Tag Archives: “c’est dommage”

Speaking truth to power

Stained glass window of St. Thomas Becket in C...
Thomas Beckett spoke Truth to Power

Professor David Nutt, chairman of the UK’s Advisory Council on the Misuse of Drugs, is now a former chairman. He has joined by other scientists (2 so far) resigning in protest as the government’s heavy handed dismissal of Professor Nutt.  The minister, Alan Johnson, has said he had ‘lost confidence’ in the scientist for something he wrote in a scientific article.

The thought police are out in force once again.  But more important is the apparent abuse by this government minister of the whole point of advisors.  They must speak truth to power. In the absence of the speaking of truth, we will have self-censorship, political correctness, and general bowing and scraping to the political powers.  What the politicians don’t get, and Alan Johnson in particular, is that a candid and often challenging relationship is part of this delicate balancing of truth and power.

Indeed, there is clear abuse of power in silencing critics. There is a candle that burns in Canterbury Cathedral, testimony to this very issue (referring to St Thomas Beckett).  Truth is the first casualty of ministerial hubris.

In the end, we, that is taxpayers, and the general well-being of society, suffer when ministers can be so cavalier in dismissing people they don’t agree with.

Distinguishing between giving advice based on science, and political commentary is difficult navigation, as both scientists hold political views, which ministers may not like, while ministers may express scientific commentary with little grasp of its meaning.  Both can get it wrong, and much nonsense has come out of the mouths of both scientists and politicians.  But rather than shoot the messenger, politicians need to remember that they are in the main wholly dependent on right-minded scientists for advice, ones who will often hold dissenting views from the ‘spin’ that ministers seek to put on science itself. Einstein and colleagues understood this when they wrote to Roosevelt about atomic energy in 1939. It is worth noting that the US government dragged its feet on this letter until at least 1941, and it was not until 1942 that the Manhatten project began.

It is worth listening, even if you don’t like what you are being told. If scientists and advisors must speak truth to power, so power must listen to truth.

Such is the politician’s duty. Pity such duty is so poorly observed.

What’s an EHR for, anyway?

Sample patient record view from VistA Imaging
Example of EHR (VISTA)

There is trouble in e-health land, at least in Ontario’s funny notion of what they might mean.  EHealth Ontario has been subject to an emergency audit of its procurement or not of an electronic health record [EHR] by the Auditor General of the province.  Apparently, somewhere approaching C$1 billion has been spent with virtually nothing to show for it.  The problems lie in a bad ehealth strategy, and inappropriate use of consultants.

There are lessons here for other jurisdictions, as they seek to embrace the benefits of EHRs, and ehealth more widely, in particular. Of course, what is an EHR for, is the core question.

One of my alma maters, McMaster University, has sprung into the fray saying it has an EHR called OSCAR that could be implemented for perhaps 2% of the estimated cost of a provincial EHR.  Their argument being that a lot of doctors are using it.

EHRs are not a tool for doctors, though.

EHRs are an integrated information repository to facilitate better healthcare.  Doctors are not the only oranges, and nurses, physios, social workers, pharmacists, OTs, oh, yes patients and parents, informal carers, too, need access to health records. In my view, patients should own and hold their own health record, to ensure high audit standards (would you let an error remain on your health record if you knew about it?).

Servicing the specific needs of doctors alone is not an EHR strategy worth having, and doctors themselves should be the first to say this. It is time they showed leadership within the wider healthcare system, and rejected self-serving models, such as McMaster’s, which automate obsolete information models. McMaster, too, should have known better.

The Ontario Ministry of Health has wisely rejected OSCAR’s offer, but for the wrong reasons.  Citing the need for doctors to choose their own systems, just shows their continuing logic of catering to the needs of a particular health profession, rather than addressing the systematic provision of patient information within an integrated decision-support system.

All this is being driven by beleagured officials who really need to think again about their priorities and why they really need an EHR.  Perhaps they are afraid to admit to having made a mistake.  Such hubris.

Clearly more work is needed to define the purpose of the EHR and the goals for an ehealth strategy in Ontario (and other jurisdictions of course), before more taxpayers’ money is spent on ehealth.

Oh yes, apparently Ontario are going for a tender on a diabetes registry. NYC has one. I fear the worst.

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Why is the US having trouble with health reform?

So various US publications have waded into the health reform debate with comparing the US with the UK’s NHS.  These commentary, as many other bloggers and those on Twitter, are of varying degrees of stupidity, ignorance and general lack of insight.

It is worth keeping in mind that for decades, there have been comparisons between Canada’s healthcare system (very similar to the UK’s NHS, but there are very important differences, too) and the US.  The Americans have these debates constantly and the various lobby groups are well-equipped to flood the ether with their rhetoric. There is a deep-seated concern about ‘socialised’ medicine, about the role the state usurping individual responsibility, and about power and control.

And the spirited defence of the NHS will no doubt continue apace.

But underlying the debate is the unanswered question of why does the US have so much trouble with reforming its healthcare system in the first place.

One reasons is that Americans seem have a lot of trouble with what are called free-riders.  Because their system is insurance based, those who do not take out/cannot afford health insurance, get a ‘free ride’ on the taxpayer, through the federally funded Medicare/Medicaid programmes for instance.

By and large, Americans philosophically are liberal in their outlook, and believe that individuals should make the most of their gifts, so the system rewards, and celebrates success, and while not necessarily punishing failure, ignores it as long you pick yourself up and get on with improving your life.  Ideologically, that means that it is hard to grasp that everyone may have an interest in the general welfare of individuals, AND that the responsibility for the general welfare is the responsibility of government. Practically that translates into a political ideological debate about the role of the state.

Why does that matter?

The US politically is a different system from parliamentary democracies. In the latter, political parties stake out ideological territory (left, right, socialist, whatever) and the electorate chooses.  In the US, the United States itself IS the ideology.  The political parties are interpreters of this founding ideology and the electorate chooses within that ideology from the political parties.  That explains in part why there is a narrow range of political choice on offer in US elections, and why, under the skin, all political beliefs flow back to the founding ideology of the US Constitution, and its revolutionary roots.  The US believes it is the definition of democracy, so why would one have varying degrees of political persuasion if you’ve already solved the hard problem.

That means that the health reform debate is predicated on historical consensus about the political objectives of the US as a democratic entity. One of these principles challenges the role of government, another principle addresses individual liberty and third focuses on how the US interprets the public interest and general welfare.  The third principle is NOT interpreted by the state (as in the US, the state is a creation of the people), as it is parliamentary systems (where the state exists independently of the people — read Hobbes).  In the US, the resolution of a political debate amongst competing interests determines the public interest as the state does not have an independent existence and so cannot have its own guiding principles.

Why should this matter?

Because in the US, these debates nourish the democracy itself. The discussion is not esoteric but fundamental to the concept that Americans have of their country.  Such debate in UK, France, Germany, Canada, etc, with universal health systems, will invariably invoke principles to resolve the issue, that can not work in the US political arena.  The difference, of course, is that while the Americans will have the debate, other countries will sit complacently by while their governments pursue reform policies which should be challenged and debated outside the government.  The differences are subtle, but important.

NICE, the Rule of Rescue and Supererogation: or what’s the State for anyway?

Lifeboat (rescue)
Someone will come, we all hope.

NICE’s position on the rule of rescue is incompatible with the purpose of the NHS as a state mandated healthcare system which must at least be the option of last resort for people where social values and preference would provide healthcare — despite NICE’s analysis.  Government cannot let HTA bodies such as NICE ignore the rule of rescue.  NICE argues that it adequately takes account of this — but there is a discontinuity in the applicable decision logic below and above NICE’s QALY threshold.  NICE in effect is applying below the line logic to above the line issues.  The issue of compliance and indeed civil disobedience may be applicable as doctors are prohibited from violating their professional codes of conduct, or acquiescing in acts or procedures that would cause them to violate their ethical code.  A doctor strictly speaking cannot not aid a person caught by the NICE threshold cutoff, where they are able.  The state is obligated to interevene and pay for expensive care as it is not an act of supererogation, but it is the State’s duty. Therefore, the State must act in cases above the line out of duty —  aiding people who might cost a lot by HTA QALY benchmarks but if the state doesn’t act, and who will?  This is especially troublesome in the UK where the NHS is presented as the health provider of last resort — not something NICE has clearly thought through.  Will the politicians allow NICE to wag, so to speak, the objectives of universal healthcare?

As other countries adopt NICE-like thinking, how will they come to understand the role of the state?

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