Health Care
Polly on Top Ups
Polly addresses the "problem" of people topping up their NHS treatment with their own money and thereby risking being denied any further NHS treatment.
There\’s a glaring hole in her reasoning:
The National Institute for Clinical Excellence (Nice), one of Labour\’s best inventions, scrutinises all available evidence to decide what the NHS should provide once new drugs have EU licences. But Nice has been under siege from the drug companies, claiming their products are turned down because of cost. However, Nice is independent, and not primarily a rationing mechanism: it sanctions any drug with good evidence for effectiveness. It has only refused 5% of drugs – those that offer perhaps a few weeks\’ more painful end of life at huge cost. It makes the same decisions any wise family should make before paying privately, if only they knew the evidence.
Now, perhaps a tad unfashionably, I\’m a supporter of the essential idea of NICE. At root it\’s a form of cost benefit analysis . From taxpayers\’ dosh, we should only provide those drugs and services which are indeed cost effective. This is true whether we\’re talking about cancer drugs and it\’s also true out there in the wider world. We should only invest in, say, train safety up to the point where the costs of doing so are balanced by the benefits done. Similarly with the environment and climate change: we should only pay to mitigate climate change to the extent that such mitigation is cheaper than adaptation.
Cost benefit analysis is good for society, certainly. However, the error comes here:
same decisions any wise family should make
Ah, no. We\’re all well aware that there are things which benefit individuals but which do not benefit the wider society: all too aware. But we also need to understand that there are things which might make sense at a societal level which do not, necessarily, at an individual level.
The cost benefit analysis which society faces over the funding of drugs is rather different from the one an individual does. For society is asking the question "how much of other peoples\’ money should be spent to save or extend this life?" The individual is asking a very different question. "How much of my money should I spend to extend my life?"
The two are entirely different questions. By analogy: we do indeed have a welfare safety net, rightly so. There is an amount which it is righteous that I pay into society that the poor do not starve (leave aside whether it is State driven or charitable here). But the diet that the poor receives from that zakat? A reasonable and nutritious one? Or filet steak and caviar? And would it be immoral that the societal minimum diet guaranteed to all would be less sumptuous than the one that I might purchase for myself out of my own remaining resources?
There are those who would and have argued that yes, such would be immoral. Old JC got nailed to a cross for, amongst other things, suggesting that the correct reaction to a cold beggar was to divide your cloak into two and to bed down with him, asking if you might share his cold.
You might have noticed that we don\’t in fact run society along such lines and that we have in fact rejected this idea that the spending of our collective resources "should" be the same as we spend our private ones.
In other words, Nice is not refusing drugs any doctor should be suggesting it\’s wise for individuals to buy.
The NHS makes the same cost decisions individuals should make,
And there again is the mistake. The cost benefit analysis of how society deploys its limited resources is an entirely different one to that of an individual facing the same situation. And that is the problem with Polly\’s analysis. She\’s insisting that the micro and the macro are the same, when they clearly are not.
Incumbents\’ Protection Act
Another sighting.
Companies offering high-priced genetic tests have found themselves under pressure in the US, after officials launched a crackdown on their operations in California. Thirteen companies offering genetic testing have received cease and desist letters from the state\’s department of public health, in a move that could force them to stop selling their tests to the public.
Genetic testing services offer customers the chance to examine their genome for susceptibility to common diseases and conditions – usually for a fee in excess of $1,000 (about £500). Typically customers send in a sample of their DNA, such as a saliva swab, in exchange for information on potential health risks.
Although no specific regulations apply to the growing industry, state law dictates that their laboratories must be fully certified and that customers can ask for a test only on doctor\’s orders. The firms have been given two weeks to prove they meet those standards, with the threat of a $3,000 a day fine if they flout the rules.
"There\’s either concern they don\’t have a licence, there isn\’t a physician\’s order, or both," a state spokesperson, Lea Brooks, told the Associated Press. "That\’s what\’s under investigation."
Yes, yes, of course this is terribly important. Vital.
The move by Californian officials was welcomed by the chief executive of a leading DNA diagnosis company, the Iceland-based Decode, who said he was happy to see more rules in place. Kari Stefansson told the Guardian that his company had not received communication from California, but that genetic information was too complex and detailed to be unregulated.
Quite, Absolutely nothing about a company established in the market being delighted to see its smaller and upstart rivals bound with protocols and regulations that it can afford to bear now, is there.
No, no, clearly not. Perish the very thought.
The Wisdom of Whores
Elizabeth Pisani has a piece today that roughly outlines where we are with AIDS today.
There\’s two entirely different epidemics: the African one, which is indeed largely heterosexual, and the one everywhere else, which is:
The second epidemic covers the rest of the globe. Nine out of ten humans (and three in ten of those infected with HIV) live in countries where the virus is spread mostly when people buy and sell sex, when they shoot up drugs, and when men have anal sex with lots of other men. Only a minority do these things in any country, but that still adds up to several million people worldwide. We know how to prevent HIV in these populations, and we have known for years that in Asia, the Americas, Europe, North Africa and the Middle East, if you do that prevention well, HIV won\’t spread farther. Even if you don\’t control HIV in these populations, it won\’t go all that much farther.
If this story, and how the international bureaucracies are shaking us all down about it, is of interest, then I recommend her website, Wisdom of Whores and also her recent book of the same name.
Epidemiology, public choice economics, Uncle Milt\’s four ways to spend money, they\’re all there.
Well, Yes.
Arguing that what we actually need to clean up hosptials is somone actually responsible for doing so: bring back Matron in other words. Yes, quite, however, this part ain\’t true:
Everyone also knows that C difficile is a hard nut. Unlike MRSA, which is found only in hospitals (which means it falls into that fascinating category of \’iatrogenic\’ ailments, those caused by medical interventions), it\’s found in the environment.
I can\’t remember whether it\’s many of us or most of us that carry MRSA but to say that it only occurs in hospitals is very definitely wrong.
Finally Some Sense
Patients who pay for “top-up” drugs will no longer be denied free NHS treatment, the Government will announce next week.
n a major reversal of policy, the Department of Health will review the present rules, which ministers regard as unfair and a penalty for people fighting life-threatening illnesses such as cancer.
It will announce an end to the “co-payments” system, in which those who buy drugs that the NHS has deemed too expensive are made to pay for the rest of their care.
Thank the Lord for that: it always was a nonsense that if you were prepared to use your own money to add to your treatment you would then be denied the treatment you had already paid for.
Organic Milk is Healthier?
I\’ve just stumbled across (via) what looks like an excellent resource. OK, it\’s funded by the NHS but it is indeed a public health service and informing the public about health issues seems fair enough.
A sample of their output.
Remember last week there were stories all over the place about how organic milk is better for you?
Umm, that\’s not quite true.
The results do not demonstrate conclusively that organic milk contains the best nutritional properties. In fact, the most favourable nutritional properties seemed to be found in milk from the non-organic low-input farms that used a spring calving system.
And yes, they do take you through all the steps to get you there, including links to the original research etc.
I\’m not sure how quickly they put up stories (I suspect they\’re a day or two behind the newspapers) but this will be a wonderful resource for us bloggers I\’m sure.
Linda O\’Boyle
A woman dying of cancer was denied free National Health Service treatment in her final months because she had paid privately for a drug to try to prolong her life.
Linda O’Boyle was told that as she had paid for private treatment she was banned from free NHS care.
She is believed to have been the first patient to die after fighting for the right to top up NHS treatment with a privately purchased cancer medicine that the health service refused to provide.
Our Glorious NHS, the Wonder of the World it is.
Far better that you should die rather than treatment should be unequal.
Truly, the equality of the grave.
Gosh, Really?
Medically unexplained physical symptoms (Mups) are one of the most common problems in modern medical practice,
Of course, if they were exp\’lained physical symptoms then they wouldn\’t be problems, would they?
Wondrous
The National Health Service has refused to pay for an operation to prevent a pensioner’s agonising migraines because the woman paid privately for earlier treatment.
The Wonder of the World it is, Our Glorious NHS.
Now This Is Interesting on Autism
OK, very much preliminary findings but:
Chemicals found in pet shampoos may be linked to a raised risk of autism, a study of how environmental factors influence the developmental disorder has suggested.
Mothers who used pesticide-based shampoos to wash their pets while pregnant were twice as likely to have a child with an autistic spectrum disorder as those who did not, according to early results from a US research team.
Hedged around with all sorts of "preliminary", "confirmation bias" and so on. However, it does fit in with what seems to be the best explanation of the causes of autism, the idea put forward by Simon Baron Cohen.
I\’ll leave aside all the details and point just to the actual mechanism he posits: that it\’s the influence of testosterone upon the developing foetus. If these pesticides do indeed change the levels of such in the mother\’s bloodstream (hmm, not sure, does testosterone cross the placental boundary?) then it all fits neatly together.
One thing should be noted though: Baron Cohen thinks that genetics (the rise of assortative mating) is the primary driver of the rise in cases: but he\’s never ruled out the thought that there could be environmental triggers as well. Given that autism is actually a diagnosis of symptoms (in the same way that "cancer" is) rather than a specific disease, there\’s no reason why there can\’t be both, genetic causes and environmental: there could be cases caused solely by either plus those caused by the interplay.
Mandatory Vaccination
No, not a good idea I would think.
Primary schools will be compelled to demand proof that pupils have had a full range of jabs – including measles, mumps and rubella – before allowing them to register.
It\’s one thing to say that children should be vaccinated, another to insist that they must.
The ideas have yet to be discussed with the Prime Minister, who is expected to react cautiously. Dr Hamish Meldrum, chairman of the BMA, said forcing parents to have children immunised was "morally and ethically dubious" and would go "beyond the nanny state to a police state".
He said: "A Stalinist approach like this would be likely to backfire on an unprecedented scale, and to increase opposition to vaccinations."
There is that, the political objection.
The Labour proposal is modelled on a compulsory system in America, where parents are threatened with jail if children are not immunised.
Hmm, I rather doubt that….for the vaccination programs in the US are done by the States. Thus, as federalism rather requires, there are many different systems. One of the more common is that vaccinations are indeed required before entering the public school systems. Yes, this has added (however little) to the home schooling movement.
So, practical arguments against it, civil liberties ones as well. There\’s also the point that certain groups are morally opposed to certain of the jabs. For example, the new MMR uses a culture taken from an aborted foetus to create the rubella part of it. The official position of the Catholic Church was (at least it was, whether it still is I don\’t know) that good cannot come from an evil deed and that thus that specific vaccine should not be used by Catholics. I\’m sure there are other religious groups with objections to one, more or all of them (do Jehovah\’s Witnesses vaccinate?).
Finally, there\’s a large group (for some meaning of large: in this case, too big to ignore politically) of children who shouldn\’t be vaccinated at all: those with weakened immune systems for example.
Mandatory vaccination therefore won\’t really work: not unless there are a series of opt out clauses. Whjich, given the size of some of the groups, means that we\’ll not be far off where we are now.
Excellent News!
As you know, one of the themes around here is that cost benefit analyses need to be, well, focussed on both costs and benefits. So this is excellent news indeed:
Tens of thousands of Alzheimer’s sufferers and their families had their hopes raised yesterday as two drug companies won a landmark victory in the Court of Appeal.
The court ruled that the powerful body that controls the prescription of new drugs must give up its most precious secrets — how it measures the benefits that novel treatments bring.
The ruling is the first case that NICE, the National Institute for Health and Clinical Excellence, has lost in court. It means that in future it will have to be completely transparent in the way it reaches its decisions, revealing the inner workings of the computer models it uses to measure value for money.
I\’ve no hassle with the basic idea of NICE, nor with the idea of using QUALY (quality adjusted life years) as the measure of value for taxpayers\’ money. And while I wouldn\’t be interested in poking around the details of their economic models myself I do insist that it\’s important that someone does, someone independent.
For we\’ve got a fairly large number of cases, the details of recent decisions, where such cost benefit analyses seems to be disregarded: where, in the details of the argument something is twisted so as to provide the outcome desired rather than the one the evidence really points to.
A non-exhausitive list.
1) The claim that the UK has the largest gender pay gap in Europe. This is reached by using both full time and part time workers: and the UK is structurally different in the number of women who work part time. If we look at full timers only, then the pay gap is below the EU average.
2) Before the EU imposes import restrictions (tarrifs or quotas) it is supposed to provide an estimate of the costs and benefits. Not surprisingly, it only ever provides cost numbers for the benefits to producers: not the costs to consumers.
3) Cannabis reclassification. There has indeed been a rise in psychosis associated with cannabis consumption. However, there\’s been no rise in psychosis as a whole. The cannabis related rise was taken to mean that cannabis was causing the rise: when the lack of a general rise means it is more likely that those becoming psychotic were self-dosing with the more widely available cannabis.
4) Many use the WRAP report on how many squiddely tonnes of CO2 emissions are saved by our current recycling to argue that we should therefore be doing more such. Illogical: it may well be that recycling aluminium cans (as it does) saves both emissions and money. That has absolutely nothing whatsoever to do with whether wormeries and their associated worm farts are better or worse for emissions than landfill and methane capture.
No, these aren\’t all about cost benefit analyses. But they are all about much the same point. Unless we can see the details of how an argument, a chain of evidence, is constructed, we cannot have any confidence in the conclusions reached.
Thus the release of NICE\’s full economic model is something to be celebrated.
Slightly Odd
Parents who look after their children at home rather than send them to playgroups may be increasing their chances of developing leukaemia by 30 per cent, according to research published today.
The thought is that exposure to the various childhood ailments primes the immune system, making it less likely to go out of control (ie, one of the types of leukaemia) later on when it meets an infection.
Fair enough: but I thought we already accepted that at least certain types of childhood leukaemia were in fact caused by viral infections? Thus greater exposure should lead to a higher risk?
Oh well, way beyond my pay grade here.
Not the Toughest of Recruitment Calls to Fill
Some drug trials find it easier to get the guinea pigs than others.
Gene Therapy
Hundreds of thousands of people with failing eyesight have been given fresh hope of a cure after gene therapy techniques were used to treat a teenager.
The treatment transformed the life of a severely visually impaired 18-year-old. Healthy genes were injected into one eye, leading to a significant improvement.
Eh? How does this work? I was under the (obviously mistaken) impression that gene therapy only worked if you could get it into the cells that then replicated. That is, that you needed to get it into the actual genetic structure of the individual and that thus such therapy really only worked upon hte next generation.
Clearly, I\’m wrong, but seriously? Just inject the healthy genes into the afflicted organ and everything starts to work?
Ambitious
Our aim is to stop malaria deaths by ensuring universal coverage in Africa by the end of 2010.
All in 32 months, eh?
Forgive me this prediction: it ain\’t gonna happen.
Not The Most Surprising of Findings
A cuddle from mother is a natural painkiller for babies, according to a new report.
Premature newborns suffered less if they experienced skin-to-skin contact with their mother as they underwent a painful medical procedure, their study found.
A cuddle also appeared to help babies recover from pain more quickly.
Anyone else entirely unsurprised by this?
One thing it might lead to though is something of an explanation for why things like Reiki massage and so on do inded work in reducing pain. The theory that these Woo Woo things are based on is of course entirely Woo Woo, except for the fact that someone is paying attention, taking time with the patient and that skin on skin contact. We\’re primed to like all three of thoe things, even if supported by mumbo jumbo.
Voodoo Health Economics
…but the equally foolish claim, refuted by all available evidence, that the magic of the marketplace can produce cheap health care for everyone. …
How about this as an idea? Health care is expensive because health care is expensive: it requires huge amounts of labour (in the US, 13.5 million people) and vast amounts of capital ($800 million to bring a new drug to market).
How about the idea that there is *no way* to produce cheap health care for everyone? We can dance around the minor issues, choice, quality, access, these sorts of things, but we\’ll never invent a method of health care that provides high quality care to everyone that is cheap.
NHS Vouchers
Yes, to be welcomed.
Tens of thousands of NHS patients will be given money to pay for their own health care in a controversial "voucher" scheme under new government plans.
Patients with a range of illnesses will have direct control of "individual health budgets", allowing them to decide how to spend money at present allocated for them by the NHS.
An interesting question though: will they be allowed to top up their vouchers?