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Tuesday, December 24, 2002
Our UK Correspondent States British Doctors Are
Going to War Against the NHS
We’ve received a number of email over the past month from our UK liaison concerning the National Health Service’s (NHS) fight with doctors over work and pay contracts, which points out the fundamental mistrust that doctors and government have of each other. Although the current status of the “war” may have changed, for the purpose of our discussion it is the process that’s important. Americans should take note if they still think that a single-payer system will create an amicable relationship between doctors and the government without bartering the welfare and HealthCare of patients.
David Charter and Oliver Wright report in British News that several groups of consultants have formed private companies to negotiate deals for extra work with the NHS trusts and private hospitals. Consultants are not expecting an exodus from the NHS, but this could be the response for extra cash to clear waiting-list backlogs in the evenings and on weekends. Two of the examples cited are as follows:
A blueprint is PathLore, a private company of 50 pathologists in Nottingham. All physicians work in the NHS but sell out-of-hours services to NHS trusts. Ian Ellis, director of PathLore, said that although the company aimed to make a profit, it helped hospitals to reduce their waiting lists in order to meet government demands. “The NHS has a desperate shortage of pathologists working for them and hospitals have a certain amount of work which needs doing,” Dr Ellis said. “PathLore is simply offering these hospitals a chance to get the work done, at no greater expense to them or their pathologists.”
Another prototype has been set up by four urologists in Reading. Derek Fawcett, a consultant urologist who helped form the partnership, said it was driven by several factors, including the new clinical governance regime and NHS shortages. “There has been a feeling around about whether there is a different way of doing things rather than being an employee of the NHS,” he said. “We are a minority, we are a small profession and we are greatly in demand.” He said that he could foresee more surgeons sub-contracting themselves back to provide services “on a much tighter contract driven by us rather than the Department of Health.” He added: “We have formed a private partnership in order to deliver private practice within the same clinical governance lines as the NHS. It does give us a properly organised business basis to say one day, if we are so fed up with our terms of employment, we could retreat to that and sub-contract our services back to the NHS. I personally hope to God that never comes because I think the NHS is a worthwhile organisation but driven by too many targets.” (Doesn’t hope spring eternal?)
Defeated BMA Could Lose Power to Broker Pay
Health Correspondents Oliver Wright, and David Charter also reported in the British News that the British Medical Association (BMA) is facing the break-up of its power to negotiate doctors’ pay, admitting that it had lost the confidence of its members following a contract vote. Afterwards, Ian Bogle, the BMA’s chairman, admitted that the organisation had been “out of kilter” with its members. “We did not see things lurking in the woodwork, where 66 per cent of our colleagues did,” he said. “We thought the contract would work in the spirit it was negotiated . . . ”
The vote is likely to spell the end for the BMA’s role in negotiating contracts nationally. The BMA said that it would forcefully oppose any attempts by the government to try to introduce the new contracts “piecemeal.” Derek Machin, acting chairman of the consultants’ committee, said that the government needed to make sure it was in touch with BMA members and would be canvassing their views. “When we went around the country on road shows to explain these proposals, what was clear was that there was considerable vitriol towards the new contract,” Mr Machin said. “What has come out of this is a recognition that we need to reconnect with our members.”
He added that the question of waiting-list targets, which many consultants felt were distorting surgical priorities, was of crucial importance. He said: “Targets are a very major issue. Every consultant has had problems with political targets and many are very unhappy with them. Only about 25 per cent of consultants had made significant sums from private work yet 66 per cent of voters had rejected the contract. In a statement, Dr Hawker said: “Consultants have delivered their verdict . . . ”
Doctors Face Guerrilla War over Contracts
David Charter and Oliver Wright also reported that wounded Health Secretary Alan Milburn aims to pick off new NHS consultants one by one. Milburn was planning a war of attrition to divide and rule hospital consultants after they overwhelmingly rejected a new contract designed to slash NHS waiting times. The vote was a serious blow to the Health Secretary’s plans for reform and could fatally undermine the Government’s manifesto pledge that by 2005 no patient should wait more than six months for hospital treatment. Mr Milburn will now try to patch up his modernisation programme by encouraging hospital trusts to appoint all new consultants. These tactics will put him on a collision course with the doctors he most needs on board, the young specialists who voted four to one against the proposed contract despite almost two years of talks by hospital managers for the NHS and the British Medical Association for doctors.
Ben Franklin’s Essential Liberty Message
The BMA, which was the physician union that led British doctors into the NHS, is now at war with both doctors and the government. Is our own AMA following the same pattern? Does the US want a health care war like the UK’s health care war? Do we really want to hold the medical profession hostage? Despite the continuous reforms of the British NHS for 50 years, desperation continues as people fall through the “safety net”–dying before their number comes up to obtain health or hospital care. It seems appropriate to paraphrase Ben Franklin’s essential liberty message and apply it to health care: They who give up essentially high quality private-based health care to obtain a little temporary single-payer safety net, will have neither high quality health care nor the health safety net.
Excessive health care utilization is not always patient directed. Sometimes the patient is totally on the byline of what’s happening to him or her since no one looks to the patient for payment in a free healthcare system. A friend told me that his mother, who was 91 at the time, experienced some chest pain. Her family doctor informed her that since there were a number of new cardiac drugs which might benefit her, he would like a cardiology consultation. The cardiologist, however, did a catheterization and found some nearly occluded vessels. He asked a cardiac surgeon to do a coronary artery bypass graft (CABG). After five days, the usual length of stay for the procedure, the family was told that, being an old lady, she would be sent to a convalescent hospital for a month or so. In fact, she spent the next 40 months in the facility–dying there. A year or so later, the family recollected that they had been relatively uninvolved in any significant discussions about the risks vs benefits of the procedures, including the CABG. It had merely been a case of “sign here” and “we need to do that.” The pain his mother experienced prior to the operation wasn’t all that severe and was not incapacitating. They had only requested a cardiology consultation for medical treatment that their personal physician had recommended. Now the family believes that with appropriate discussion, they would have preferred to have their mother in her own home a half block away, even if she had died in a few months, rather than the forty months she spent in a convalescent hospital several miles away at a great inconvenience. They sold her house which just covered the $120,000 convalescent hospital at $3,000 per month. The taxpayers through Medicare took care of the $125,000 hospital bill. But in retrospect, they believe the quarter million spent was of no value to their mother, that it actually worsened her quality of life and caused great inconvenience and emotional duress to the family. In the open Medical MarketPlace, full disclosure would naturally occur at each step of the way and any unwanted or unnecessary procedures would not be done. The lesson that seems so difficult to learn is that such unnecessary and unwanted extravagance can only occur with third-party payment when the patient is uninvolved in the purchase of health care. That is why all socialized or single-payer initiatives will always fail. Writing checks on the Federal treasury will bankrupt any nation, even the wealthy ones.
National HealthCare Systems in the English-speaking
World (No 9)
In his recent update of the “Twenty Myths about National Health Insurance,” John C Goodman, PhD, president of the National Center for Policy Analysis (www.ncpa.org), states that ordinary citizens lack an understanding of the defects of national health insurance and all too often have an idealized view of socialized medicine. For that reason, Goodman and his associates have chosen to present their information in the form of rebuttal to commonly held myths.
Myth Nine: Countries with Single-payer Systems
Eliminate Unnecessary Care.
A frequent criticism of the US health care system is that it is wasteful because a considerable number of procedures are “unnecessary.” For example, in 1989 Robert Brook of the RAND Corporation asserted that “perhaps one-fourth of hospital days, one-fourth of procedures and two-fifths of medications could be done without.” In support of this contention, RAND researchers pointed to wide variations in 123 medical procedures for Medicare patients in various parts of the country. The rate at which the procedures were performed varied by as much as 6, 7, or 8 to1, with no apparent explanation. Areas that were high in performing one procedure were often low in performing another. Other studies have found similar results. But knowing there are variations does not reveal whether some patients are being shortchanged and others over-treated.
The RAND Study of Unnecessary Care.
A subsequent RAND study collected medical records for 5,000 Medicare patients treated in 1981 and convened a panel of experts to judge the appropriateness of three procedures. The results showed that in slightly more than a fifth of the cases, the procedure performed was judged inappropriate and therefore unnecessary. For carotid endarterectomy (the removal of plaque in the major arteries to the brain), the procedure was judged appropriate only about one-third of the time. National media widely reported these results, and they became Exhibit A in building the case for the managed care revolution during the 1990s. But a closer examination reveals there was more going on than first meets the eye: Why did RAND need to convene a panel of experts? The reason was that researchers could not answer questions about appropriateness by merely consulting the medical literature. Once the experts were convened, they were far less unified than media reports suggested.
Reexamining the Evidence of Unnecessary Care.
In the RAND study, each expert initially expressed a personal judgment. Thereafter, they met for discussions wherein group pressure favored consensus and members often changed their minds. Indeed, the most remarkable fact about the RAND study was that even with all of the efforts to arrive at a definitive judgment, 7 of 9 experts could agree less than half the time that the procedures were either definitely appropriate or definitely inappropriate.
Unnecessary Care in Other Countries.
One might suppose that in countries where health care is rationed and many medical needs are unmet, doctors would tend to provide only “necessary” care. This turns out not to be the case. According to RAND research, those who receive care may not be those most in need of care. A review of the medical records on CABGs performed in the Trent regions of Britain found that many were performed for less than appropriate reasons, using both British and American criteria. In some regions, coronary angiograms and CABGs were found to be inappropriate about 50 percent of the time and 60 percent of gallbladder removals with a laparoscope were judged to be inappropriate when reviewed by a panel of experts. The RAND research found similar results in other countries with national health insurance as well. In Israel, the study found that 29 percent of gallbladder removals were performed for what it termed “less-than-appropriate” reasons. Another report found that in Sweden, 19 percent of referrals for coronary revascularization were judged to be inappropriate.
The RAND summary concluded, “Contrary to the researchers’ expectations, habitual rationing of resources did not restrict use of these sophisticated and expensive treatments to only those who would most clearly benefit from them.” Similar findings apply to other European countries besides Britain.
FINAL ISSUE OF SCANDLEN'S HEALTH POLICY COMMENTS
Greg Scandlen of the National Center for Policy Analysis announced that SCANDLEN'S HEALTH POLICY COMMENTS of Wednesday, December 4, 2002 was the last issue of his newsletter. He invites us to subscribed to the NCPA’s Weekly Health Policy Digest which is a weekly compendium of articles that have been presented in NCPA's Daily Policy Digest. You may subscribe to this by going to http://www.ncpa.org/sub/. In fact, if you haven't already, be sure to check out all the other resources NCPA offers on its web site at http://www.ncpa.org. Look especially at the "Debate Central" site at http://www.debate-central.org/. Greg assures us the NCPA will continue to offer the most comprehensive collection of free-market health information available on the Web. We will print some of his highlights we’ve held over from his reports as the occasions arise.
Is There an Advantage to Competition in the Practice
On this eve of Christmas, we pause to reflect on why people of every religious and ethnic group want to enjoy the freedoms of our country. Perhaps the radical son, David Horowitz said it well when he stated in a medical conference that at no time in history have his Jewish people enjoyed such freedom as they have in a Christian country as ours. He also said it really didn’t fully materialize until there were Protestants competing with Catholics for the hearts and souls of mankind. I have many Hindu, Sikh, Muslim, and Buddhist friends who want their families to come to the USA where they can enjoy religious and economic liberties unavailable to them in their own country. It is Christmas that has given us the greatest religious tolerance and freedom the world has ever experienced. So on this Christmas eve, may we wish each and everyone of you a Joyous Twelve Days of the Christmas season with your families and loved ones.
MedicalTuesday Recommends the Following Efforts in
The weekly Health Policy Digest, a health summary of the full NCPA daily report, can be accessed by logging onto NCPA (www.ncpa.org), where you can also register to receive these reports. The Mercatus Center at George Mason University is a strong advocate for accountability in government with Nobel Laureate Vernon L Smith, PhD, on the faculty. You may register your email address or read their government accountability reports as well as information on Dr Smith at www.mercatus.org. Martin Masse, director of the Montreal Economic Institute, is the publisher of the webzine: Le Québécois Libre. His enlightening free market-based articles can be found at www.quebecoislibre.org/apmasse.htm. We also recommend the market-based reports of Lew Rockwell, president of the Ludwig von Mises institute. Please log on at www.mises.org to obtain the foundation’s reports or log onto Lew’s premier free market site at www.lewrockwell.com.
MedicalTuesday Recognizes the Following Efforts in Restoring the Doctor & Patient Interface: PATMOS EmergiClinic - www.emergiclinic.com - where Dr Robert Berry, MD, an emergency physician and internist, provides prompt care for many of the injuries and illnesses treated in Emergency Rooms at a fraction of their cost as well as an internal medicine practice; Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP) www.sepp.net for his efforts in Protecting, Preserving, and Promoting, the Rights, Freedoms, and Responsibilities of Patients and Health Care Professionals, with a special page for our colleagues in nursing; SimpleCare for their success in restoring private practice, www.simplecare.com; HealIndiana as a supporter of market-based medicine, www.HealIndiana.org; and the AAPS representing physicians in their struggles against bureaucratic medicine www.AAPSOnline.org.
Stay Tuned to the MedicalTuesday.Network
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Del Meyer, MD, CEO & Founder