Labour begs to be screwed by private sector. Again.

With alarming regularity, the Labour government decides that the private sector is somehow going to magically solve the perceived problems with any public sector organisation. The latest, if true, comes from this story on the BBC website. Failing hospitals, as identified by their inability to meet government targets, will be ‘encouraged’ (told, perhaps) to get managers from either succesful NHS trusts or the private sector to try and run the hospitals. Now, bringing in successful NHS managers might be a good idea. I can support that on the grounds that running one NHS hospital successfully may be an indicator that a person can successfully run a different NHS hospital, though it doesn’t guarantee it of course. But bringing in people from the private sector is fraught with danger. This statement, from the health minister Ben Bradshaw is the most alarming: 

“But there may be examples where no NHS hospital is interested in taking over a failing hospital, or where local NHS managers think that in order to have more competition and choice for people locally that bringing in a private manager on a franchise arrangement will be the most sensible idea”

Franchise arrangement seems to be code for privatisation. Bring in a private manager under a franchise arrangment as far as I can tell will mean that Anytown NHS Hospital Trust will soon read ‘Virgin (or Boots or whoever) Hospitals Anytown, providing services to the NHS and private sector’. This would be a very bad thing. Private sector healthcare providers have a different objective than do public sector providers because the private sector needs to generate profits and the public sector does not. How does the private sector generate profits from the NHS - by cutting costs. And what happens when costs are cut - care for patients is comprimised.

Now, I don’t think the private sector is entirely bad, obviously. Where would we get new drugs if it wasn’t for the pharmaceutical companies after all. I just think that when the objectives of the private and public sector clash we have to be very careful about the solutions to the problems we are facing. The private sector is no panacea either, and has no monopoly on good management. If you doubt this, then think about the current credit crunch/sub-prime crisis, entirely a result of private sector managers managing poorly. Ministers should be awfully careful about the magic word competition - it doesn’t necessarily improve the product on offer.

Mixing public and private care

In today’s Guardian there is an article about a woman who was denied access to treatment on the NHS because she opted to pay for part of her treatment privately. This woman was diagnosed with bowel cancer that had metastisised to other parts of her body including her stomach and underwent the conventional first and second line therapies that are offered by the NHS. The woman, Linda O’Boyle, has now unfortunately died.

What is interesting about this case is the fact that reason she was denied continuing care on the NHS is because after not responding to the conventional treatments, she wanted to try the drug cetuximab, a newish treatment on the market that is currently undergoing reviews to see if it should be licensed and whether or not it is cost-effective for certain forms of colorectal cancer (the newspaper uses the term bowel cancer but my experience is that colorectal is the preferred term). In 2006 NICE issued guidance that it was not recommended for use as a second line treatment. It is currently being reviewed for clinical and cost-effectiveness for first-line treatment of metastisised colorectal cancer.

Negative externalities

Externalities feature prominently in welfare economics. And they are a serious business in health economics. Externalities are those things that arise out of a transaction but that are not a direct component of that transaction. So for instance the person that buys petrol and the firm that sells it to them represent the transaction, and the benefits to each can be easily measured. The person gets to drive their vehicle and the firm gains revenue. But as we all know (though some continue to deny) when the petrol is burnt it releases green house gases, primarily carbon dioxide. Because this effect of the transaction isn’t reflected in the cost of the petrol and it happens to fall on other people who are not part of the original transaction, this release of greenhouse gases is an externality - and most people would agree that it is a negative externality.

But all that is very serious and since this is not a serious post, I shall return to this concept in a more serious fashion at a later date.

I’m more concerned with a less important example of an externality. In the UK, we are coming quickly upon the first anniversary of the ban on smoking in public places. If we think of this as a transaction between government and the populace with the intention of improving public health generally and the health of certain groups of workers more specifically then we can judge whether the ban is economically efficient by comparing the improvements in health with the cost of introducing the ban. But that’s a job for someone else.

Here, I am concerned with one positive and one negative externality. The positive is that my clothes now no longer stink of smoke when I get home from the pub meaning I can wear the same shirt or jumper the next day without necessarily having to wash them. The negative one is that all of my favourite pubs stink. Of piss. When you were allowed to smoke in pubs this seems to have covered the scent of stale urine wafting in from the gents toilets. This is absolutely a negative thing. It has made one of my former favourite places virtually uninhabitable as far as I am concerned. I bet no one saw this coming when they proposed the ban. They could have included incentives for pubs to improve their toilet facilities if they had foreseen this problem. This particular externality is borne by the publicans, since they don’t much benefit from the smoking ban in economic terms (few pubs will have seen their revenues increase as a result of the ban after all). And of course, it is borne by the olfactory senses of anyone that has the misfortune to be sat too close to the toilets.

Abortion, hybrid embryos and idiots

I don’t plan to write too much about these issues, since I don’t know if I have the time to do it with the seriousness I think it deserves. But here is an example of why I think that the anti-choice, anti-science and anti-progress lobby need to sharpen their act before anyone will really take them seriously.

Edward Leigh MP doesn’t understand nature:

“In embryos, we do have the genetic make up of a complete human being and we could not and should not be spliced together with the animal kingdom.”

Humans of course are part of the animal kingdom, and it seems that the view that we are somehow above it seems to be important when it comes to opposing embryo research.

Apart from that, three high profile Labour MPs also voted against amendments to the Human Fertilisation and Embryology Bill to allow for the creation of hybrid embryos for research, bowing to the will of the
Catholic Church rather than perhaps, oh I don’t know, voting in line with the government elected by the population at large. So if your MP is one of the following government ministers - Ruth Kelly, Des Browne or Paul Murphy, perhaps you should have a word with them about why the pope holds more sway with them then their own constituents.

This isn’t the most coherent post I realise, but when I see this craven idiots rejecting important medical advances based on their sky-fairy beliefs I get a little worked up.

Abolishing prescription charges is not progressive

I’ve said it before, and I’ll say it again - abolishing prescription charges is not a good use of NHS resources. But that’s what the Fabian Society, a left-leaning think tank says the Prime Minister should do to revive his flagging political career. Let us review why this idea, far from being progressive would actually be regressive. First, most people don’t pay for their prescriptions. The list of people in England who don’t pay for prescriptions begins with the following, people that:

• are on Income Support, income-based Jobseeker’s Allowance or the guarantee credit of Pension Credit. Your partner and children will also be entitled to free prescriptions. If you are getting Working Tax Credit and/or Child Tax Credit, you may be entitled to free prescriptions, depending on your income
• are 60 or over
• hold a valid medical exemption certificate
• are under 16.
• are still in full-time education, in England or Scotland and are 16, 17 or 18. You must show proof to the pharmacist
• suffer from a specific medical condition.
• get a war or service disablement pension, need prescriptions for your disability and hold an exemption certificate
• are a prisoner.

Dog fosters kittens

A dog raising cats! Could this possibly be the missing evidence for macroevolution that the evolution deniers keep blathering on about? Er…. no, but it’s probably as close as they’re ever likely to see to prove their age old canard that if evolution were true, why don’t we see dogs giving birth to cats.

But really, this is just an excuse to post about cute kitties and puppies.

NICE lose appeal court case

I’m coming to this a bit late, but the National Insititute for Health and Clinical Excellence has lost in the appeal case about the guidance it issued for Alzheimer’s drugs. The appeal from the pharmaceutical company Eisai Limited was based on the idea that NICE was insufficiently transparent about how it reached its decision. The decision, it seems, centred around the fact that NICE only made a available a read-only copy of the economic model that was created to evaluate the cost-effectiveness of the drug. The company thought that they should have had access to a fully executable file.

This hits pretty close to home for me, as a lot of what I do now and have done over the past few years is to create these models, which are then considered by various committees who then take decisions on whether or not the drug or technology should be funded on the NHS. My own view on this is that it shouldn’t make much difference to the decision making process, though I do have some concerns.

Feynman is always relevant

Ok, so maybe that’s a bit of an exaggeration, but Richard Feynman, one of the most influential physicists of the 20th century (and probably amongst the greats of all time) is relevant in a lot of situations. For example, if you ever see or read someone trying to explain complementary or alternative medicine (ie woo) using quantum behaviour, but aren’t sure why they are wrong even if you think they are, since it all sounds so wishy washy, then I suggest a Feynman chaser. Perhaps his chapter on quantum behaviour from Six Easy Pieces, available at good booksellers everywhere.

It’s to one section in the second chapter in this book to which I turn now (Penguin edition, published 1998, pages 23 - 27). In it, Feynman is discussing what he calls fundamental physics - the most basic properties of physics that we currently know that explain the way our world works, based on observation, reason and experiment. Feynman uses the analogy of an observer watching a game of chess. I want to take this analogy and apply it to the way that health economists do much of their work in the area of cost-effectiveness analysis (CEA) or cost-utility analysis (CUA), since I think it rather an apt description. To begin:

“What do we mean by “understanding” something? We can imagine that this complicated array of moving things which constitutes “the world” is something like a great chess game being played by the gods, and we are observers of that game. We do not know what the rules of the game are; all we are allowed to do is to watch the playing. Of course if we watch long enough, we may eventually catch on to a few of the rules. The rules of the game are what we mean by fundamental physics.”

Keeping tabs on the unethical claims of the ‘natural’ health industry

Something that irritates me greatly is the occasional unethical behaviour of many firms involved in the sale of goods and services such as homeopathic remedies and other alternative medicine products. So, because I can’t keep track of and comment on all instances of such behaviour myself, I thought I might try and collect and post links to posts on other sites which have dealth with such naughty behaviour.

I’m not interested in flagging up pointless treatments and remedies, lots of people already do that and no doubt do it better than I could. I’m looking at collating those instances of downright dishonesty and unethical behaviour from those people who claim to have nothing better than the best interests of the patient in mind. So send in your favourites by leaving a comment below and I’ll try and get them into the list and repost it at regular intervals.

To start, we have:

• Le canard noir brings us yet another tale of a less than 100% honest media quack. This time, it’s Jayney Goddard, who is no less than a professor. From a univeristy whose web-page doesn’t work. But that shouldn’t matter too much I suppose, Patrick Holford is a professor at a real university and it doesn’t make him right or useful. But Jayney is also president of the Complementary Medical Association, which looks as though it sounds more impressive than it is (see the Quackometer post). It appears to be set up for the purpose of generating income for Jayney Goddard. I’ll also leave the description of her time spent at Imperial College London to LCN. Bigging up her credentials and using TV debates on homeopathy to push her products. Ethical or not, I can’t decide.
• The Quackometer, where le canard noir deconstructs some incredible stupidity from Neal’s Yard Remedies here. To be fair, the company deserves a right of reply, so here is a mission statement of sorts from this particular supplier of natural health care products . I’ll let you judge whether not selling people water as an anti-malarial is ethical.
• I’d to hate to see NYR being picked on in as the first item in the list all on it’s own, so here is an another excellent example, this time courtesy of David Colquhoun and the good people at Boots, the massive high street chain of chemists for whom nothing is more important than your health - except their profits. Here is what David had to say about Boots Energy Super Strength CoQ10 . Here is what Boots have to say in their mission statement and in their code of business ethics about relationships with the customer. Again, I report, you decide (a bit loike fox news without the wilful dishonesty).

Erlotinib not funded by NICE?

I read in the Metro this morning that NICE has decided not to fund erlotinib (trade name of Tarceva) for non-small cell lung cancer. However, that was the only place I could find any information. Odd. The guidance isn’t due to be issued until June 2008 according to NICE’s website. And there are plenty of news items on the drug from 2006, when NICE first ruled on whether it should be funded on the NHS.

It’s difficult to make a judgment without full information, but if the costs and effects are anything like what has been reported in the press then the right decision has probably been made. The drug costs in the region of £6,700 per cycle of treatment and may extend life up to six months. On the face of it, that doesn’t look good for its chances. None of the reports I looked at mentioned anything about quality of life either, which is incredibly important in these case. It’s not just important to prevent death when making these decisions, but we also have to think about what value there is attached to the life that is saved. If we spend heroic amounts of money saving a life only to then put the patient on life support until they die, we might wonder if the money is well spent.

Rest assured though that decisions like these aren’t easy - even for the soulless folks that are health economists. Of course we don’t want to cause unnecessary suffering, although no doubt that is what the accusation will be when the guidance is published. But in all cases, alleviating suffering in one area means inducing suffering in another by denying someone else access to NHS resources (through the principle of opportunity cost). What we try and do is help find rules for making those sorts of decisions. I find it very difficult when the disease is something as underfunded in research terms as lung cancer - there are very few effective ways to treat this disease and not much money goes towards finding new one. But my emotional response doesn’t mean the decision is necessarily wrong. For all we know, introducing this new treatment could lead to money being taken away from palliative care for terminally ill lung cancer patients. Now that would be an emotional nightmare for most people.

So, a tough decision for NICE, but on the face of it probably the right one. I will be interested to see the full guidance report when it is published.