Markets, politicians, and the NHS
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7222.1383 (Published 27 November 1999) Cite this as: BMJ 1999;319:1383
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Not long ago, Dr. Sidney Wolfe, who was the Director of the Public
Citizens' Health Research group (a non-profit watchdog of the drug
industry) testified before the Senate Committee on labour and Human
Resources, chaired by Senator Edward Kennedy. One of the cases that he
exposed was against a company called the Physicians Computer Network
(PCN), which was really a frontline organisation for the ten largest drug
companies. PCN gave doctors a big, elaborate "practice management"
hardware and software package that computerises details of every patient,
their ills, diagnosis, bills and even book-keeping. In Klein's language
(2) PCN was perhaps the epitome of quality improvement, quality management
and organisation of health care.
But there was a catch in the whole deal. There were two conditions
that were necessary in order to receive the equipment. One, to allow the
PCN to hook in to a phone modem so that they could access the information
anytime (except for the name and address of the patient), and secondly,
the doctor must watch 32 ads a month that appear on the computer system
and answer one clinically-oriented question per ad. Thus the doctor
confirmed the procurement of the equipment worth over $35,000.00 at an
investment of less than an hour of his time - the time which he had taken
to watch the ads to such an extent as to modify his own prescribing
practices.
In 1989, Attorney General James Shannon of Massachusetts, commenting
on the marketing practices of pharmaceutical companies, said: "It is
important that medical decisions are made solely on the interests of the
patients and not on the basis of inducements made by any drug firm" (1).
British drug firms, many of which are owned by American companies, are
fighting vehemently to oppose the Medicines Information Bill (which
provides the public with a full report on safety trials of each drug)
under tha claim that the Bill eliminates healthy competition between drug
firms (1). Maybe that's what we need - less competition and more human
concern!
We hear a lot of talk about quality, but as long as customers are
complaining we have not reached the goal. Quality is conformance to
standards and requirements, aiming at zero defects, with a flexibility and
responsiveness to change. Perceived quality of service is influenced by
technical and functional decisions. Quality of health care is a growing
concern among health care professionals. It cannot be reduced to simple
customer satisfaction. Efficiency, efficacy, appropriateness,
acceptability and equity are dimensions of health care quality. The
quality of health care is not driven up solely on the basis of the
professional integrity of health care providers. And according to the
Joint Commission for the Accreditation of Health Care Organisations,
quality care requires inter-disciplinary performance improvement
activities to ensure quality improvement.
It is vital that we realise that problems such as drug promotion,
baby foods and tobacco are just a tip of the iceberg which represents a
world system of economics and politics in which all of us are enmeshed.
There are very good reasons why some people are rich and stay rich and due
to the very same reasons some are poor and remain poor. Some of the best-
intentioned efforts to improve food and economic situations in developing
countries have only succeeded in making matters worse (3).
The NHS could be a trend-setter as a watchdog of drug marketers and
politicians who are so busy interfering in the medical profession that
they have precious little time to do anything else (4) - a watchdog that
bites!
References:
1. United States Senate Hearing on Drug Company Fraud and Bribery. In,
"Amazing medicines the drug companies don't want you to discover".
University Research Publishers, Tempe, Arizona, 1993; 13-28
2. Klein R. Markets, politicians and the NHS. BMJ 1999; 319: 1383-84
3. Aitken J. Christians in International Health. Guidelines No: 70,
Christian Medical Fellowship Publications, UK
4. Oommen T. Watchdogs must bite. eBMJ, January 4, 1999, in response
to Abraham et al: Rethinking Transparency and Accountability in Medicines
Regulation in the UK. BMJ 1998; 318: 46-47
Competing interests: No competing interests
May I add to Rudolf Klein's final paragraph a third question - "Will
the status of the NHS as an emotive political tool prove its undoing, as
its sustainability in its present form becomes increasingly incompatible
with the demands of our political future?"
Competing interests: No competing interests
Mr Klein asks some very important questions. Who should decide what
should be in the NHS remit to treat as the organisation slumps into the
next millenium?
The job of Government is to represent the public interest.
Over the last decade patients have suffered inspite of
the Patient's Charter, Fundholding and Waiting List Initiatives. Now we
have gimmics such as NICE, CHIMP,
and PCT's. Without any new money how will secondary
care cope with the inevitable increase in therapeutic cost
resulting from the improved diagnostic and screening protocols from
primary care? Will this increased auditing and excellence in papework
diminish physician-patient time?
There are only so many things that GP's and Consultants can do.
Whitehall policy makers have relied on the cheap labour of intermediate
staff for too long and now face further physician shortages as European
working initiative rulings will inevitably be reinforced.
A doctor's prime responsibility is to achieve the best treatment for
the individual. It is becomming apparent that the Government has long
since washed its hands of this responsibility by organising PCT's as a
cost cutting exercise; inspite of some of the poorest per capita spending
on Healthcare. Should we as a profession turn a blind eye? What are our
legal responsibilities in obtaining best Healthcare? We need to employ our
own spin-doctors through our BMA funding to pressure for bowel cancer
screening. How many British people are aware that lung cancer can be
screened for cost effectively through spiral CT scanning?
What transpires is anyone's guess- rationing of treatments on the
NHS, more private heathcare or better taxation redistribution may result.
It must, however, involve a greater public awareness and participation in
the debate, afterall it is they who are being denied consistantly
competent modern therapy.
Competing interests: No competing interests
Markets, politics, and health care in Hong Kong
There is a striking parallel between the current health care reform
exercise in Hong Kong and what Klein reflected on in his editorial (Nov
27) about the NHS.(1)
While the British government invited Alain Enthoven
to guide NHS reform in the '80s, Hong Kong officials have recently sought
advice from William Hsiao, another American academic. On the system's
organisational architecture, the ultimate direction of Hsiao's Harvard
Report is towards creating a competitive market model for vertically
integrated health service delivery,(2) similar to Enthoven's "internal
market model" for the NHS.(3) To this end, Hsiao argues for the
purchaser-provider split of the current Hospital Authority, which is
responsible for all public hospitals in the territory and accounting for
92% of total bed-days.(2) On financing, the fundamental tenet of "money
following the patient" in the Harvard Report calls for cross-sectional
risk pooling in the form of compulsory social insurance called the "Health
Security Plan", and a longitudinal medical savings plan for elderly and
long-term care - "MEDISAGE".(2)
Hong Kong's policy makers seem poised to go a different route than Hsiao's
prescription, as were their British counterparts in 1991 with Enthoven's
advice. User fees will probably rise substantially to offset the upward
cost spiral, and to shift middle-class individuals back to the private
sector, where a larger proportion of them sought care before quality and
management reforms of public hospitals earlier in the decade. While not
favouring Hsiao's advice of competitive integrated care, the government
does appear ready to build on its regional "clustering" of specialist
outpatient and hospital services. It is likely that primary care will be
vertically integrated into these clusters, thereby achieving seamless or
integrated care, albeit under the single umbrella of the Hospital
Authority. Perhaps then, its name will be changed to Health Authority.
Again, the parallel with current NHS structure is readily apparent.
It will be interesting to see to what extent the white paper, to be
released next year by the Health and Welfare Bureau outlining the actual
blueprint for change, is influenced by the Harvard Report. As with
Enthoven in the NHS reforms, if Hsiao's ideas were influential, it was
because they provided a common vocabulary to and "crystallised ways of
thinking" about reforms for doctors, nurses, allied health professionals,
bureaucrats and the lay public in the ongoing health care debate.(1)
Gabriel M. Leung
assistant professor
Sarah M. McGhee
director, Health Services Research Group
Anthony J. Hedley
professor and head
Department of Community Medicine, University of Hong Kong, 7 Sassoon
Road,
Pokfulam, Hong Kong
References
1. Klein R. Markets, politicians, and the NHS. BMJ. 1999;319:1383-4.
2. Hsiao W, Yip W. Improving Hong Kong's health care system: why and
for whom? Hong Kong: Printing Department, HKSAR Government, 1999.
3. Enthoven AC. Reflections on the management of the National Health
Service. London: Nuffield Provincial Hospitals Trust, 1985.
Gabriel M. Leung MD, MPH, CCFP(C)
Assistant Professor
Department of Community Medicine,
7 Sassoon Road,
South Wing, Patrick Manson Building
Faculty of Medicine, University of Hong Kong,
Hong Kong
Competing interests: No competing interests