selection. As reported by the Guardian,

The computerised application system for the training posts that lead to consultant jobs was scrapped by a review set up this week to establish why many of the best-qualified candidates had been left without a single interview.

The review, led by the Academy of Medical Royal Colleges, took just three days to bin the online system, which was supposed to deliver a centralised and fairer application process. Junior doctors who have not got interviews in round one will be re-assessed the old way, through scrutiny of their CV and a structured interview.

Last night the Royal College of Surgeons said the computerised selection process had 'clearly failed and has caused deep distress.'

The article gave a bit of insight into what was wrong with the new system.

The online application form, (Medical Training Application Service) was supposed to be fairer. Doctors were scored for their answers to generalised questions about their attitude, motivation and approach to their work - which had to be answered in 150 words. Shortlisters saw the responses to a single question without the context of the rest of the form. More weight was given to these questions than to the CV.

In some parts of the country, the scoring system was leaked, enabling some candidates to tailor their answers.

To make the folly of the Medical Training Application Service (MTAS) system clearer, take a look at some of the questions a surgical candidate would have to answer, as found in a post by the redoubtable NHS Blog Doctor:

• B6 What experience of delivering teaching do you have?
• B7 Which of your research or audit studies has made the greatest contribution to your practice and why? Clearly describe your level of involvement and the outcome.
• C1 Describe a recent example from your surgical experience of a time when you found it difficult to make an effective judgement in a challenging situation. How did you overcome this difficulty, and how has this experience informed your subsequent practice?
• C2 Provide a recent example from your surgical experience of when you have had to co-ordinate the activities of a team in a critical situation. What approach did you take to get the best out of the team? How has this experience developed your ability to direct others effectively?
• D1 Mistakes can and do happen in medical practice. Describe a specific example where the outcome of action you took in response to a clinical mistake/error (made by you or someone else) caused you to reassess how you subsequently dealt with similar situations. What action did you take at the time and how has your practice now changed?

Each answer was limited to 150 words. The system had no capacity to verify the truthfulness of the responses.

An editorialist in the Telegraph summarized the problems.

With the new computerised system, which also encouraged numerous applicants from abroad, already hard-pressed consultants were frequently asked to plough through 500 or 600 applications. Instead of being trusted to use their well-honed professional judgment, they were required to grade these applications according to a bizarrely rigid, illogical points system. Many of the questions were somewhat pious and woolly, and consultants thus found it almost impossible to discern the best candidates from the answers. [And that assumes that the answers were completely honest and accurate, which could not be assured - Ed] The result is that many extremely competent candidates weren't shortlisted for any job in any region. Now 8,000 British junior doctors, each of whom cost the British taxpayer £250,000 to train, have been left jobless and deeply demoralised. Growing numbers of principled consultants are flatly refusing to interview shortlisted candidates because the process thus far has been so fatally flawed.

The editorialist, Jenny McCartney, summarized some of the larger issues.

But surely no one can have seen this disaster coming? Yes, they did.

Last summer, the British Medical Association openly pleaded with the government to delay the MTAS, on the basis that the reforms were incomplete and that "information necessary for selection will not be adequate." A contemptuous Department of Health ignored the warning.

This fiasco contains virtually all the elements that have contributed to the dismal failure of numerous Blairite policies: the urge for sweepingly radical gestures without intelligent planning for the aftermath, the failure to listen to experts in a given field and the naive enthusiasm for vast, unwieldy, centralised computer systems.

The political mediocrities in New Labour are instinctively suspicious of professional elites, whether those elites are composed of Oxbridge dons or hospital consultants. No matter that members of such elites are largely there by dint of cleverness and hard work: this Government's instinct is to wrest decision-making power from them in the name of 'fairness.'

'Fairness' - as the Government dully conceives of it - essentially means that the direction of one's life is determined not by graft or intelligence but by crude chance.

The Government's abject failure to understand such basics makes me think that in Britain we have got matters entirely the wrong way round. Instead of doctors being forced to obey rules set by politicians, should we not have politicians compelled to follow the time-honoured rules of doctors? After all, the most famous edict of medicine is the very one that New Labour so constantly and disastrously forgets: 'Primum non nocere: first, do no harm.'

I don't want to comment on British politics, which would be like stepping into quicksand for an American. But I would conclude by noting that the faults attributed to "Blairite" policies by this editorialist also describe in general a lot that has gone wrong with American (and probably other countries') health care.

The idea of breaking the medical "guild," and handing power over to managers and bureaucrats (see here for the American version) has had terrible consequences for every health care system to which it has been applied.

Kudos, though, to British doctors, who were willing to stand up and refuse to take any more.

Post Title → "Modernising Medical Careers" Goes into the [Trash] Bin

UK "Modernising Medical Careers" Initiative Spirals Downward

Last week we discussed the controversy over the new UK system for selecting physicians for senior specialty training positions. Things only seem to be going downhill. Again, commenting at risk of misunderstanding the context in the UK...

A group of senior surgical consultants suspended interviews of "short-list" candidates because they had no confidence in the system that selected them. Per the Daily Telegraph, Bob Spychal, the Chair of the interview panel, said,

The 10 surgeons were unanimous. We know we have disappointed the candidates and we have spoken to all of them, but we have no confidence that the system is robust and fair. It is not fit for purpose. Someone had to do something. Perhaps other panels in other specialities will do the same thing.

Meanwhile, the Academy of Medical Royal Colleges urged the Ms Patricia Hewitt, the Health Secretary, "to undertake an urgent review of the process of selection." Dr Jonathan Fielden of the British Medical Association warned "we now have no faith in the system."

Then, the Department of Health did agree to review the system, but, according to the Guardian, it did not agree to stop or immediately modify the interview process. In fact, according to the Telegraph, a government official insisted the system continued to work "well." This provoked the British Medical Association to accuse the government of arrogance. Said Dr Fielden,

The arrogance of the department in ignoring this has resulted in the most devastating effect on a generation of junior doctors.

And the Dean of the Royal College of Psychiatrists, alarmed at the "total lack of transparency" in the selection process, warned of the effect on the "human rights and mental health of trainees."

Meanwhile, in a separate report in the Guardian, "the British Medical Association accused the government yesterday of instilling a 'culture of fear' across the NHS to stop doctors revealing how health service reforms are putting patients' lives at risk." Dr Fielden said, "there is a culture of fear in the NHS and doctors are under severe pressure to meet targets and keep their mouths shut."

What a mess. Of course, it appears to be a perfect example, writ large, of the effects of transferring power over health care from physicians and other health professionals to executives, managers, and bureaucrats. In the UK, most of these health care leaders are government employees. In the US, many of them are executives of for-profit and not-for-profit corporations. But, in general, putting in charge people with inflated ideas of their own managerial powers and little notion of how health care works or the values of health care professionals seems to have the same effect whether they are in charge of government agencies or private, for-profit or not-for-profit corporations. We see disorganization, seeming lack of concern for effects on the health of patients or the morale of physicians, lack of transparency, and attempts to silence critics and restrict free speech, in sum, mission-hostile management

At least in this case, the UK doctors have had the courage to speak up, maybe before things go irreversibly wrong. In the US, we physicians seem afraid to hold our heads up individually, lest we be hammered down. But we are hammered down anyway.

Post Title → UK "Modernising Medical Careers" Initiative Spirals Downward

Mission-Hostile Management: "Chaos" as the UK NHS Implements "Modernising Medical Careers"

A year ago we posted bout the problematic new system, called "Modernising Medical Careers," (MMC) that UK National Health Service (NHS) managers had put in place to match junior physicians with specialized training positions (called specialist registrar positions). Concerns at the time centered on importance in the matching process of applicants' responses, in the form of very short essays, to standardized questions posed on a web-site. It seemed there would be no way to check the accuracy of their answers, that the relevance of the questions to one's ability to practice in a given specialty was questionable, and that the whole system devalued traditional measures of clinical competence and educational performance.

I wrote last year's post with some trepidation, fearing that I may have not adequately understood the context of the new system in the UK (although I spent some time in the UK in the 1990's gaining experience with the generally excellent medical education system there.) Now MMC is up and running, and the results don't seem pretty, perhaps validating my concerns. Per the BBC,

Doctors' training was revamped in 2005, with the aim of speeding up progress so juniors could reach consultant level in an average of 11 years, rather than the current 14.

However doctors who have been through their initial stage of training under both the old and the new systems are all competing for a limited number of specialist training posts.

Remedy UK says early results from a survey of over 1,300 doctors suggest an overwhelming majority do not think the system is a fair way of selecting new doctors.

There are also concerns that the website set up under the Modernising Medical Careers system to co-ordinate job applications simply cannot cope.

Problems reported range from people being unable to upload application details to not being able to access the site to see if they have an interview - which started just two days after being announced via the site - and the potential staffing problems on wards caused by junior doctors heading off to interviews at the same time.

Doctors also report that some highly experienced colleagues had not been selected for interview, and that the way the system is organised means only a limited number of posts are available for doctors with the most experience, including those who have taken PhDs.

Jamie Wilson, a London-based psychiatry student - one of many who has contacted the BBC to raise concerns about the system - said: "The whole system is a shambles, and the applications process is chaotic."

A spokesman for the BMA said the reason for the problems boiled down to the new training system being rushed in.

"It's a huge task to get these tens of thousands of doctors into new jobs."

He added: "There is evidence that very competent and able doctors have had no interviews at all."

But a Department of Health spokeswoman said: "Medical employment, like any other employment, is competitive."

[However,] doctors are set to take to the streets to protest about what they say is a "shambolic" system which could see at least 6,000 without training posts.

A grassroots movement is organising the march in London on March 17, and claims 1,000 doctors have already signed up.

When doctors threaten to march in the streets, things must be getting really bad.

In two articles in the Telegraph (here and here), there was additional emphasis on the new system's apparent inability to identify the most experienced and qualified physicians.

[A Professor of Plastic and Reconstructive Surgery said] They have spent an enormous amount of money creating this new system and the whole thing is spiralling into chaos. It is quite immoral to inflict this on motivated young doctors. I cannot find a single doctor who is happy with this flawed process and ultimately it is the patients who will suffer.

Bernard Ribeiro, the president of the Royal College of Surgeons, wrote to all members on Thursday listing five 'fundamental difficulties' in the system.

'For 18 months I have tried to get this system modified and the number of surgery places expanded,' Mr Ribeiro said. 'I have not succeeded. This system must be reviewed urgently.' [Note that in the UK, surgeons are referred to as 'mister.']

Problems listed by the royal college are: 'woolly' questions on the application forms; concern that qualifications have not been taken into account; concern about the adequacy of training for assessors; inconsistent rating and errors in reporting the results.

As I noted earlier, one wonders if this chaos reflects the preference by modern managers, be they in the UK or the US, for computer based solutions for every problem. The tendency to believe automation is the magic solution to every problem may create particularly unhappy results when the computerized system is set up by people who seem to have little understanding of the clinical and educational context in which it is to be deployed. But modern management philosophy in the US (and I suspect in the UK) seems to believe managers can succeed even if they have little knowledge of the specific context and values of the organization which they seek to manage. It seems to be a recipe for the mission-hostile management that we now see so often in health care.

To get an idea how upset UK junior doctors are, see NHS Blog Doctor.

Post Title → Mission-Hostile Management: "Chaos" as the UK NHS Implements "Modernising Medical Careers"

Sometimes There Are Consequences

A depressingly large number of the posts on Health Care Renewal deal with cases of mismanagement, conflicts of interest, and even corruption that infrequently seem to result in proportional consequences to those responsible.

There have been a few recent exceptions, to a degree.

UnitedHealth Foray Into Running British GP Practices Blocked

We had previously posted about attempts by UnitedHealth in the UK to take over practices formally run by local GPs. These attempts seemed to be facilitated by bureaucratic bidding requirements that emphasized being able to produce reams of business-speak more than ability to deliver good patient care.

The Times (UK) just reported that the High Court has now blocked one of these attempts, the same one used as an example in our post. The Court found that the Primary Care Trust (PCT) which put the contract out for bid "had a duty to consult [with the local community] and they did not properly perform it." The PCT now must again put the contract out for bid.

"Naturopathic Physician" To Go To Jail

We had previously posted (here and here) about a local "naturopathic physician," who claimed to be able to treat a variety of conditions, including ones as serious as metastatic cancer, with harmless and effective natural treatments. Curran purported to do "live blood analyses," which lead to diagnoses of such things as "parasites" in the blood.

The Providence Journal just reported that Curran will be going to jail for 12 1/2 years. The judge said that Curran was "not your run of the mill scam artist," but "the worst of the worst," who "scared the living daylights out of people." At the trial, it turned out that not one of approximately 300 people who had the "live blood analysis" was given a clean bill of health.

Scrushy Must Re-Pay His Bonuses

Although former HealthSouth CEO Richard Scrushy was acquitted of federal fraud charges, we previously posted about his conviction by a state court for bribery, conspiracy, and mail fraud. Now the Associated Press has reported that Scrushy must also re-pay $47.8 million in bonuses he received from the company during years when the company was actually losing more than $400 million. The judge said, "without annual net income, Scrushy could not have had the opportunity to earn the target bonuses."

Summary

In my humble opinion, we need to restructure the health care system so that there are negative incentives for bad behavior, and that these incentives are proportional to the badness of the behavior. Individual health care professionals are subject to strict licensing requirements and can be sanctioned by state boards in the US for behavior that is short of criminal. However, the leaders of the biggest health care organizations can often walk off with golden parachutes even after egregious behavior, save for those few who end up with criminal convictions. Somehow, we need to ensure that there are big negative incentives for health care leaders, like Scrushy, who put lining their own pockets ahead of fulfilling their organizations' missions.

Post Title → Sometimes There Are Consequences

Missing the Target

In the Times (UK), an eloquent critique of target setting in the National Health Service by Raymond Tallis:

in the case of the NHS, target-mania is not only damaging in the long term, but also a direct threat to patient safety.

Last month’s report by the Healthcare Commission on the outbreaks of infectious diarrhoea in Stoke Mandeville hospital, in which 334 patients fell ill and at least 33 died, makes instructive reading. Managers, we learnt, overrode the advice of the expert clinicians on their own staff and thus failed to isolate infected patients to control the outbreak. This active mismanagement was driven by a need to meet targets, in particular the requirement to clear patients from the accident and emergency department within four hours. Patients in A&E with infections were admitted to open wards rather than isolation facilities, which were in short supply.

Will this kind of evidence be the death knell for targets and, more importantly, for the arrogance — political power mistaking itself for technical expertise — that lies behind them? Like many bad ideas, targets are intuitively attractive.
In practice, the impact of targets has been damaging and must bear some of the blame for the failure of the vast and welcome increase in NHS funding to deliver a proportionate increase in care.

It is sometimes forgotten that if one kind of activity is prioritised then all others are “posteriorised”. For example, the initial focus on coronary heart disease meant that development of services for cardiac arrhythmias andnon-cardiac conditions was held back. Conditions that are not prioritised still have to be treated. Secondly, priorities determined by the discomfort of a minister at the dispatch box may not match clinical priorities. Thirdly, meeting targets will itself become the overall priority: resources are commandered for this even if it is not cost-effective. The collateral damage to the care of patients with non-targeted conditions will be all the greater.

The greatest damage will be to aspects of care that cannot be measured — human kindness, listening and talking that patients value enormously and that are so important in chronic disease. When targets are set the measurable always displaces the immeasurable.
There are other less obvious, but no less serious, adverse effects of centrally determined targets. The implicit contempt for the competence and motivation of the professionals in the service is profoundly demoralising. A recent study by Frank Blackler, of Lancaster University, confirmed what one might have expected — that the target culture has led to poor leadership and paralysis among hospital trust managers. And it is not difficult to imagine the impact on clinicians who are at the receiving end of its puerile simplifications, remote from the complex realities of clinical care.

The assumption that clinicians will not try to improve their services without political “incentivisation” — carrots and Semtex — is profoundly irritating, not to say exasperating, for those who have being trying to improve their services for many years and found the experience to be rather like riding a bicycle up a sand dune. To be finger-wagged into doing something that one has been endeavouring to do without support is almost as bad for morale as being forced to act on priorities determined by political rather than clinical need.
And then there is the dangerously distracting effect of changing targets — one aspect of the unending “redisorganisation” of healthcare. The Healthcare Commission criticised the management of Stoke Mandeville for “taking their eye off the ball”. More likely they were transfixed by a particular ball — the political agenda — that was in constant, unpredictable motion.

Targets are also corrupting, creating a parallel world of delivery that is remote from the real world. In the Soviet Union, when targets for screw production were set in terms of the numbers of screws produced, factories manufactured millions of screws the size of iron filings. Target met. When targets were set according to weight, the factory workers produced one massive screw. Target met. It is hardly necessary to say that this did not add to the wealth of the country.

As the saying goes, read the whole thing.

In case anyone thinks that this issue is relevant only in the UK - the currently fashionable "pay for performance" (P4P) movement in the US is a sub-species of target setting. (See previous post here and here.) Maybe we in the US should look at the British experience before rushing off to implement P4P.

Post Title → Missing the Target

The High "Cost of Courage" in the UK

A while ago, the Pittsburgh Post-Gazette published a series called The Cost of Courage about physicians threatened with punishment or who lost their jobs because they complained about quality problems at their hospitals.

Now there is a UK version of this. The Guardian just reported that Dr Otto Chan, at the Barts and the London NHS Trust, was fired after he complained about a huge backlog of unread x-ray films.

from 2000 the number of films started to accumulate in the Royal London. 'At first it was just few packets from outpatients and inpatients but gradually they built up. By 2001, it was 10,000 packets of film (each packet contains up to eight images) and by 2002, it was up to 15,000 packets. They were stuffed into boxes and kept in the corridor.

'One day I turned up and they had all disappeared. I tracked them down to a storeroom which had been locked, and it transpired that the inspectors from the Commission for Health Improvement [now the Healthcare commission] were coming round on a visit.' Managers at the time said that the move was taken to protect safety of patient records.

These films were finally read at the end of 2002 after Chan demanded action, and threatened to go public with it. But the hospital administration then allowed a second backlog of another 15,000 packets of film to build up between 2003 and 2004. This time, there was no agreement to read all of them. Apart from chest X-rays the second pile of films was never checked by radiologists.
Dr Chan, 49 and a father of six, was suspended 18 months ago, and then dismissed last month - a decision he is now fighting. 'I believe I was sacked because I was marked out as a whistleblower and a troublemaker, and that's because I refused to accept that thousand of films lying jumbled up in a corridor constituted good patient care,' he said.

In January 2005, Chan was suspended and accused of professional misconduct. The trust, under threat of legal proceedings from Chan, appointed an internal investigation panel headed by a QC which took 12 days of evidence about the saga, and which included other doctors' accounts of the piles of films. The findings of the panel remain confidential but it is understood that in April this year, they concluded that although there were 'serious deficiencies' in his behaviour towards managers, he had made a 'very substantial contribution' to the trust, and they should consider re-employing him under a different structure.

Chan was therefore shocked to be told on 7 June that he was 'summarily dismissed'.

Amazingly, a hospital leader seemed to admit the existence of the x-ray backlog, and that many x-rays were never read.

In a statement last night, Dr Charles Gutteridge, medical director of the trust, said: 'It is true that at times in the past our radiology service experienced considerable pressure, due to the volume of films and a national shortage of qualified radiologists and radiographers. It should be emphasised that the images concerned were from patients with the lowest clinical risk. Patients with the highest clinical risk have always been reported urgently.'

He denied that Chan was fired because of his whistle-blowing:

The panel concluded that there were grounds for dismissal. The dismissal was in no way connected with issues with our radiology processes in the past.

However, the Mirror reported that Chan

was accused of bullying and racism towards his junior doctors but colleagues said that far from being a bully, Dr Chan was 'a delight to work with'. One said: 'It's an utter disgrace. The public are being deprived of a doctor who can help save lives. His skills are irreplaceable.'

Furthermore, the Guardian noted

Charles Blakeney, a radiologist at the Royal London who worked for years with Chan, said: 'The way in which he [Chan] has been victimised is to my mind, disgraceful. He raised the issue of the unread films because it mattered to him that patient safety was being compromised. I was shocked beyond belief, as were many others, when he was dismissed.'

And it gets considerably worse. The Mirror reported that the practice of suspending UK doctors and nurses who questioned management or complained about quality is widespread. A spokeswoman for a nurses' group, Campaign Against Unnecessary Suspensions and Exclusions, charged, "People are being excluded on the basis of unsubstantiated allegations and often within days of them highlighting an area that could cause embarrassment. Put simply, it's the quickest and easiest way to get whistleblowers to shut up."

Examples cited by the Mirror included,

One senior consultant was sent home for 'not being a team player' and a radiologist for 'an unauthorised audit'.

And increasing numbers of staff claim they are suspended for raising concerns about poor practice or patient safety.

Some doctors and nurses claim they have been banned from work just because of personality clashes with their managers.

They are forced to stay at home while trusts conduct investigations into alleged offences such as 'bullying' or 'harassment'.

A highly qualified mental care nurse claims she has been excluded for more than two years for raising concerns about the safety of elderly patients. Another nurse has been suspended for nearly six months after she complained of being sexually harassed by a lesbian senior colleague.

It seems that the "cost of courage" in the UK is as high as it is in the US. Furthermore, some in the UK seem to have borrowed the tactics frequently employed by academic administrators in the US, accusing those who question their leadership of politically correct charges such as "bullying," "harassment," or "racism." (See the FIRE web-site, and the ACTA online blog for other US academic examples.)

Quality health care will not long survive such a totalitarian mind-set on the part of its organizational leaders.

Post Title → The High "Cost of Courage" in the UK

In the UK, Large Corporations Awarded Contracts to Run GPs Surgeries

The British Medical Journal’s News section reported UnitedHealth Group’s latest foray into the British market [Arie S. Can GPs compete with big business? Brit Med J 2006; 332:1172-1173 ] (I write this in the hope that I am not misunderstanding any important aspect of the context in the UK.)

Apparently, in the UK, primary care trusts (PCTs) may contract with a variety of parties to provide primary care services in particular areas. Increasingly, these contracts are being awarded to for-profit corporations, some based outside the UK. For example, the article recounts the search for a new primary care provider for Langwith village in Derbyshire. A local general practitioner (GP), Dr Elizabeth Barrett, "proposed setting up a small team to run the Langwith surgery," Instead, the contract was awarded to United Health Europe (UHE), a "fledgling subsidiary" of UnitedHealth Group.

There are a number of reasons that "private healthcare companies are in the process of snapping up several other small surgeries around the country." One is that "PCTs are under huge pressure to find the cheapest solutions." Furthermore, some may see "large companies as providing stability, reducing risks and costs, and offering longer opening hours and more efficient and specialised services." Furthermore, the PCTs often set up complex bidding processes. So, "although GPs may have an inherent advantage over private firms because of their experience in primary care, the way the bidding process has changed, if you don’t have a masters degree in business administration you’ll struggle to cope with the paperwork." For example, "just to express interest, a bidder has to present its ‘vision’; submit a 16 page prequalification questionnaire; and provide a three year projection of cash flow, income, and expenditure." "Many NHS professionals do not know how to put together proposals that can compete with a large corporation."

It saddens me that the UK seems to be heading towards duplicating some of the mistakes made here in the US. The process used to select primary care providers seems to embody the notion that managers know more than doctors about health care promulgated by the early advocates of managed care in the US (see related post here). Why else would anyone think that skill at filling out complex bureaucratic applications is the most important attribute of a primary care provider?

Furthermore, some in the UK seem to think that the major characteristics of large, for-profit health care organizations, such as UnitedHealth Group, are stability, reduced costs, and more efficiency. Maybe they should be reading Health Care Renewal to find out some other things about such organizations. For example, we have recently posted about the lavish compensation afforded the CEO of UnitedHealth Group, in contrast with its stated mission to provide affordable and accessible care (see recent post here, with links to previous posts). UnitedHealth is currently under investigation by the US Securities and Exchange Commission (SEC) and a US federal grand jury because of questions about the timing of stock options given to the CEO. And UnitedHealth has been subject of a number of news reports showing how it has aroused the ire of physicians and patients alike (for example, see most recent posts here and here).

On the other hand, some in the UK are resisting repeating mistakes made in the USA. In its reporting about Langwith village, the BMJ noted "several local people in this traditionally staunchly Labour voting area are up in arms that the PCT wants to put their surgery into the hands of what this small, isolated, and deprived community sees as a foreign company. They say they will boycott the new practice if UHE is allowed to take over." A former miner said, "they think we’re daft. They always thought miners had no brains. What miners have is courage." Maybe they have both courage and brains.

Post Title → In the UK, Large Corporations Awarded Contracts to Run GPs Surgeries

New UK Research Integrity Panel Formed in Response to Blumsohn - Procter and Gamble - University of Sheffield Case

A new UK Panel for Research Integrity in Health and Biomedical Sciences has just been launched, per the Guardian. The panel will support the self-regulation of institutions, but will also "support whistleblowers alleging research fraud." The inspiration for the panel partially came from the "example of Aubrey Blumsohn.... "

We had posted a while back, and then more recently here, about the story of Dr Aubrey Blumsohn's dispute with Proctor and Gamble (P&G) and the University of Sheffield in the UK. In summary, Blumsohn and Professor Richard Eastell had done clinical research on the risedronate (Actonel), sponsored by P&G, the drug's manufacturer. P&G refused Blumsohn access to the original data from the study he was ostensibly running, and hired a ghost-writer to write abstracts in his name. Blumsohn protested to Eastell, who advised him not to make waves because P&G "is a good source of income" for the university. When protests to other university officials produced no results, Blumsohn told the story to the press, whereupon the university suspended him.

While announcing the new panel, Professor Michael Farthing, the Principal of St. Georges Medical School of the University of Londong, noted that Blumsohn was a "very sophisticated whistleblower who could not find an ear. Instead of taking it seriously, [the university] suspended him." Farthing also noted that it was "a great embarrassment in the UK" that there was no organization to "audit research misconduct." Furthermore, Professor Sir Ian Kennedy stated, "The UK's research community needs to demonstrate its integrity in the conduct of research. The poor practice and misconduct of a few undermine public confidence and can put volunteers and patients at risk."

Well said. This sounds like a step, albeit perhaps belated, forward. Maybe Dr Blumsohn will yet have a chance to appeal to this panel. Unfortunately, it was constituted too late to prevent the TGN 1412 calamity.

Post Title → New UK Research Integrity Panel Formed in Response to Blumsohn - Procter and Gamble - University of Sheffield Case

"Thinly Veiled Political Desire to Deprofessionalise Medicine"

Last month we posted on an ostensible reform of the British system for matching graduating medical students with hospital training positions. The new system would eliminate face-to-face interviewing, and substitute for them a web-based data collection system. In a letter to the Times (UK), senior academics suggested that this system could be easily gamed, and would thus be unfair.

Unlike many stories posted on Health Care Renewal, this one quickly rated a lead editorial in a major medical journal, the Lancet. [Anonymous. UK medical schools: undervalued and undermined. Lancet 2006; 367: 1029.]

After reviewing the facts in the case, the editorial noted, "respected academic clinicians who have dedicated themselves to teaching medical students and preparing them for practice quite reasonably ask why politicians are now involving themselves in the procedures for selecting and training doctors." Thus, "by shifting responsibility for newly qualified doctors this way, the government is creating a cohort of disenfranchised and demoralised young clinicians who feel hampered in pursuing career paths that best suit their talents and patient needs." The editorial concluded, "the Department of Health's unprecedented and mistaken incursion into medical education, together with its covert attack on medical schools, are yet further examples of thinly veiled political desire to deprofessionalise medicine."

Boldly treading into the arena of international comparisons, let me submit that in the UK, health care is dominated by a single large organization, the National Health Service. In the US, health care is dominated by multiple slightly less large organizations, some governmental, some for-profit corporations, and some not-for-profit corporations. Yet the effects of veiled politically, ideologically, or economically motivated desires to deprofessionalise medicine in both countries were often similar. Both seemingly heeded Einthoven's call to break the physician's "guild," by putting managers and bureaucrats over patients and physicians (see related post here). Doing so did not control costs, access or quality, but did give managers and bureaucrats more power and more money.

Instead, maybe both countries need a third way - perhaps I should use another term - a different pathway. Instead of empowering managers and bureaucrats, we need a system that empowers patients and reinforces physicians' (and other health professionals') professionalism. Failing to do so just lets health care's downward spiral continue.

Post Title → "Thinly Veiled Political Desire to Deprofessionalise Medicine"

No Human Touch

I approach commenting on developments outside of the US with some trepidation, but here goes...

A story carried by the Times (UK) noted there has been a drastic overhaul of how physicians will be selected for post-graduate hospital training positions (internship and house officer positions, or internship and residency, in the US terminology). A new system, called Modernising Medical Careers (MMC), requires that after applicants submit their usual application and CV (curriculum vitae), they must fill out an on-line form, divided into six sections each requiring two answers of 75 words each. The applicant must discuss his or her educational achievements, how well he or she "matches the General Medical Council's Principles of Good Medical Practice, his or her leadership qualities and abilities to participate in teamwork."

Points will be assigned to each answer by a panel. There will be no attempt to check the accuracy of any answer. Based on the points assigned an applicant, "a computer is used to match applicants with jobs." Applicants will not be interviewed.

This new system provoked a letter written to the Times, signed by 84 academic leaders. The letter stated, "under this plan, our house officers, now known as 'foundation trainees', are being selected anonymously by computer rather than by interview." The letter noted that under the new system, 660 of 6035 UK graduates have not been accepted into a training position. Thus, "our students are understandably bitter, angry, demoralised and confused by a process that has been implemented without adequate consultation and without regard to pleas from the medical profession to continue interviews to select candidates for training." Furthermore, "it is difficult to identify the logic behind MMC." It warned, "despite the obvious failure of this year's selection process, the Department of Health is steaming ahead to procure a new IT system which will be used to select foundation trainees, perhaps wasting 8 million [pounds sterling] of public money."

An accompanying editorial asked, "how can adjudicators possibly assess individuals' character and potential without coming face to face with them?" In addition, "so long as adjudicators are selecting blind, students can massage their answers and attempt to manipulate the system. For instance, applicants simply have to tick a box stating that their spoken English is good enough to communicate with patients and colleagues on medical issues." The results have been, "bright and well-qualified applicants are finding themselves without a berth. At the same time, hospitals have reported a worrying number of trainees turning up for duty with an inadequate command of English or with substandard skills."

Commenting with trepidation.... As the Times editorial noted, it is rather hard to assess an applicants' clinical communication skills just by reading their responses to a web-based form. I have interviewed quite a few internship applicants, so I recognize that it is hard to distinguish among many well-qualified applicants. I value the interview, however, because it does allow me to identify the occaisional candidate who has severe difficulties interacting or communicating with other human beings. Abolishing interviews, in my humble opinion, certainly risks rating candidates by their "ability to talk a good story," as the Times news article put it.

It seems that UK managers have the same fascination with computers that US managers and executives have. It seems so easy and rational to take creaky, human based operations and streamline them by basing them on the web. This removes the need to deal with people directly, and their pesky individual characteristics. It fits with the ideas popular in the 1980s that to improve health care, rational managers had to take over from all too human physicians. But replacing human judgments with computer programs may produce a system that does not respond to human needs.

Post Title → No Human Touch

Another Big Pharma in trouble for "doctoring" information

Merck has been found in breach of the UK drug industry's code of conduct for modifying professional advice distributed to doctors treating high blood pressure, in a way that favored one of its own drugs. See story below.

There has been much in the news about possible manipulation or concealment of clinical trials data by the pharmaceutical industry. However, that industry also devotes considerable resources to medical education and development and provision of medical guidelines to the clinical community.

It is imperative that:

1) Such information development be done in a manner above reproach, which probably means as a non-profit venture with some degree of separation from the company's profit-driven management (such as in the case of the Merck Manuals and Merck Index), and

2) That non-medical people stop being given decision-making authority over clinical matters. Here, a non-medical employee of the British Hypertension Society "had authorized the change [in the guidelines to favor Merck] at the company's suggestion." Lack of medical knowledge, the likely problem here, while a better excuse for such conduct than, for example, illegal financial incentives or improprieties, is still a poor excuse for a non-medical person holding the ability to "authorize changes to clinical guidelines," especially in a medical society. Not mentioned is what happened on the company side. It seems both the company and the society were at fault here.

This reflects a problem I have noted in the Medical Informatics occupation, where the organizational structures in healthcare organizations and pharma place people into informational leadership positions who are lacking what I consider essential education and experience in biomedical information science. Their decisions are usually deleterious to efforts at improving informational provision and flow to clinicians and scientists, and a lot of time is spent devising ways to "work around the Boss."

This is often due in part to conflation of information technology and technologists with information science and information scientists. The two are distinct, but quite common is a profoundly Procrustean belief that being an expert in IT automatically makes one an expert in information science (Merriam-Webster: Procrustean - marked by arbitrary often ruthless disregard of individual differences or special circumstances).

Applied medical informatics work in such settings can thus be described as being "Director of Workarounds to Defective Organizational Structures", since that's what the incumbent spends a lot of their time doing - instead of more creative work that can advance the organization in useful and productive ways.

-- SS

Merck in trouble for doctoring advice

Merck, the US pharmaceuticals company, has been found in breach of the UK drug industry's code of conduct for modifying professional advice distributed to doctors treating high blood pressure, in a way that favoured one of its own drugs.

The Prescriptions Medicines Code of Practice Authority, the UK drug industry's self-regulatory arm, will next week rule against the company for changing guidelines compiled by the British Hypertension Society (BHS), a group of medical specialists.

The incident highlights the close links between pharmaceuticals companies and professional medical associations, which have come under growing scrutiny as part of a broader examination of potential conflicts of interest when drug companies market their products.

The probe was sparked by Des Spence, a Scottish doctor who runs No Free Lunch UK, a group of doctors that lobbies for greater transparency in the links between the medical profession and drug companies.

Mr Spence became concerned about information sponsored by Merck and widely distributed among doctors that described the so-called "ABCD algorithm" for drug treatment developed by the BHS.

The algorithm advises doctors which drugs to use to treat patients based on their age, ethnic background and reaction to different treatments. It recommends the first treatment of choice should generally be ACE Inhibitors, a class of cheap generic drugs.

However, Merck paid for and distributed thousands of cards, posters and computer mouse-mats for doctors for reference in their practices, in which the order and phrasing of the recommended drugs was switched to give greater prominence to its own more expensive patented drug Cozaar, which generated nearly $3bn in sales last year.

Professor Neil Poulter, BHS president at the time, said the "switch" by Merck was "a shame and an error". A non-medical employee of the BHS at the time had authorised the change at the company's suggestion.

Merck UK said it would not be appealing.

Post Title → Another Big Pharma in trouble for "doctoring" information

NHS Told: Put Money Before Medicine

I am wary of writing about health care systems in countries other than the US, since my failure to understand the intricacies of their contexts may lead to errors.
So I quoted the headline above from a story in the (UK) Guardian, and here are some excerpts:

Patricia Hewitt, the health secretary, will call for the end of the "handout culture" in the NHS this week and demand that financial management be put ahead of clinical objectives.
On Thursday, Ms Hewitt will issue the first rulebook for NHS managers in an attempt to eliminate the financial deficits threatening to destabilise reform plans for hospitals and primary care services. She is expected to say that financial management must have a higher priority than clinical objectives during the coming year, a shift expected to enrage medical staff.

It sounds like the medical staff will have reason to be enraged. I would say putting money before medicine is a good way to encapsulate the external threats to physicians' core values that certainly are not just an American problem.

Post Title → NHS Told: Put Money Before Medicine

When More Equals Less in the British NHS

The Times (UK) and other UK papers have reported on continuing deficits afflicting the UK National Health Service (NHS). For example, this Times report noted how London hospitals are delaying elective services for as much time as is allowed by national targets (e.g., outpatient appointments, 13 weeks, elective surgery, 6 months). Furthermore, "other NHS trusts are saving money by removing patients from waiting lists, a policy condemned yesterday by doctors." "Dr Paul Miller, chairman of the British Medical Association's consultants committee, said this practice was 'outrageous.'"

A Times editorial wondered why these deficits were happening, given that "NHS spending has increased by 20 billion [pounds sterling] since 2000, a 40 per cent rise." Particularly,

Money that voters expected to go to the sharp end has instead been spent on administration. Since 1998, the number of NHS managers in England has risen three times as fast as the number of clinical staff, doctors and nurses. At the same time, despite the injection of billions, NHS productivity has fallen 1 per cent a year since 1997, which itself is an indictment of those managers.

The rising numbers and costs of health care managers, accompanied by rising costs of health care, but not necessarily better access or quality, seems to be a frequent, if not global pheonomenon. (See our previous post about the rapidly rising numbers of US managers here.)

Again, part of the problem is that work in a bureaucracy tends to grow to occupy all the bureaucrats. A bigger part of the problem, as we just noted, is that many of these managers don't seem to understand the health care context, or share the values of health care professionals.

Post Title → When More Equals Less in the British NHS

Embattled Hospital Advertises for an Arts Curator

Things have been pretty tough for most hospitals in the UK. According to the Daily Telegraph, many hospital trusts have been going heavily into debt. In 2004, they were collectively 366 million pounds sterling in the red, and are projected to be about 800 million pounds in debt this year. As the Telegraph put it, "frantic cost-cutting measures had led to closed wards, cancelled operations, reduced staff numbers and angry creditors." Furthermore, "economists blame higher spending on NHS bureaucrats, increased reliance upon the private sector, higher costs of NHS litigation and higher wage bills." Although in 2000 the government "decided there were too few hospital beds per head of population," "the number of overnight beds in England has fallen steadily, from 186,290 in 2000 to 184,207 last year."
I wonder how those in the US who champion global budgeting in a single-payer health system as a way to nearly painlessly control health care costs would respond?
Meanwhile, a truly picturesque example of questionable management priorities has appeared. Addenbrooke's Hospital in Cambridge has been under fire since a patient committed suicide after asking a physician to "direct her to a tall building so she could jump off" (see the article in the Guardian) and for having one of the worst MRSA (methicillin resistant staphylococcus aureus) rates in the country (see article in the Cambridge Evening News). So the hospital received plenty of unwanted publicity when it advertised a part-time art director's position (at a 37,000 pounds per year rate), described as a "dynamic art curator to manage, lead and develop the hospital's art collection" (see the article in the Times). The hospital claimed that the money came from charitable donations, and that "the therapeutic benefits of art in hospital which embraces visual arts, poetry, music, dance and gardens is well recognised and encouraged by the Department of Health" (see the article in the Daily Mail.) But in the Times, an unnamed hospital nurse said "it's disgusting," and noted that the salary rate for the curator was only slightly less than that of a nurse manager.
The tendency of hospital administrators to focus on their pet projects, even when basic care is under threat, apparently is not limited to the US.

Post Title → Embattled Hospital Advertises for an Arts Curator

Unintended Consequences of Reducing Junior Doctors' Hours

From the Guardian, a reminder about unintended consequences.... The UK now must limit work hours of hospital house staff to the European Union limit of 58 a week. The previous limits were 72 hours "on call," and 56 working a week. Of course, the European Union regulations were not accompanied by any funds to pay for the work that house-staff could no longer do. The Guardian article describes how limitations on hospital staffing at night may mean that emergencies may not be attended by those physicians with the necessary expertise to handle them optimally. For example, the Guardian recounts how a geriatrician was required to attempt the resuscitation fo a newborn baby. Furthermore, some junior doctors charged they were coerced into falsifying reports of hours worked to avoid onerous penalties on their hospitals.

Post Title → Unintended Consequences of Reducing Junior Doctors' Hours