From the Washington Examiner

From the Globle and Mail

The heart and soul of Newfoundland politics is in for repair – and it’s not in his home province or even in Canada, for that matter.

Newfoundland Premier Danny Williams is scheduled for heart surgery in the United States, a move that throws into question his province’s and his nation’s health-care system.

A source confirmed to The Globe and Mail late yesterday that Mr. Williams has left St. John’s for an undisclosed destination in the U.S. to have heart surgery later in the week.

The 59-year-old Conservative left yesterday morning, spokesperson Elizabeth Matthews said, without disclosing his location. While some of his critics were tight-lipped last night, the online public questioned his exodus – why the care he needed was not available in Canada, or whether he preferred treatment in the U.S.

His departure for a U.S. hospital is being met with both sympathy and anger as few details have emerged.

The severity of Mr. Williams’ condition is not publicly known, however he was reportedly not overly concerned about his health, as he told close friends his greatest regret was the possibility of missing his Tuesday night hockey outings.

The remaining details are expected to be revealed at a news conference today by Deputy Premier Kathy Dunderdale.

At risk is the already tarnished image of the province’s health-care system, which has suffered in recent years.

In October 2008, Mr. Williams apologized for a string of breast cancer test mix-ups. And though he demoted health minister Ross Wiseman last July, he also defended his record, saying there was no other member of his government he’d have rather had lead the portfolio at the time.

The current Minister of Health and Community Services, Jerome Kennedy, declined an interview request last night.

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Posted from the London Telegraph

In a letter to The Daily Telegraph, a group of experts who care for the terminally ill claim that some patients are being wrongly judged as close to death.

Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away.

But this approach can also mask the signs that their condition is improving, the experts warn.

As a result the scheme is causing a “national crisis” in patient care, the letter states. It has been signed palliative care experts including Professor Peter Millard, Emeritus Professor of Geriatrics, University of London, Dr Peter Hargreaves, a consultant in Palliative Medicine at St Luke’s cancer centre in Guildford, and four others.

“Forecasting death is an inexact science,”they say. Patients are being diagnosed as being close to death “without regard to the fact that the diagnosis could be wrong.

“As a result a national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients.”

The warning comes just a week after a report by the Patients Association estimated that up to one million patients had received poor or cruel care on the NHS.

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Posted from the Daily Mail

Patients in Health Service hospitals are far more likely to go hungry than criminals in jail, scientists warned yesterday.

They say frail and elderly patients do not get the help they need with meals, and nobody checks whether they get enough to eat.

Despite years of Government promises to tackle poor hospital nutrition, food still arrives cold, and patients often miss out because meal times clash with tests and operations.

The Daily Mail has been highlighting the scandal of old people not being fed properly in hospital as part of its Dignity for the Elderly campaign.

Hospital meals are often taken away untouched, because they are either unappetising or are placed out of patients’ reach.

The latest figures show 242 patients died of malnutrition in NHS hospitals in 2007  -  the highest toll in a decade. More than 8,000 left hospital under-nourished  -  double the figure when Labour came to power.

The NHS throws away 11million meals every year, and many nurses say they are too busy to help the frail eat.

Earlier this year the Mail revealed that some hospitals spend less on meals than the average prison.

Ten hospitals spent less on breakfast, lunch and an evening meal than the £2.12 a day allocated for food by the prison service. One spent just £1.

Although most hospitals do spend more than £2.12, prisoners end up better nourished than patients, say experts from Bournemouth University. After studying the food offered to inmates and across the NHS, they found patients face more barriers in getting good nutrition.

Professor John Edwards said around 40 per cent of patients were already malnourished when they were admitted to hospital, but their condition did not tend to improve while they were there.

‘If you are in prison then the diet you get is extremely good in terms of nutritional content,’ he said.

‘The food that is provided is actually better than most civilians have.

‘There’s a focus on carbohydrates, then there’s the way they prepare the food, it’s very healthy. They don’t add salt and there’s relatively little frying of food  -  if you have a burger then it goes in the oven. Hospital patients don’t consume enough.

‘And from the work we’ve done we know that people who sit round a table eat a lot more, but this doesn’t happen in hospitals.’

His colleague, Dr Heather Hartwell, said fruit and vegetables were given out in hospitals ‘but this doesn’t mean it’s eaten’.

While patients suffer due to a loss of appetite as a result of their illness, they often go hungry because there is no one to help them eat.

Dr Hartwell said once food was prepared, it generally hangs around waiting for porters to transport it to patients. Then it may be left on wards until it goes cold.

‘Ward staff also don’t actually know how much patients are eating because it is domestics who clear the trays away,’ she said. ‘This is an example of fragmentation in hospitals that does not necessarily happen in prisons.’

The research found temperature and texture are among the most important factors in patients’ satisfaction with food.

It concluded lack of appetite due to a medical problem is probably the main reason for under-nutrition, but said hospitals can make improvements.

Liberal Democrat health spokesman Norman Lamb said: ‘It’s incredible that so many hospitals are failing to serve healthy meals. If prisons can serve good food then so can hospitals.’

The Department of Health said: ‘The majority of patients are satisfied with the food they receive in hospitals, and we are working to improve services further.

‘The Nutrition Action Plan, Improving Nutritional Care, outlines how nutritional care and hydration can be improved and highlights five key priority areas for NHS and social care staff to work with.

‘We have also introduced the concept of “protected mealtimes” where all non-urgent activity on the ward stops, so that patients can enjoy their meals.’

SASKATOON — The incoming president of the Canadian Medical Association says this country’s health-care system is sick and doctors need to develop a plan to cure it.

Dr. Anne Doig says patients are getting less than optimal care and she adds that physicians from across the country – who will gather in Saskatoon on Sunday for their annual meeting – recognize that changes must be made.

“We all agree that the system is imploding, we all agree that things are more precarious than perhaps Canadians realize,” Doing said in an interview with The Canadian Press.

“We know that there must be change,” she said. “We’re all running flat out, we’re all just trying to stay ahead of the immediate day-to-day demands.”

The pitch for change at the conference is to start with a presentation from Dr. Robert Ouellet, the current president of the CMA, who has said there’s a critical need to make Canada’s health-care system patient-centred. He will present details from his fact-finding trip to Europe in January, where he met with health groups in England, Denmark, Belgium, Netherlands and France.

His thoughts on the issue are already clear. Ouellet has been saying since his return that “a health-care revolution has passed us by,” that it’s possible to make wait lists disappear while maintaining universal coverage and “that competition should be welcomed, not feared.”

In other words, Ouellet believes there could be a role for private health-care delivery within the public system.

He has also said the Canadian system could be restructured to focus on patients if hospitals and other health-care institutions received funding based on the patients they treat, instead of an annual, lump-sum budget. This “activity-based funding” would be an incentive to provide more efficient care, he has said.

Doig says she doesn’t know what a proposed “blueprint” toward patient-centred care might look like when the meeting wraps up Wednesday. She’d like to emerge with clear directions about where the association should focus efforts to direct change over the next few years. She also wants to see short-term, medium-term and long-term goals laid out.

“A short-term achievable goal would be to accelerate the process of getting electronic medical records into physicians’ offices,” she said. “That’s one I think ought to be a priority and ought to be achievable.”

A long-term goal would be getting health systems “talking to each other,” so information can be quickly shared to help patients.

Doig, who has had a full-time family practice in Saskatoon for 30 years, acknowledges that when physicians have talked about changing the health-care system in the past, they’ve been accused of wanting an American-style structure. She insists that’s not the case.

“It’s not about choosing between an American system or a Canadian system,” said Doig. “The whole thing is about looking at what other people do.”

“That’s called looking at the evidence, looking at how care is delivered and how care is paid for all around us (and) then saying ‘Well, OK, that’s good information. How do we make all of that work in the Canadian context? What do the Canadian people want?’ ”

Doig says there are some “very good things” about Canada’s health-care system, but she points out that many people have stories about times when things didn’t go well for them or their family.

“(Canadians) have to understand that the system that we have right now – if it keeps on going without change – is not sustainable,” said Doig.

“They have to look at the evidence that’s being presented and will be presented at (the meeting) and realize what Canada’s doctors are trying to tell you, that you can get better care than what you’re getting and we all have to participate in the discussion around how do we do that and of course how do we pay for it.”

Posted from the Wall Street Journal

In the last few years, I have had the opportunity to compare the human and veterinary health services of Great Britain, and on the whole it is better to be a dog.

As a British dog, you get to choose (through an intermediary, I admit) your veterinarian. If you don’t like him, you can pick up your leash and go elsewhere, that very day if necessary. Any vet will see you straight away, there is no delay in such investigations as you may need, and treatment is immediate. There are no waiting lists for dogs, no operations postponed because something more important has come up, no appalling stories of dogs being made to wait for years because other dogs—or hamsters—come first.

The conditions in which you receive your treatment are much more pleasant than British humans have to endure. For one thing, there is no bureaucracy to be negotiated with the skill of a white-water canoeist; above all, the atmosphere is different. There is no tension, no feeling that one more patient will bring the whole system to the point of collapse, and all the staff go off with nervous breakdowns. In the waiting rooms, a perfect calm reigns; the patients’ relatives are not on the verge of hysteria, and do not suspect that the system is cheating their loved one, for economic reasons, of the treatment which he needs. The relatives are united by their concern for the welfare of each other’s loved one. They are not terrified that someone is getting more out of the system than they.

The latter is the fear that also haunts Americans, at least those Americans who think of justice as equality in actual, tangible benefits. That is the ideological driving force of health-care reform in America. Without manifest and undeniable inequalities, the whole question would generate no passion, only dull technical proposals and counterproposals, reported sporadically on the inside pages of newspapers. I have never seen an article on the way veterinary services are arranged in Britain: it is simply not a question.

Nevertheless, there is one drawback to the superior care British dogs receive by comparison with that of British humans: they have to pay for it, there and then. By contrast, British humans receive health care that is free at the point of delivery. Of course, some dogs have had the foresight to take out insurance, but others have to pay out of their savings. Nevertheless, the iron principle holds: cash on delivery.

But what, I hear social philosophers and the shade of the late John Rawls cry, of British dogs that have no savings and cannot afford insurance? What happens to them? Are not British streets littered with canines expiring from preventable and treatable diseases, as American streets are said by Europeans to be littered with the corpses of the uninsured?

Honesty compels me to admit that the atmosphere in the PDSA rather resembles that in the National Health Service for British humans, and no dog would go there if he had the choice to go elsewhere. He has to wait and accept what he’s given; the attendants may be nice, or they may also be nasty, he has to take pot luck; and the other dogs who go there tend to be of a different type or breed, often of the fighting variety whose jaws once closed on, say, a human calf cannot be prised open except by decapitation. There is no denying that the PDSA is not as pleasant as private veterinary services; but even the most ferocious opponents of the National Health Service have not alleged that it fails to be better than nothing.

What is the solution to the problem of some dogs receiving so much better, or at least more pleasant, care than others? Is it not a great injustice that, through no fault of their own, some dogs are treated in Spartan conditions while others, no better or more talented than they, are pampered with all the comforts that commerce can afford?

One solution to the problem of the injustice in the treatment of dogs would be for the government to set up an equalizing fund from which money would be dispensed, when necessary, to sick dogs, purely on the basis of need rather than by their ability to pay, though contributions to the fund would be assessed strictly on ability to pay.

Of course, from the point of view of social justice as equality, it wouldn’t really matter whether the treatment meted out to dogs was good or bad, so long as it was equal. And, oddly enough, one of the things about the British National Health Service for human beings that has persuaded the British over its 60 years of existence that it is socially just is the difficulty and unpleasantness it throws in the way of patients, rich and poor alike: for equality has the connotation not only of justice, but of hardship and suffering. And, as everyone knows, it is easier to spread hardship equally than to disseminate blessings equally.

I hope I shall not be accused of undue asperity towards human nature when I suggest that the comparative efficiency and pleasantness of services for dogs by comparison with those for humans has something, indeed a great deal, to do with the exchange of money. This is not to say that it is only the commercial aspect of veterinary practice that makes it satisfactory: most vets genuinely like dogs at least as much as most doctors like people, and moreover they have a pride in professional standards that is independent of any monetary gain they might secure by maintaining them. But the fact that the money they receive might go elsewhere if they fail to satisfy surely gives a fillip to their resolve to satisfy.

And I mean no disrespect to the proper function of government when I say that government control, especially when highly centralized, can sap the will even of highly motivated people to do their best. No one, therefore, would seriously expect the condition of dogs in Britain to improve if the government took over veterinary care, and laid down what treatment dogs could and could not receive.

It might be objected, however, that Man, pace Professor Singer, is not a dog, and that therefore the veterinary analogy is not strictly a correct or relevant one. Health economics, after all, is an important and very complex science, if a somewhat dull one, indeed the most dismal branch of the dismal science. Who opens the pages of the New England Journal of Medicine to read, with a song in his heart, papers with titles such as ‘Collective Accountability for Medical Care—Toward Bundled Medicare Payments,’ or ‘Universal Coverage One Head at a Time—the Risks and Benefits of Individual Insurance Mandates’? On the whole, I’d as soon settle down to read the 110,000 pages of Medicare rules.

A few simple facts seem established, however, even in this contentious field. The United States spends a greater proportion of its gross domestic product on health care than any other advanced nation, yet the results, as measured by the health of the population overall, are mediocre. Even within the United States, there is no correlation between the amount spent on health care per capita and the actual health of the population upon which it is spent.

The explanation usually given for this is that physicians have perverse incentives: they are paid by service or procedure rather than by results. As Bernard Shaw said, if you pay a man to cut off your leg, he will.

But the same is true in France, which not only spends a lesser proportion of its GDP on health care than the U.S. but has better results, as measured by life expectancy, and is in the unusual situation of allaying most of its citizens’ anxieties about health care. However, the French government is not so happy: chronically in deficit, the health-care system can be sustained only by continued government borrowing, which is already at a dangerously high level. The French government is in the situation, uncomfortable for that of any democracy, of having to reform, and even destroy, a system that everyone likes.

Across the Channel, there is very little that can be said in favor of a health system which is the most ideologically egalitarian in the western world. It supposedly allots health care independently of the ability to pay, and solely on the basis of clinical need; but not only are differences in the health of the rich and poor in Britain among the greatest in the western world, they are as great as they were in 1948, when health care was de facto nationalized precisely to bring about equalization. There are parts of Glasgow that have almost Russian levels of premature male death. Britain’s hospitals have vastly higher rates of methicillin-resistant Staphylococcus aureus (a measurement of the cleanliness of hospitals) than those of any other European country; and survival rates from cancer and cardiovascular disease are the lowest in the western world, and lower even than among the worst-off Americans.

Even here, though, there is a slight paradox. About three quarters of people die of cardiovascular diseases and cancer, and therefore seriously inferior rates of survival ought to affect life expectancy overall. And yet Britons do not have a lower life expectancy than all other Europeans; their life expectancy is very slightly higher than that of Americans, and higher than that of Danes, for example, who might be expected to have a very superior health-care system. Certainly, I would much rather be ill in Denmark than in Britain, whatever the life expectancy statistics.

Perhaps this suggests that there is less at stake in the way health-care systems are organized and funded, at least as far as life expectancy is concerned (not an unimportant measure, after all), than is sometimes supposed. Or perhaps it suggests that the relationship of the health-care system to the actual health of people in societies numbering many millions is so complex that it is difficult to identify factors with any degree of certainty.

In the New England Journal of Medicine for July 3, 2008, we read the bald statement that ‘Medicare’s projected spending growth is unsustainable.’ But in the same journal on Jan. 24, 2008, under the title ‘The Amazing Noncollapsing U.S. Health Care System’ we had read that ‘For roughly 40 years, health care professionals, policy-makers, politicians, and the public have concurred that the system is careening towards collapse because it is indefensible and unsustainable, a study in crisis and chaos. This forecast appeared soon after Medicare and Medicaid were enacted and have never retreated. Such disquieting continuity amid changes raises an intriguing question: If the consensus was so incontestable, why has the system not already collapsed?’

The fact that collapse has not occurred in 40 years does not, of course, mean that it will not collapse tomorrow. The fact that a projection is not a prediction works in all directions: prolonged survival does not mean eternal survival, any more than a growth in the proportion of GDP devoted to health care means that, eventually, the entire GDP must be spent on health care.

Therefore I, who have no solution to my own health-care problems, let alone those of the United States, say only, beware of health-care economists bearing statistics that prove the inevitability of their own solutions. I mistrust the fact that, while those people who work for commercial companies (rightly) have to declare their interests in writing in medical journals, those who work for governmental agencies do not do so: as if government agencies had not interests of their own, and worked only for the common good.

The one kind of reform that America should avoid is one that is imposed uniformly upon the whole country, with a vast central bureaucracy. No nation in the world is more fortunate than America in its suitability for testing various possible solutions. The federal government should concern itself very little in health care arrangements, and leave it almost entirely to the states. I don’t want to provoke a new war of secession but surely this is a matter of states’ rights. All judgment, said Doctor Johnson, is comparative; and while comparisons of systems as complex as those of health care are never definitive or indisputable, it is possible to make reasonable global judgments: that the French system is better than the British or Dutch, for example. Only dictators insist they know all the answers in advance of experience. Let 100—or, in the case of the U.S., 50—flowers bloom.

Selfishly, no doubt, I continue to measure the health-care system where I live by what I want for myself and those about me.

And what I want, at least for that part of my time that I spend in England, is to be a dog. I also want, wherever I am, the Americans to go on paying for the great majority of the world’s progress in medical research and technological innovation by the preposterous expense of their system: for it is a truth universally acknowledged that American clinical research has long reigned supreme, so overall, the American health-care system must have been doing something right. The rest of the world soon adopts the progress, without the pain of having had to pay for it.

—Theodore Dalrymple is the pen name of Anthony Daniels, a British physician.