Category Archives: Innovation

Quality of Care and Medicines Use are Linked

A central feature of any high performing healthcare system or organisation includes best practice in medicines use and management. As all aspects of healthcare are under varying degrees of financial stress these days, cost controls and appropriate use of medicines must support the highest standards of clinical practice and safe patient care.

Medicines optimisation is one strategy as the use of medicines influences the quality of healthcare across the whole patient treatment pathway.

Failure to optimise the use of medicines across this pathway may arise from:

  • misuse of medicines (failure to prescribe when appropriate, prescribing when not appropriate, prescribing the wrong medicine, failure to reconcile medicines use across clinical hand-offs;
  • “clinical inertia” and failure to manage patients to goal (e.g. management of diabetes, and hypertension post aMI) [O’Connor PJ, SperlHillen JM, Johnson PE, Rush WA, Blitz WAR, Clinical inertia and outpatient medical errors, in Henriksen K, Battles JB, Marks ES et al, editors, Advances in Patient Safety: From Research to Implementation Vol 2: Concepts and Methodology), Agency for Healthcare Research and Quality, 2005];
  • failure to use or follow best-practice and rational prescribing guidance;
  • lack of synchronisation between the use of medicines (demand) and procurement (supply), with an impact on inventory management and
  • loss of cost control of the medicines budget.

The essential challenge is ensuring that the healthcare system and its constituent parts are fit for purpose to address and avoid these failures or at least minimise their negative impact.

Medicines costs are the fastest growing area of expenditure and comprise a major constituent of patient treatment and recovery.

The cost of drug mortality was described in 1995 [Johnson JA, Bootman JL. Drug-related morbidity and mortality; a cost of illness model. Arch Int Med. 1995;155:1949/56] showing the cost of drug mortality and morbidity in the USA and costed the impact at $76.6 billion per year (greater than the cost of diabetes).

The study was repeated five years later [Ernst FR, Grizzle A, Drug-related morbidity and mortality: updating the cost of illness model, J Am Pharm Assoc. 2001;41(2)] and the costs had doubled.

Evidence from a variety of jurisdictions suggests that drugs within the total cost of illness can be substantial, for instance:

  • Atrial fibrillation: drugs accounted for 20% of expenditure [Wolowacz SE, Samuel M, Brennan VK, Jasso-Mosqueda J-G, Van Gelder IC, The cost of illness of atrial fibrillation: a systematic review of the recent literature, EP Eurospace (2011)13 (10):1375-1385]
  • Pulmonary arterial hypertension: drugs accounted for 15% in a US study [Kirson NY, et al, Pulmonary arterial hypertension (PAH): direct costs of illness in the US privately insured population, Chest, 2010; 138.]

Upward pressure on the medicines budget include:

  • medicines with new indications (be careful, some of this is an artefact of drug regulation gamed by manufacturers)
  • changes in clinical practice which has an uplift effect on medicines use (especially if guidelines are poorly designed)
  • increasing the number of prescribers (keep in mind that prescribers are cost-drivers)
  • medicines for previously untreated conditions (this trades-off with reduced costs in misdiagnosis, mis-/delayed treatment)
  • therapeutic improvements over existing medicines, and
  • price increases (think of monopoly generic manufacturers, for instance).

Downward pressures include:

  • effective procurement methods (e.g. avoid giving winners of tenders ‘the whole market’ and ensure that rules enable generic competition)
  • use of drug and therapeutic committees and drug review processes (it is all about knowing where the money goes for improving value)
  • use of prescribing and substitution guidelines e.g. generic substitution (oh yes, enforcing it, too; it also helps to ensure OTC medicines are not reimbursed by insurance as this adds to competitive pricing pressure and improves patient choices)
  • positive and negative hospital formularies (yes, hard choices)
  • pro-active clinical pharmacy services engaged in both business and professional domains, (this means ensuring the expertise of pharmacists are central to decision-making) and
  • reduction of waste (you don’t want to know how much drug waste there is but estimates are up to 30% of expenditure is waste).

Additional sources of pressure in either direction come from:

  • population case-mix (that means paying attention of the health of the nation)
  • changing prevalence and incidence over time (also paying attention to the determinants of ill-health, particularly avoidable causes and effects by age cohorts)
  • performance and efficiency of clinical workflow across the patient pathway (this is where money gets wasted at light speed and where it can also be saved; clinicians are in control of workflow so engaging them in areas where they can make a difference matters a lot)
  • medicines payment and reimbursement practices including patient co-payments where they exist and the structure of hospital budgets or financing, (do we want to discuss the unintended and perverse consequences of the payment system?) and
  • healthcare system regulations (yes, where many problems are caused in the first place).

Many of the drivers of problems can be addressed through a combination of professional staff development, better use of information, particularly within decision-support systems to support guidelines and prescribing compliance, and organisational interventions.

Unbundling: the future of health and social care to 2035

The King’s Fund, a UK health charity ran a scenario essay writing competition, which I entered. I didn’t win, but here is the link and of course congratulations to the winner: (winner, runner up and other scenarios, but not mine).

Below is a  version of my submitted scenario, revised and generalised to any care system. The scenario builds on the notion of service unbundling and draws on strong and weak signals of changes likely to impact health and social care perhaps to about 2035. The scenario is written as a retrospective view from the year 2047.

Unbundling 2035

Between 2016 and 2035, the way that people worked had substantially changed by widespread digitisation of information. Smart machines and robots had moved from doing physical work to being central to much cognitive work and which led to fundamental restructuring of the economy. By 2035, taxation was changing from taxing people to taxing the work done by devices, cognologies, and robots.

The fault lines between reality and expectations were starkly evident during the 2020s, as public investment in health and social care struggled to cope with the rapidly changing world. People were becoming accustomed to flexible access to personalised services that came to them and expected the same from care provision. Rising displeasure at service decline led to middle-class flight to alternatives with rising use of private medical insurance, progressively fracturing the social contract that legitimated publicly-funded care. Indeed, by 2028, 38% of the population used private care, with over 55% amongst Millennials.

Fearful health and social executives and worried Ministers of Health had reacted to these stresses by pulling the system even more tightly together, to protect jobs and avoid the failure of publicly-funded institutions.

This fed further public displeasure by the dominant middle-aged Millennials who challenged the traditional approaches to health and social care. In the United Kingdom, for instance, this unrest led to the 2028 Referendum on their tax-funded healthcare system, leading to the replacement of this system with social insurers and personal Social and Health Care Savings Accounts.

The process of changes in health and social care around the world has become known as Unbundling. This brief historical retrospective outlines three of the key components of that unbundling.

The 1st Unbundling: of knowledge and clinical work

Professional knowledge was affected by digital technologies which had unbundled knowledge from the expert. This changed how expert knowledge was organised, used and accessed; research institutions and knowledge-based organisations were the first to feel the changes, with librarians being one of the first professions to face obsolescence. Rising under-employment, particularly in traditional male-dominated occupations was still being absorbed by the economy.

Routine cognitive work and access to information and services was increasingly provided by cognologies (intelligent technologies) or personal agents as they were called. Widely used across society, they were embedded in clinical workflow from diagnosis to autonomous minimally invasive surgery. By this time, jobs with “assistant” in the title had generally disappeared from the care system, despite having been seen as an innovative response to workforce shortages through the late 20-teens. These jobs had turned out to be uninteresting, and being highly fragmented, required time-consuming supervision.

The benefits of precision medicine were substantial by this time, enabling earlier diagnosis and simpler and less invasive treatments. Theranostics, the merging of diagnosis and therapy, unbundled the linear care pathway and the associated clinical and support work. This also led to the unbundling of specialist clinical services, laboratory testing and imaging from monopoly supply by hospitals. Indeed, the last hospital was planned in 2025, but by the time it opened in 2033, was deemed obsolete.

The 2nd Unbundling: of financing and payment

The unbearable and unsustainable rise in health and social care costs necessitated better ways to align individual behaviours and preferences with long term health and well-being. Behavioural science had shown that people did not always act in their own best interests; this meant the care system needed people to have ‘skin in the game’, best done by monetising highly salient personal risks.

Existing social insurance systems which used co-payments were more progressive in this direction, while countries with tax-funded systems were forced to reassess the use of co-payments, and financial incentives. The Millennials, having replaced the baby-boomers as the primary demographic group, were prepared to trade-off equity for more direct access to care. It also became politically difficult to advance equity as a goal against the evidence of poorer health outcomes as comparisons with peer countries drove performance improvements.

The use of medical/social savings accounts was one way that gave individuals control of their own money and building on consumerist behaviour, this directly led to improved service quality and incentivised provider performance as they could no longer hide behind the protecting veil of public funding. The social insurers were able to leverage significant reforms through novel payment systems, and influence individual health behaviours through value-based (or evidence-based) insurance not possible under a taxation system.

The 3rd Unbundling: of organisations

With people used to having their preferences met through personalised arrangements, care was organised around flexible patterns of provision able to respond easily to new models of care. This replaced the “tightly coupled” organisational approach known in the early part of the 21st century as “integration”, which we know led to constrained patient pathways, and limited patient choices unable to evolve with social, clinical and technological changes.

The big-data tipping point is reckoned to have occurred around 2025. Because the various technologies and cognologies had become ambient in care environments they were invisible to patients, informal carers, and care professionals alike; this enabled the genesis of smaller and more diverse working environments.

By 2032, medical consultants were no-longer hospital-based, having become clinical care social organisations, with their cheaper, smaller, portable, networked and intelligent clinical resources. Other care professionals had followed suit. These clinical groupings accessed additional clinical expertise on as-needed basis (known as the “Hollywood” work model); this way of organising clinical expertise helped downsize and reshape the provision of care and met patient expectations for a plurality of care experiences.

It takes time to shift from the reliance on monopoly supply of care from hospitals in those countries that continued to pursue a state monopoly role in care provision. However, most repurposed themselves quite quickly as focused factories, while the more research-oriented specialised in accelerating the translation of research into daily use, helped along by the new research discovery tools and the deepening impact of systems biology which was making clinical trials obsolete.

Conclusion

This Unbundling arose as a product of the evolution of social attitudes, informed by the emerging technological possibilities of the day. The period from 2016 to 2025 was a critical time for all countries, exacerbated by shortages in the workforce coupled with economic difficulties and political instability.

Today, in 2047, we are well removed from those stresses that caused such great anxiety. We must marvel, though, at the courage of those who were prepared to build what today is a leaner, simpler and more plural system, removed from politicised finance and management decisions.

It is hard to imagine our familiar home-based theranostic pods emerging had this trajectory of events not happened. As our Gen-Zeds enter middle age, they will, in their turn, reshape today’s system.

Plus ça change, plus c’est la même chose.

27 December 2047

Note on the Scenario

This scenario is informed by strong and weak signals, including:

Ayers A, Miller K, Park J, Schwartz L, Antcliff R. The Hollywood model: leveraging the capabilities of freelance talent to advance innovation and reduce risk. Research-Technology Management. 2016 Sep 2;59(5):27–37.

Babraham Institute. The zero person biotech company. Drug Baron. http://drugbaron.com/the-zero-person-biotech-company/

Cook D, Thompson JE, Habermann EB, Visscher SL, Dearani JA, Roger VL, et al. From ‘Solution Shop’ Model to ‘Focused Factory’ in hospital surgery: increasing care value and predictability. Health Affairs. 2014 May 1;33(5):746–55.

Cullis P. The personalized medicine revolution: how diagnosing and treating disease are about to change forever. Greystone Books, 2015.

Does machine learning spell the end of the data scientist? Innovation Enterprise. https://channels.theinnovationenterprise.com/articles/does-machine-learning-spell-the-end-of-the-data-scientist

Eberstadt, N. Men without work. Templeton, 2016.

Europe’s robots to become ‘electronic persons’ under draft plan. Reuters. www.reuters.com/article/us-europe-robotics-lawmaking-idUSKCN0Z72AY

First 3D-printed drug just unveiled: welcome to the future of medicine. https://futurism.com/first-3d-printed-drug-just-unveiled-welcome-future-medicine/

Ford M. The rise of the robots: technology and the threat of mass unemployment. Basic Books, 2015.

Frey BC, Osborne MA. The future of employment: how susceptible are jobs to computerisation? Oxford Martin School, Oxford University, 2013.

Generation uphill. The Economist. www.economist.com/news/special-report/21688591-millennials-are-brainiest-best-educated-generation-ever-yet-their-elders-often [accessed December 2016]

Lakdawalla DN, Bhattacharya J, Goldman DP. Are the young becoming more disabled? Health Affairs, 23(1-2004):168-176.

Susskind R, Susskind D. The future of the professions: how technology will transform the work of human experts. Oxford UP, 2015.

Topol E. The creative destruction of medicine: how the digital revolution will create better health care. Basic Books, 2012.

With Samsung’s ‘Bio-Processor,’ wearable health tech is about to get weird. Motherboard. http://motherboard.vice.com/read/with-samsungs-bio-processor-wearable-health-tech-is-about-to-get-weird

patience and the political process around UK exit

While folks have been quick to jump on the results of the referendum as evidence of democracy at work, (and perhaps that is partly true), a few days later we see the consequences. Economic challenges anew, social discontent in the UK (racism and xenophobia legitimated by the exit vote) and political meltdown in the UK’s parliament.

I want to focus on process. The Commission president wants the article 50 triggered essentially now. Of course, Juncker’s call is just more evidence of his fundamental autocratic ways; he did say he dislikes referenda as do I, but I suspect for him it betrays a disregard for democratic process in favour of bureaucratic expediency. Tusk says that the UK is the one that must act and the rest of the EU must wait. This shows a much more nuanced understanding of democracy and is only right.

Until the UK signals otherwise, it is still a full member of the EU within the meaning of Article 1 of the Treaty on European Union. The UK’s Commissioner was hasty in his departure, and today’s display at the European Parliament unbecoming but feeds the egos of MEPs who tear down more often than they build up.

But process matters. The UK’s Parliament must receive formally the advice it sought from the referendum, which is non-binding. Few countries would dignify the results of a referendum of this magnitude with a simple majority, but require perhaps 75% with some turnout requirement (even compulsory voting for that matter). The UK prime minister is not the government; the UK Parliament is what is sovereign, so it must actually pass a bill in Parliament and that is what can only trigger Article 50 (it may help to read the Lisbon wording).

In the UK, no parliament can bind a successor parliament; therefore, a general election would in effect return a new parliament which can simply ignore the referendum results. Indeed, such a general election would likely be fought over the terms of departure and that isi probably the right thing to do. Converting the referendum votes into constituency votes would likely lead to a minority of MPs being elected that would have supported a Leave position anyway. Given the chaos we see coupled with voter regret, it is unlikely a Leave position would be politically successful.

Furthermore, Parliament must be satisfied that the referendum actually is the will of the people. Given what has been a shambolic campaign, we now see the Leave campaign rowing back from their pledges, while much of the evidence presented by the Remain campaign is coming true. In the end the result is suspect. Granted the vote revealed underlying divisions within UK society, but that is not what the referendum was asking. Parsing the vote in those terms is disingenuous.

It is clearly not in the EU’s interests to see the UK leave, despite what appears to be the fond wishes of some authoritarians in the Commission. Indeed, the leave vote may in fact trigger the sorts of EU reform that was not possible before; nothing like having the chickens come home to roost! It would be a tragedy for the EU to lose the UK just when it would be implementing reforms that would not just reassure the UK, but also deal with the more widespread Euroskepticism and nationalist threats to European unity itself. And of course, it would be a Pyrrhic victory for the UK.

The EU needs to help the UK government chart its way through the process, to understand the process that must be followed and not hasten the UK’s demise within the EU through impatience or intemperate comments. Restraint at the political level across the EU will do more to support the UK find its way out of this mess.

The EU and UK need the outcome to be a win:win. A UK exit is not that.

 

 

UK out of the EU: access to medicines and medical device technologies

I’m continuing the theme of the previous post, by looking at life sciences, healthcare implications for the UK exiting the EU.

  1. The NHS, the UK’s public healthcare system, procures medicines in many cases through the benefits of the single market. While it is not clear what impact an exit will have on pricing itself, failure to ensure access to that single market will inevitably lead to the increase in drug costs. I’d hazard a guess of 10%. Given the difficult financing circumstances of healthcare expenditure in the UK, an increase of this magnitude, will have a knock-on effect on patients and their care.
  2. Apart from the price impact, UK patients may find access to medicines and medical devices restricted as the UK exits the wider European market overseen by the European Medicines Agency. The UK is not every companies’ first choice of a market to launch a new medicine or device, but with an exit, it clearly will drop further down the queue. Excluded from products launched in the rest of the EU, the UK can only wait for companies to ‘get around’ to including the UK.
  3. And apart from the loss of a degree of certainty of access to medicines and devices within the EU, a UK exit, the UK will need to introduce a separate regulatory scheme to replace the European Medicines Agency approach, adding costs and an additional regulatory hurdle for companies. The UK can, of course, try to harmonise itself with EMA, but in the end, departing EMA will reduce patient access to medicines.
  4. Is the UK market big enough to make a difference? Perhaps for some, but I suspect the economics coupled with the overall difficulty new products face contesting the UK market points to a general decline in product availability. At least with the EU, access to medicines and devices could be compared to other EU states; with an exit, the UK stands alone and does not look particularly welcoming.
  5. Of course, the NHS could have a rethink as is slowly underway and move to ensure access to new medicines and technologies. But that may require a different assessment whether the current way of financing the NHS itself is sustainable and that has really little to do with leaving the EU, although the EU does offer a safety value for patients denied care by the NHS. All this is now in jeopardy.
  6. The European Medicines Agency will need to leave the UK, and with it will go not just those jobs, but a whole domain of expertise. That expertise with EMA made the UK within the EU, one of two global centres of excellence in medicines regulation, along with the US FDA, Few people outside this area will appreciate the consequences of EMA departing, but it will be felt within pharmaceutical who maintain many high-paid and knowledgeable staff focused on medicines regulation. All this expertise goes and with it a capability within the UK that can never be regained. Whoever gets the agency, Sweden, Denmark, elsewhere, will be a net gainer of  talent from which to build tremendous domestic capabilities.

UK out of EU: healthcare implications

The British public in the Referendum on the EU has voted for the UK to relinguish membership in the EU. This, in time, will be seen as a mistake for various reasons and of course it will take some time to come to pass.

While I have been from time to time critical of the EU, I think it has brought significant benefits to everyone in the healthcare arena, restrictions on competencies notwithstanding.

The Referendum choice is not without consequences for the UK. I for one do not expect the UK to be given an easy time by its former EU partners, but the risk is that in the end, a congenial arrangement will be needed, if nothing else, to offset the risk of isolationism in the UK, which would do no one any good. While it may be seen as an example of democracy at work, the Referendum ended up really being a political punching match amongst the political parties and not really about the EU membership itself. The Prime Minister Cameron failed to act in the country’s best interests by trying to ensure the focus was on membership issues and not political infighting but he had by mid-campaign lost any influence as jingoist sloganeering took over from reasoned discourse. It is not wonder that the public voted as they did, and made the referendum a vote of non-confidence in the government instead. As they say, now repent at leisure.

That said, there are a few areas to reflect on which a strict exit would involve and which we should really try to protect.

  1. The ability of UK citizens to have access to healthcare services when travelling in the EU, through the EHIC arrangement will at some point end. It may be protected should the UK decide to accept free movement of people. It is not a good situation for countries so close and where people move so easily across borders not to have a mutual arrangement for healthcare. This must be protected in some form, as there could be public health risks on the one hand, and avoidable suffering for people who become ill. Absent that, UK citizens will require some sort of medical travel insurance which is never a good deal at the best of times. I doubt anyone really thought of that.
  2. Reciprocal arrangements for providing access to a country’s social security/healthcare system (the S1/A1 forms) will also in time cease. This will impact people retiring, but also people working, even temporarily, in an EU state. I doubt anyone running a workshop in another state worries about whether they’re carrying the EHIC, S1/A1 or their social security cards, but for the British, where no cards are required, this will present a new requirement and added business costs if nothing else. As many European countries do offer considerable lifestyle benefits, Brits will still likely wish to retire in an EU state, whereever family or friends are or where their heart is. While it is sensible to have controls in place to ensure proper system funding, it should really be a matter of priority to ensure that retirees at least enjoy some measure of security. There are comparable arrangements worth looking where similar circumstances exist (e.g. Canadian “snowbirds” and Florida).
  3. UK research is, at least according to the domestic crowd, pretty good, and does stand up to international scrutiny with many UK universities in the top tier. But much of the research funding comes from EU sources and has supported academics, departments and much intra-EU research collaborations. Life sciences research in particular benefits and it is unlikely the UK government will in any form be able to replace the lost funding. The implications are on the order of fewer institutions actually do the high standard of work, simply because there is less money, some universities will for forced to scale down their research, becoming smaller and perhaps marginalised or just focus on teaching. But the UK university system is research driven and universities that do little research are low rated anyway. I do really worry that universities and research will suffer in the UK and hope that the UK continues to be an active participant, even if at arm’s length.
  4. We heard a lot about immigration during the Referendum, but more of the xenophobic sort without actually grappling with the value to the UK that immigrants bring. Past the rhetoric, the UK has been a good destination for people to build their careers. Many have come to work in the UK’s National Health Service (about 4% of the NHS workforce is from the wider EU). Will this stop or shrink? The UK does not have the educational production capacity to replace the loss of immigrants with skills for healthcare, such as doctors, or nurses. With the exit likely having a profound impact on public finances, it is unlikely either that the UK will be able to afford to build the necessary capacity to make up for the loss. This will further reduce the standards of care as staff shortages bite even harder. Of course this might change, but the NHS has had staffing shortages for decades, and manifestly under-produced graduates in healthcare professions, so it is not clear why they would suddenly find the money that wasn’t there before. The UK will likely either opt back into the single market / free movement of the Norway sort, or go its own way with some point-based system to control immigration. The latter will only lead to tit-for-tat retaliation by the EU, which is to no-one’s benefit.
  5. Without listing them all, the UK is part of so many networks in healthcare areas, from research communities, to health technology assessment, to rare diseases and public health surveillance and so on. One must assume that these will scale down unless efforts are made to ensure they are protected in some form. In the end, though, the UK will be the loser as will the EU. A brain-drain toward the EU is not unimaginable and indeed for many people likely. The US will clearly beckon and the EU member states should also consider the implications. The UK will not like this, but this may be a good example of the consequences of the referendum decision. A brain-drain, while asset-stripping the UK, will require I suspect some reform of domestic employment systems, but with high unemployment in some EU countries, why would they want to give jobs to “foreigners”. Of course, EU institutions might change their own employment policies to make it easier to employ folks from the UK and many would likely gladly move. I know I would.

That’s a short list of a few things, on this day of days I would have wished were otherwise.

Does healthcare actually need the EU?

It is in the interests of the Commission to play countries off against each other in order to demonstrate the inescapable logic of the “European project”. The Commission suffers from the so-called “secretariat problem”: it is not a member state but a “secretariat” for the member states, and in this way pursues its own interests despite having been established by its members to further their own objectives. Secretariats do this, and take on a life of their own.

 

Various treaty language broadly excludes healthcare from EU policy making. The European Court of Justice has defined cross-border consumer rights. The European Commission, mindful of these, walks a thin line creating policy in the interstitial spaces that have the indirect effect of wagging the member state dogs. But that is the Commission defines its role in the absence of countervailing and/or collective action by member states. Consistent with bureaucratic behaviours, it focuses on technical issues, which in time come to define and constrain the policy spaces that member states have to deal with. The result is that member state autonomy and decision-making is constrained by prior technical issues.

The challenge is altering or indeed revoking the European Commission pan-European agenda set by the treaties, and which gives them license to literally expand like a gas into adjacent policy areas (arguing expediency rather than formal competency). This behaviour is well known in bureaucracies. It is not helped by the Commission being a monopoly supplier of legislation. Monopolists always do this.

What is more perverse is that the Commission has the mandate for ever closer union, which operationalises activities which undermine inter-state cooperation and collective or joint initiatives, undermines national interests, or more strongly, replaces the national interest with the “closer union” logic.

We now know that ever closer union cannot be an operational goal as it only feeds greater justification for the Commission to act — remember it is a monopolist defining its own scope of practice. When the Commission acts, members states must react.

In these days of the UK in/out referendum (23 June 2016), it is timely to review the functioning of EU institutions including the fundamental logic of the Commission.

 

P.S. I’ve been living in a few other EU member states, have been quite pre-occupied with work, hence the radio silence on this blog.

 

UK Balance of EU Competencies Review of Health: first thoughts

The UK government is releasing, over time, its review of the balance of competencies of EU legislation. Within the first 6 papers released is the one on Health, Review of the Balance of Competencies between the United Kingdom and the European Union: Health.

At minimum, these reviews provide a timely perspective on this balance of competencies, and provides a focus for further commentary. Other EU members states may find it useful to be reminded what this balance is. It is not always in the interests of the European project to look at all things taken together as it shows whether overall the claimed benefits are in fact there. But such policy review, if that is another way of talking about them, does draw a line in the sand against which to measure and assess changes in the future, and avoids the problem of the boiled frog syndrome, where small incremental changes are not noticed until it is too late.

Health is a funny subject for the EU as it is both inside and outside the European competency box, depending on how you define things. Countries can run their healthcare systems broadly as they wish, and maintain control of financing, but the European Court of Justice, in a variety of decisions, has defined the contours of that national control, as seen through the lens of the single market, and freedom of movement of goods and services in particular — both of which are agnostic with respect to health. It all depends whether you think of healthcare systems commercially or socially. That hospitals are socially beneficial but also commercial entities does not help, any more than drugs as goods flowing across EU borders, and so on.

The report concludes in the main that the balance is about right. There is little argument with the benefits of European action in medicines regulation, public health, tobacco, etc. Where the UK has a problem is with employment policy as it impacts the UK more generally and the National Health Service specifically. Different logic of the relationship between the employee and the workplace applies in the UK and this throws up a wide range of relevant issues.

The Working Time Directive is the elephant in the room here. The concerns are how the NHS structures clinical work, trains junior doctors, and generally organises itself to provide for continuity of care. Other countries, not just the European ones, have the same concerns about over-worked doctors. The heroic fictional doctors on television, who nap on couches and awake fully prepped to save patients is fantasy. Next time you’re in mid-Atlantic, be grateful your pilots got a good night’s sleep. The criticism of the WTD is more an indictment of the inability of the NHS and its massive provider infrastructure to put in place appropriate patient management systems that ensure a sensible balance of workload and rest. But the Health Paper makes the point that the European Court’s judgements have actually further constrained operational flexibily within the NHS. While the paper notes that the NHS operates on a 24 hour system, it actually doesn’t as it isn’t fully staffed on weekends, and many services operate within a traditional working hour day (e.g. laboratories, imaging). Much of this arises from the politically influenced structure of the NHS which has made it very difficult for alternative providers to enter the healthcare market in the UK, and thus offer relevant services, whether day-case surgery, or imaging, at times more convenient to patients. However, other countries in Europe appear able to manage demand and service provision more easily, so one much wonder why the NHS problems of their own doing.

The other area that exercises the NHS is free movement of patients. Medical tourism is a big issue in the UK, as its health system is based on residency. Social insurance systems have built often formidable barriers to gaining healthcare cover because they generally link the insurability with the workplace. Self-employed individuals are frequently disenfranchised from full benefits, and often pay disproportionately. Retired people continue to need insurance. But an insurance system does make cross-border transactions much easier. The UK has not really understand the operational dimension of the differences for UK taxpayers moving within Europe. The Limosa Convention is not mentioned in the briefing, while the European Health Insurance Card is. The EHIC is only really for tourists and retired people and the paper promotes the benefits of them. However, the EHIC is not for people temporarily located in another country for employment or work purposes.  They do not refer to the bureaucratic overhang of the A1 and S1 forms needed for people working in other EU countries and the forum-shopping associated with it as countries seek to get ‘the other country’ to pay the bills. I wonder how many people realise they need an S1 to run a seminar in another country as this is defined as work, or that working from home and living in country A while your office is in country B could be a bureaucratic nightmare. The report is silent here.

UK Balance of EU Competencies Review of Health: first thoughts

The UK government is releasing, over time, its review of the balance of competencies of EU legislation. Within the first 6 papers released is the one on Health, Review of the Balance of Competencies between the United Kingdom and the European Union: Health.

At minimum, these reviews provide a timely perspective on this balance of competencies, and provides a focus for further commentary. Other EU members states may find it useful to be reminded what this balance is. It is not always in the interests of the European project to look at all things taken together as it shows whether overall the claimed benefits are in fact there. But such policy review, if that is another way of talking about them, does draw a line in the sand against which to measure and assess changes in the future, and avoids the problem of the boiled frog syndrome, where small incremental changes are not noticed until it is too late.

Health is a funny subject for the EU as it is both inside and outside the European competency box, depending on how you define things. Countries can run their healthcare systems broadly as they wish, and maintain control of financing, but the European Court of Justice, in a variety of decisions, has defined the contours of that national control, as seen through the lens of the single market, and freedom of movement of goods and services in particular — both of which are agnostic with respect to health. It all depends whether you think of healthcare systems commercially or socially. That hospitals are socially beneficial but also commercial entities does not help, any more than drugs as goods flowing across EU borders, and so on.

The report concludes in the main that the balance is about right. There is little argument with the benefits of European action in medicines regulation, public health, tobacco, etc. Where the UK has a problem is with employment policy as it impacts the UK more generally and the National Health Service specifically. Different logic of the relationship between the employee and the workplace applies in the UK and this throws up a wide range of relevant issues.

The Working Time Directive is the elephant in the room here. The concerns are how the NHS structures clinical work, trains junior doctors, and generally organises itself to provide for continuity of care. Other countries, not just the European ones, have the same concerns about over-worked doctors. The heroic fictional doctors on television, who nap on couches and awake fully prepped to save patients is fantasy. Next time you’re in mid-Atlantic, be grateful your pilots got a good night’s sleep. The criticism of the WTD is more an indictment of the inability of the NHS and its massive provider infrastructure to put in place appropriate patient management systems that ensure a sensible balance of workload and rest. But the Health Paper makes the point that the European Court’s judgements have actually further constrained operational flexibily within the NHS. While the paper notes that the NHS operates on a 24 hour system, it actually doesn’t as it isn’t fully staffed on weekends, and many services operate within a traditional working hour day (e.g. laboratories, imaging). Much of this arises from the politically influenced structure of the NHS which has made it very difficult for alternative providers to enter the healthcare market in the UK, and thus offer relevant services, whether day-case surgery, or imaging, at times more convenient to patients. However, other countries in Europe appear able to manage demand and service provision more easily, so one much wonder why the NHS problems of their own doing.

The other area that exercises the NHS is free movement of patients. Medical tourism is a big issue in the UK, as its health system is based on residency. Social insurance systems have built often formidable barriers to gaining healthcare cover because they generally link the insurability with the workplace. Self-employed individuals are frequently disenfranchised from full benefits, and often pay disproportionately. Retired people continue to need insurance. But an insurance system does make cross-border transactions much easier. The UK has not really understand the operational dimension of the differences for UK taxpayers moving within Europe. The Limosa Convention is not mentioned in the briefing, while the European Health Insurance Card is. The EHIC is only really for tourists and retired people and the paper promotes the benefits of them. However, the EHIC is not for people temporarily located in another country for employment or work purposes.  They do not refer to the bureaucratic overhang of the A1 and S1 forms needed for people working in other EU countries and the forum-shopping associated with it as countries seek to get ‘the other country’ to pay the bills. I wonder how many people realise they need an S1 to run a seminar in another country as this is defined as work, or that working from home and living in country A while your office is in country B could be a bureaucratic nightmare. The report is silent here.

Could the medicine you don’t take properly kill you? It may depend on your age.

The lost of my trilogy picks up on medicines again.

In the US, not taking medicines correctly is thought to be the fourth leading cause of death – could this be true?

WHO data on mortality captures medicines use in a variety of categories. I ran the data on the categories concerned with medicines-related harm (ICD-10 codes: X40-X44,X60-X64,Y10-Y14,Y45-Y47,Y49-Y51,Y57). It is less than 1% for any European country for the whole population, but breaking it down by age cohorts reveals interesting results that show at different ages, in different EU countries, there are age-related variations in cause of death, rising with age. None, however, emerges as a leading cause of death on its own.

However, medicines use sit within a system of patient care. Therefore, medicines misuse and medication errors may create conditions for a co-morbidity to assert itself. And of course, whether the drugs were toxic for the patient at a particular dose (keep in mind, pills for instance come in standard sizes and may need to be cut in half or so to get an accurate dose for a patient). Working through this data, though, does highlight areas to pay attention to, and in particular countries where there appear to be noteworthy higher risk. I’d like to see better analysis of medication errors.

Once again, before we target the drugs bill as being out of control, let’s get a better understanding of the dynamics of medicines use itself. We may be spending money foolishly or carelessly. What are the incentives in health systems that may actually encourage this sort of professional conduct?

The devil is not just in the detail, but in the data and in clinical practices.

Want to know more?

WHO datasets are here: http://data.euro.who.int/dmdb/

 

What is the cost of excess hospitalisation in Europe?

Continuing with my thoughts today on excess costs (last post was on medicines waste), I thought I think about excess hospitalisation, another type of waste.

Excess risk of hospitalisation is calculated as the difference between observed hospitalisation (for a condition) and expected population rates.

What are the determinants of excess hospitalisation?

  • Excess hospitalisation can be driven by factors which increase population risk, such as influenza/epidemics, and seasonal and weather variation (e.g. respiratory/COPD, asthma, stroke).
  • Readmissions are viewed as excess hospitalisation.
  • There is some research, in the US, showing ethnic and gender variation in hospitalisation.
  • Complex conditions indicate potential for excess admission with failed primary care but that is a design feature of the health system. Complex/high risk patients disproportionately account for hospital activity. Depending on the other co-morbid conditions, some conditions signal excess costs some of which translate into (excess?) hospitalisation (e.g. Alzheimers), depending on how care is managed.
  • Not having a primary care doctor is a factor in excess use of emergency services and hospital emergency departments, and in turn to excess hospitalisation. On average, perhaps 10% of excess (inappropriate) emergency visits convert into admissions.
  • There is also misdiagnosis and excess length of stay caused by adverse hospital events (such as hospital acquired infection, accidents, patients falls, dropping patients, medicine errors).
  • Excess capacity (where utilisation is less than about 70%) leads to over-provision of care and obviously excess hospital admission. Incentives in reimbursement systems can drive hospitalisation.

Just so you don’t think I’m making this up, consider:

  1. US data show 17.6% of all Medicare hospital admissions were readmissions costing $15 billion annually, of which $12 billion was deemed preventable admission.
  2. The number of BSIs caused by MRSA and G3CREC was extrapolated from EARSS prevalence data and national health care statistics. Prospective cohort studies, carried out in hospitals participating in EARSS in 2007, provided the parameters for estimating the excess 30-day mortality and hospital stay associated with BSIs caused by either MRSA or G3CREC. Hospital expenditure was derived from a publicly available cost model. Trends established by EARSS were used to determine the trajectories for MRSA and G3CREC prevalence until 2015. In 2007, 27,711 episodes of MRSA BSIs were associated with 5,503 excess deaths and 255,683 excess hospital days in the participating countries, whereas 15,183 episodes of G3CREC BSIs were associated with 2,712 excess deaths and 120,065 extra hospital days. The total costs attributable to excess hospital stays for MRSA and G3CREC BSIs were 44.0 and 18.1 million Euros (63.1 and 29.7 million international dollars), respectively. Based on prevailing trends, the number of BSIs caused by G3CREC is likely to rapidly increase, outnumbering the number of MRSA BSIs in the near future. [de Kraker M, et al. Mortality and Hospital Stay Associated with Resistant Staphylococcus aureus and Escherichia coli Bacteremia: Estimating the Burden of Antibiotic Resistance in Europe, PLOS Medicine, October 2011]
  3. A total of 538,580 admissions generated 4,310,654 hospital bed-days and total costs of €940,026,949. People with diabetes accounted for 9.7% of all hospital discharges, 13.8% of total stays, and 14.1% of the total cost. Of the total cost for individuals with diabetes (€132,509,217), 58.3% were excess costs, of which 47% was attributable to cardiovascular complications and 43% to admissions for comorbid diseases. Individuals 45–75 years of age accounted for 75% of the excess costs. The rate of admissions during the study year was 145 per 1,000 inhabitants for individuals with diabetes compared with 70 admissions per 1,000 inhabitants for individuals without diabetes. [Oveira-Fuster G, et al. Excess Hospitalizations, Hospital Days, and Inpatient Costs Among People With Diabetes in Andalusia, Spain,Diabetes Care, August 2004]
  4. Schwartzberg studied health literacy among patients, and noted that patients with low literacy skills were twice as likely to be hospitalised and twice as likely to report poor health. She argues that low health literacy may cost $73 billion [US figures] annually in excess hospitalisation days alone. Much depends on improving the ability of patients (with help from their families) to carry out complex health instructions on their own. [Schwartzberg J. Patient safety. Low health literacy: what do your patients really understand? Nursing Economics, 20(3-2002), 145-147]

Want to know more?

As you local hospital to tell you what they do.