The Ether Way

The Saga of the NHS continues - in the BBC & elsewhere

I'm long overdue to post... and hope that this entry will serve.....

Several of my previous posts have dealt with the failings and trade-offs associated with government administered health care.  Unbeknownst to most Americans, Britain's NHS 'devolved' into 4 'national' services some time ago, serving, England, Scotland, Wales, and Northern Ireland. 

This recent series of articles by the BBC:

http://news.bbc.co.uk/2/hi/health/7149423.stm

http://news.bbc.co.uk/2/hi/health/7140980.stm

describes how England, Scotland, Wales, and Northern Ireland have diverged in their provision of health care since the 'national' system was broken into 4 parts some time ago.  While each participates in the 'NHS', the reality is that each independently administers its own Health Service.

As readers of this blog might have predicted, there has been propaganda about the benefits associated with 'devolution':

http://news.bbc.co.uk/2/hi/uk_news/scotland/3850805.stm

but when serious analysts wanted reliable data, most of what they got was rubbish:

http://news.bbc.co.uk/2/hi/health/4361964.stm

Commendably, interested parties have persisted in their efforts to understand the NHS, and the first two stories from the BBC above summarize their findings.  Below is a cut and paste from one of them about the characteristics of the different national systems:

England - NHS market created whereby hospitals and community services have to compete with the private sector for patients, resulting in big falls in waiting times

Scotland - Doctors have much more of a say in services, with limited involvement from the private sector. Meanwhile, patients enjoy free personal care, unlike the means-tested systems elsewhere

Wales - Close working relationship between the NHS and local government, which has meant more innovation on public health, but less emphasis on waiting times

Northern Ireland - Somewhat hamstrung by political situation, but re-organisation of trusts pushed through and good integration between social care and NHS

More information is available from these sites (the BMA site is rich with info, the others are rich with flavor):

http://www.bma.org.uk/ap.nsf/Content/devolution2007~devolution2007political

http://www.guardian.co.uk/society/2008/jan/02/nhs.health?gusrc=rss&feed=networkfront

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2008/01/02/nhs702.xml

More on the performance of nationalized health care

As the election season draws nearer, health care reform continues to vie for position as a leading issue amongst the presidential candidates. Once again, the public should expect to be regaled with stories of the compassion and fairness of such systems, as well as their potential for efficiency. Peer reviewed studies and surveys that portray such systems favorably will be widely quoted.

The recent bill to dramatically expand health insurance for children, vetoed by President Bush, is likely to evolve into a defining campaign issue. Why?  Because it is trivially easy to cast opposition to such a well intentioned program for the innocent as mean.  Bush, and many of those opposed to the bill, believe that it was another step in the gradual expansion of federal control over health care in the USA. Be certain, the language of this particular bill laid down the scaffolding for the extension of this entitlement by subsequent legislation.  Bush may or may not be mean, but he is opposed to nationalized health care.

How are nationalized health care systems doing since I last blogged about them?

Below are a few pointers to interesting stories, and what they mean to me.

Britain's NHS continues to be under-funded to a substantial degree. Like many such organizations, they have shifted resources from longer-term objectives to deal with shorter-term crises.  One way this is accomplished is to 'defer' maintenance and replacement activities.  The NHS, whose standards for physical plant and equipment are substantially lower than the US's, has done this:

http://news.bbc.co.uk/2/hi/health/7060379.stm

4 Billion pounds - about 8 billion dollars - in a country with about 1/6 the population of the US - would scale up to about $ 48 billion here.  Why the backlog? The story makes the reasons obvious:

1. There was a bureaucratic imperative to demonstrate a surplus.  They did it by shifting all of their maintenance and capital budget to the future. The shadow health secretary quoted in this article refers to this as 'a sham.' I believe he is being generous.

2. They are so over capacity that they cannot close any substantial structure for renovation without causing serious disruption of service at a regional level.

To be fair, $48 billion dollars is a small amount in US dollars relative to the US health care budget - but it is also enough money to build 48-100 new hospitals…. which is a lot of capacity.  The real problem is that they have absolutely no excess capacity in their system, largely as a consequence of previous efforts at 'cost containment.'  But parts of England are much poorer than most people realize, with > 20% of the homes in places like Liverpool, Birmingham, Portsmouth, and Leeds not having central heat (or not being able to afford turning it on):

http://news.bbc.co.uk/2/hi/uk_news/7063120.stm

The British spend over $ 3 billion a year helping these people stay warm.

Spin, the modern synonym for propaganda, continues at the political level for Britain's NHS, as demonstrated by these items:

http://news.bbc.co.uk/2/hi/uk_news/politics/7063430.stm

http://news.bbc.co.uk/2/hi/health/6725725.stm

http://news.bbc.co.uk/2/hi/health/7061590.stm

   

I could be derisive, but it would be hard to surpass the language of the usually sympathetic BBC in these stories.  There are several features of nationalized health care systems that are self-evident in these stories:

- progress is announced (sometimes untruthfully) in synchrony     with election schedules
- failure is not an option (propaganda can be used to obscure all     substantial failings)
- the leadership of such systems are those who are most  politically pliable, not the most competent
- this in turn permits fantasy planning, with outrageous     under-estimation of the time and expense of major projects (3 years vs 10, 2.4 Bn vs 12.4)
- budgets must conform with legislative allocations (requiring the layoff of a mere 17,000 healthcare workers) and are completely disconnected from demand, and
- politicians can divert vast sums for publicity stunts. 

The reduction in personnel is causing a crisis independent of problems related to maintenance:

http://news.bbc.co.uk/2/hi/health/7064398.stm

To me, the most important message of these stories is that there is now profound skepticism, at every level, of all information disseminated by the NHS.  A nationalized health care system in the US would likely arrive at a similar relationship with its press and public very, very quickly.  The major difference is that the US press would gladly vilify practitioners at the behest of politicians, a practice that the BBC is now too wise to engage in.

While the US press is usually a venue for fluff pieces which portray Britain's NHS quite favorably, the BBC publishes stories that create a completely different impression:

http://news.bbc.co.uk/2/hi/health/7062473.stm

Think about it - less than a third of diabetes receive the testing that the NHS mandates they should.  If you read the article, it's clear that the NHS does a lot of things related to diabetes care well, and is making a concerted effort to make almost everything better. Once again, failure is not arising from incompetence or lack of motivation at an individual level, but rather from a system whose resources are generated by coercive taxation and redistributed at the pace of elections and governmental fiscal cycles.  The successes and failures here are both arising from the structure of the NHS.

How is the NHS doing? Well, the truth is that it is hard to tell.  One thing is certain: medical tourism is thriving and growing in parallel with the NHS, with increasing numbers of Britons willing to pay cash out of their pockets to receive care in dozens of countries (most of which would have been inconceivable as alternatives even 15 years ago).

http://www.treatmentabroad.net/

Ultimately, it may be that our most reliable indicator of how well and nationalized health care system is functioning will be the number of such 'refugees' that it generates.  Using this as our metric, it would seem that while its leadership represents that everything is getting better, things in Britain's NHS are in fact getting much worse.

While composing this post, I felt like I was shooting fish in a barrel.  The bad news about Britain's NHS isn't hard to find.  All of the above pointers are to news stories from 2007.  Of course, bad news sells, and sells well.  The good of the NHS (like its care for the indigent with chronic diseases and cancer) isn't news. Sadly, the thrust of all of the news is that the NHS is failing by almost every measure.  This matters, as the British have the greatest experience of any western country operating a nationalized health care system.  They know how to do this - they understand the planning, the logistics, the personnel issues, the oversight, and the regulation.  On a large scale, this is likely to be as good as it gets.  Think about that.  Is Bush wrong to reject this? Is he mean? Or is he prescient in supposing that nationalized health care will work about as well as nationalized farming did in the Soviet Union?  Only history will know for sure.  Mere mortals must make their best guess using the information at hand.

Finally, it is worth mentioning that most of our information about nationalized health care comes from the press of English speaking countries.  Why? Because they generate English language documentation and news coverage.  Both the good and bad of other nationalized health care systems receive less coverage because of this language barrier.  Every once in a while, a story appears that hints at how things might be going in other countries.  Take this one from Japan as an example:

http://news.bbc.co.uk/2/hi/asia-pacific/6970192.stm

I am certain that Japan's system, like England's, has many good features. But, like every system, it's not all good, no matter what its' propagandists and spin doctors say.

Pain: The Sixth Vital Sign?

1996 – Physicians in the US treat pain conservatively.  Their practice pattern is shaped by many forces, including concerns about patient safety, chemical dependence, and diversion of prescribed opiates.  Pain in many patients is undertreated.

1999 – The Veteran’s Health Administration announces an initiative that characterizes pain as the 5th vital sign.  Highly touted, it accomplishes nothing, at least not in the first 5 years (1).

2000-2001 – The JCAHO, perhaps following the VA’s lead, announces its own initiative, also endorsing pain as the 5th vital sign.  Pain is subsequently conquered, victory is declared, and everyone lives happily ever after.  Okay, maybe not. 

    As you might expect, progress was far easier to advocate than effect.  Once again, to practitioners, the supporting documentation reads more like a poorly written horror novel than useful guidance (2)

(Click on Image to Enlarge) This is a graphic from an educational tool (2)…. I have so many problems with it that I don’t know where to begin.
    1. Everyone was taught about pain and how to manage it as a student and resident.  Everyone.  Some learned more than others, but the importance of managing pain was recognized well before the JCAHO and VA discovered it.
    2. CME for pain was proportional to how much you encountered: surgeons and oncologists talked a lot more about it than dermatologists and radiologists.
    3. Dependence, respiratory depression, and side effects are all real concerns…as is concern about regulatory scrutiny.
    4. I will admit to limited availability of role models and access to pain docs in some settings.  Both were legit then, and are now.
    5. Patients are indeed the experts about their pain.  But patients are humans, and that spans the spectrum of personalities and psychiatric disease.  Crazy people get sick and have pain too. Managing pain in patients with psychiatric disease requires a deep understanding, that is to say understanding that is more than one powerpoint slide deep.  If you understand the prevalence of psychiatric disease, and its higher prevalence among the chronically ill, you understand that this is not a minor consideration (but does manage to show up no where on their map of the world).  There are other problems with this whole self-reporting thing, as we will explore briefly below.

There has been little effort to measure the success of the JACHO initiative, but there is evidence of its aftermath.  Sales of opiate based analgesics have increased dramatically (approx 100%)(3).  It is certain then, that physicians have become more liberal in their use of opiates to treat pain.  Of course, the increased problems with chemical dependence, feared by reactionaries but not by the champions of these policies, have come about exactly as predicted (4), (5), (6)).  Even the bizarre predictions became true: that there would evolve a group of ‘professional’ patients who would visit multiple pain clinics, self-reporting chronic pain, garnering multiple prescriptions, and reselling their drugs on the street.  Opiates are dangerous to abuse, and those who care to can easily measure the body count associated with the new era of pain control (4).  Once again, it’s not small…. and it’s far more the direct product of these campaigns than their architects are willing to admit *.  To be fair, it is certain that human nature, human biology, and human avarice are the most important drivers of this problem; these initiatives simply made it worse.  Dare I say that while no one ever died of pain, lots of people have died (in the past few years) from its treatment? Or at least in part as a consequence of these initiatives?

 

We’re from the government, and we’re here to help.

   Everyone knows that this statement is generally untrue. It’s a whopper, right up there with “the check is in the mail” and “I’ll respect you in the morning”?   When is this true? Ironically, most often, when members of the armed forces are conducting operations ordered by their Commander-in-Chief (humanitarian or combat missions).  When is this not true? Well….

    As a group, proponents of health care reform advocate a greater government role in the provision of health care.  The more limited proposals advocate some combination of greater regulation and more extensive participation (e.g. expanding Medicaid).  More ambitious proposals would produce explicitly or functionally socialized health care. As we deliberate about the options, it is worth remembering that the US government in already in the business of health care,

    Not only is the US government already in the business of health care, it in fact runs 3 large health care systems in parallel.  The first is the military health care system, which in fact is a hybrid system of military hospitals specializing in the care of combat casualties and an HMO that specializes in procuring care from the lowest bidder (and if you have any friends in the service, you can ask them how it works).  The second is the Veteran’s Administration, which is one of the largest, if not the largest, vertically and horizontally integrated providers of health care on the planet.  The third is of course the Medicare system, which has been a growing force and shaping healthcare since its inception.  Only a few visionaries predicted the role that Medicare would have in shaping health care when it was proposed.

 

Everyone does it, but no one writes about it

What the heck am I doing here?  Why am I here?  More specifically, why have I agreed to participate in a blog?

    Because in medicine, there are a large number of subjects that everyone thinks about and talks about, but no one writes about.  As a group, these subjects are too social for our journals, and too political for our organizational newsletters.  The scientific front-story of medicine receives excellent coverage in our journals, as do the explicit economic issues in our various societal newsletters.

The back-story, the issues surrounding the social construction of health care at the individual, group, hospital, and societal level, has no venue for conversation.  We all wonder: where is this going? We talk about it, but there is nowhere to read about it.  The result is highly local, mostly poorly informed and poorly formulated discussion.  So what? It matters.  The truly radical changes in medicine today are in its social structure as much as in its scientific underpinnings and clinical practice.  As a group, physicians are uninformed about these social issues.  Worse, we are untrained to think and write about them.  There’s a lot to know about the social construction of health care, and physicians don’t even know where to begin.
   

Hiding the Bodies

    Although the US presidential election is more than a year away, it is already election season in the US, and would-be candidates out there raising their profile and as much money as they can.
    With campaigning comes campaign promises, which are generally worth the paper they are written, no matter which party the candidate is from.  That said, several of the Democrats have been floating proposals for health care reform.  The contention is that the US health care system is broken, and needs fixing desperately.  The candidates differ in how they think it is broken, where it is broken, how badly it is broken, and how to fix it.  The popular press is already infiltrated with the usual fluff pieces intended to serve as background material - much of which criticizes the US health care system while heaping praise on its alternatives.  One of the most popular alternatives is the British model (the National Health Sevice or NHS), which has its own combination  of strengths and weaknesses.  But no health system is perfect.  Worse, centrally controlled government health care systems retain complete control of the data they generate, allowing them to have near complete control of their image: the data that is made available to outsiders, how it is presented and analyzed.  This problem is compounded by the usual difficulty associated with collecting accurate data in any modern health care system. Trust me: I understand this one from direct personal experience.  If the people abstracting charts or gathering data for such report cards don't know what they are about, they will not ask for help.  They will produce complete rubbish and call it a report card.
    It has long been known that predicting long term demand (5 or 10 years into the future) in health care is tricky.  It is likely somewhere between difficult and impossible.  In the US, the law of supply and demand tends to minimize shortfalls in the availability of health care for the vast majority of its citizens.  In Great Britain's NHS, this translates into a substantial mismatch between resources and demand, which has in turn translated into long waits for some kinds of service.  It is also likely that this problem is further aggravated by systematic under-resourcing of health care.  That this is a problem is now explicitly acknowledged by the NHS, and they publicly track the wait for a variety of services:

http://www.waiting.scot.nhs.uk/

Interestingly, participants in the NHS are not especially realistic about the wait times, all of which are far longer than typical US waiting times:

http://news.bbc.co.uk/2/hi/health/3749801.stm

The Academic Struggle

1. The stature of medicine has changed relative to other career choices.  Highly motivated individuals choose medicine as a career much less frequently than they did when we were younger.  Medicine, which is increasingly hobbled by regulation and outside interference, is much less attractive than either business or law.  Go-getters have gone into other professions.

2. The hey-day of NIH funding in the 1970s and 1980s - when the NIH had more money than good research to fund - is the baseline that academic institutions utilize when shaping their goals and expectations for NIH funding.  The pie has gotten smaller, the quality of the work has gotten substantially better, and the number of people competing for funding has increased enormously.  The award rate is low - 10% - and likely to go down, not up, for the foreseeable future. Many believe that 'outsiders' may face insuperable obstacles to obtaining NIH funding.  Regardless, I believe that academic chairs - in all specialties - are well advised to not count upon the NIH for funding.
    Importantly, the science funded by the NIH is increasingly highly specialized. MDs are less and less competitive for the funding in the few areas that are not highly specialized.  The sad truth is that most people who obtain PhDs in biology cannot successfully compete for these funds. Indeed, the basic science has become so specialized that the people executing it may not appreciate its clinical ramifications.  Only a small subset of clinicians have the competence to (and do) read the associated basic science literature.  I remain astonished at how little I hear about P2X3, ASICs, C-Jun kinase, and JNK in our world....    The sad truth is that the manipulation of these receptors should be within the provenance of anesthesia, and it’s not.

3. There is no NIH set-aside money for anesthesia.  All of the higher-ups understand this, but it bears mention.  Why? Because even in domains where there is set-aside money (e.g. trauma), there is no longer sufficient money to keep everyone who wants to be or should be funded in money..... which is why the number of NIH funded MDs continues to decline, and is approaching the number of NIH funded anesthesiologists...
    I wouldn't bank the future on NIH  money though.  As someone who worked with an NHLBI funded researcher as a fellow, I know from direct personal experience how the HIV budget was doubled every year while the NIH budget stayed flat. 

4. The NIH payscale continues to lose ground to private practice dollars.  This is especially true in anesthesia, but is also a problem that plagues all academic medical specialties.  The sad truth is that the only way that the NIH has been able to retain investigators at the NIH is to allow them  to moonlight for the pharmaceutical industry in droves.  Attempts to control and manage this have been unsuccessful, as any ‘reasonable’ policy would require them to turn out the lights on an empty campus.

5. The proportion of students and residents who are married and have children has grown (or seems to have) over the past 20 years.  I attribute this to both the change in the kind of person who goes into medicine and may be a consequence of the HIV epidemic (which has pushed those who plan to marry to do so earlier than they once did). As a group, these people are less likely to arrive early and stay late.  This significantly diminishes their development as academics.  It has also generated the best predictor of academic success I now have - which is seeing someone here at 1800 doing non-clinical work.

6. Geographical Isolation.  As a group, we no longer practice in a very restricted geographic area, but are sprawled across an enormous complex.  This frustrates all efforts to assemble the group to a far greater degree than anyone appreciates.  Whereas it was once possible to have everyone assemble in the chairman's office or the break room for a quick 30 minute meeting, more than half of our faculty are now engaged in clinical activity that is a quarter mile from these locations.  Mid-day assembly is a terrific advantage to those departments which can sustain it.  Medicine grand rounds is a mid-day event- everyone can make it (attendance is not always great).  The price? You push some work later into the day... and stay late that day....  These mid-day meetings are an important source of stimulation and positive reinforcement from which procedure-driven medical specialties are increasingly isolated.

7. The 80 hour mindset will be a substantial obstacle for our junior faculty to overcome.  That this is in place for Gen-X will make overcoming it that much harder.

8. The regulatory burden of research has grown enormously in the past few years.  Whether your interest is in conducting human studies or animal studies, the requirements for training in 1. the protection of human subjects 2. HIPAA, and 3. Animal use and care have escalated substantially (animals still have better protection than humans).  It is no longer easy for someone competent to conduct a study to execute the necessary paperwork - they have to complete a variety of courses and training intended to increase their competence.  At most academic institutions, the IRB has become one of its largest bureaucracies, and a large number of people at these institutions now find at least part-time employment in generating the documentation needed to comply with IRB requirements.  All of this has increased the friction to doing little studies, and the start-up costs for anyone who is interested in participating in them.  One of the reasons why US based research is shifting in the direction of endless surveys and into safety is because these domains are substantially less encumbered by these regulations.  This is important - we still have faculty who are asking questions and following the path of least resistance to generate insight.  If  you haven’t found all of the obstacles yet, there is growing pressure to register every clinical trial.

9. The teaching rule.  In every other medical specialty, academics can generate income while providing clinical service at a rate which surpasses what they could in private practice.  Full professors of medicine typically earn as much or more than their private practice counterparts.  In anesthesia, a career in academia entails an absolute decline in lifetime earnings that can never be offset.  While this restricts academia to those who truly feel the call, it also prevents residents with substantial medical school debt from choosing it as a path, no matter how strongly the sirens might sing to them.

Experience

    Good Outcomes are the product of experience.  Experience is the product of bad outcomes.  That's how I learned the dictum and it's still how I repeat it.

    Patient safety has been a real interest of mine - both academic and professional - for over a decade. Safety and quality are confused and conflated in the minds of physicians, academics, health care management, government regulators, and the lay press.  Safety is about avoiding accidents and disasters from the routine delivery of healthcare; quality is about producing the best possible outcomes with the resources at your command.  There are very few people who have substantial understanding of safety in healthcare, and there cannot be anybody who has a complete understanding. 
    Bad outcomes? They're statistically measurable, you may not be able to predict which patients will have them, but if you find a group large enough, you'll be able to predict the rate of these outcomes with great precision. Examples? Death, stroke, and renal failure after cardiac surgery, catheter related blood stream infections, and urosepsis from bladder catheters are a few.  Quality might be about reducing the incidence or severity of post-operative nausea and vomiting, a relatively common problem.  Safety is about extremely rare events - chemotherapy overdose, wrong side surgery, and such.
    I'm a questions guy, not an answers guy.  If you want answers, find someone else.  Experience has taught me that finding and framing the question in many topics is extremely difficult, and constitutes a substantial portion of the real intellectual work.  Experience and the literature - basic science and clinical(applied) - inform but almost never 'answer' questions.  People who have a deep understanding of any topic appreciate this.  As group, they make poor television and newspaper interviews. 
    Like Mitch, I highly value experience.  Much of the story of medicine for the past 15 years has been about the systematic devaluation of experience.  Where muddy tales of experience have been supplanted or complemented by high quality clinical studies, this has not been a problem.  Where precious experience has been displaced by shoddy clinical science and 'expert' opinion....... the effect may even have be deleterious.  In his post, Mitch has pointed out that the world of medicine accords too much respect to weak studies.  I concur. The meaning of studies is far less evident to those with experience than those without (or with political or economic agendas).  There are numerous instances where very similar studies of the same problem have produced contradictory results.  How should we proceed? That would be a suitable subject for a book, or perhaps another post in the future.  Suffice it to say, that practitioners fall back upon either their bias or their experience when sifting through the literature.
    The centerpiece of experience is time in the trenches.  There is no substitute.  With that time comes both the glory of great saves and the heartbreak of failures.  As practitioners and communities, we measure everything we think we know and understand by how it maps with our own experience.  Everyone with substantial experience has substantial experience with bad outcomes.  Compassionate practitioners think about their failures and learn everything they can from them.  The learning (individual and collective) may be the only good that comes from these events.  Bad outcomes have a real impact on practitioners, who can sometimes become secondary casualties of these disasters.  If we expunged everyone associated with bad outcomes from medicine, there would be no one left to provide care for our patients.  My claim is this: our failures of yesterday empower us to produce our successes of today.