Monthly Archives: June 2015

More and more failures. No honesty and the denial of a Greek tax collector.. The professions no longer find this shocking – only the press.

Kat Lay reports June 30th in the Times: NHS failures are shocking, says watchdog

Our politicians are fiddling as our Health Service burns. They are in denial that there is rationing, in denial of the litigation and the overhead, and in denial that the system is fostering dependency. There is no honesty allowed in either administrators or politicians: a collective denial similar to the Greek minister of finance. Sadly, the professions no longer find this shocking …. A functioning health care system is a mutualised benefit, but when over 50% of the population get more from benefits than they pay in taxes, and have a vote, the inevitable happens. A vote for the party that promises more benefits…

A patient was told they should have just wet the bed when they complained they could not get the attention of staff to help them use the toilet for two hours, according to an NHS watchdog.

Healthwatch said its local teams had uncovered “shocking” treatment over the past year, with cases including a patient in a mental health crisis being told to “read a book or something” by a 24-hour helpline until her records could be accessed in the morning.

Anna Bradley, chairwoman of Healthwatch England, said: “The reports coming from local Healthwatch have highlighted a real range of problems across the health and care sector, from basic issues of service to serious failures to provide the level and quality of care we should all expect.”

Healthwatch, the consumer champion for health and social care, also highlighted a case of an elderly patient in a London hospital was left sitting in their own waste because staff were too busy to change their colostomy bag.

Examples were gathered via 800 visits to hospitals, GPs and care homes, as well as public events used to collect feedback. Patients reported issues such as poor access to interpreters, call bells put out of the reach of patients, and hospital parking charges.

The Care Quality Commission uses evidence collected by local Healthwatch to target inspections.

The Express 18th Jan 2015: NHS failures cost billions to taxpayers – Daily Express

The Telegraph 15th Feb 2014: NHS’s bureaucratic failures put lives at risk

The Guardian (David Prior) 16th Feb 2014: The NHS will improve only when there is nowhere to hide its failures

The Nuffielld Trust: [PDF] inquiries: learning from failure in the nhs? – Nuffield Trust

and today in The Times Kat Lay reports on yet another difference in survival chances between those in rural and city areas: Warning over bowel surgery fatality rates

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Medical legal costs ‘excessive and should be capped’ – but no-fault compensation ignored…

On 28th June BBC News reported: Medical legal costs ‘excessive and should be capped’ and Jon Ungoed-Thomas and Sarah-Kate Templeton in the Times on the same day reported: Cap on lawyers’ huge NHS fees The answer is no-fault compensation as in several other countries. The longer it is delayed the more expensive it will become. (NHS spends £700 on negligence cover for every birth)

 

PERSONAL injury lawyers who claim tens of thousands of pounds in costs for minor claims against the NHS face a crackdown on fees.

Ministers have warned that legal firms charging “extortionate” rates could have their fees capped.

The proposals come after it emerged that some lawyers charge £800 an hour for claims against the NHS and last year collected £259m .

The Sunday Times has previously revealed how one firm claimed £83,000 after winning just £1,000 compensation for its client. In another case, the same firm sought £58,000 after winning compensation of £2,500 for a patient scalded by a hot drink.

Ben Gummer, a health minister, has outlined the plans for a fees cap in a letter to Lord Dyson, the master of the rolls and head of civil justice in England and Wales. The proposals include fixing legal costs to a percentage of the compensation won for patients in claims up to £100,000.

How the Sunday Times first reported the scandal (22nd March 2009)

Gummer said: “The NHS must make sure every penny counts. Unscrupulously, some lawyers have used patient claims to load grossly excessive costs onto the NHS and charge far more than the patient receives in compensation. These financial controls will ensure money is pumped back into patient care.”

Expenditure on clinical claims has risen from about £614m five years ago to more than £1bn last year. More than £20m is successfully claimed in costs each year by legal firms for cases where compensation payouts are below £10,000.

The NHS Litigation Authority has successfully challenged some “outrageous” fees and says it saved £74m last year. However, it wants tighter controls.

Emma Hallinan, director of claims and litigation at the Medical Protection Society, which provides support and advice to medical professionals, said: “We have been calling for a fixed-cost regime . . . and it is fantastic to see that the government plans to cap excessive legal fees that are placing such a burden on the public purse.”

Ministers say the most effective way to curb compensation claims in the NHS is to improve patient safety and improve communications with patients after an adverse incident. New measures include a statutory duty of candour and tougher inspections to protect patients.

Deborah Evans, chief executive of the Association of Personal Injury Lawyers, said: “We’re always concerned about government proposals to fix costs because the emphasis is always on cost reduction rather than getting the costs right. It’s incredibly important that the fees allowed enable a sufficiently experienced lawyer to investigate a claim properly and get the right answer for the injured patient.”

Lawyers use NHS as £200 million cash cow (22nd March 2009)

LAWYERS are earning £800 an hour from the National Health Service and taking “indefensible” fees of tens of millions of pounds in legal disputes. The money is coming from a government scheme intended to compensate patients for medical blunders and inadequate care, an investigation has found.

The compensation lawyers are claiming costs and “success fees” worth about £100m a year out of the scheme. In some cases the payouts claimed are 10 times more than the damages won by the patient.

Health professionals warn that it could get much more expensive. There is an estimated backlog of cases against the NHS amounting to £12 billion in claims, of which lawyers could get up to £6 billion.

The NHS Litigation Authority (NHSLA), which operates the compensation scheme, has lambasted the fees in a submission to Lord Justice Jackson, the judge. He is reviewing civil litigation costs.

The document warns that some “no-win, no-fee” lawyers are allowed to charge the NHS compensation scheme £804 an hour to pursue patients’ claims.

It states: “The whole costs structure is indefensibly expensive in relation to the compensation awarded or agreed. It is difficult to believe that it would be sustained were it not for the lack of motivation to change it.”

Mark Simmonds, the shadow health minister, said the huge fees being earned by the lawyers would be better spent on patient care. “It is unacceptable in some cases that the legal fees are many times higher than the awarded damages,” he said.

Bertie Leigh, a lawyer who defends the NHS in litigation cases, said he regards many of the cases he sees as a “buccaneering attack on the funds of the NHS”.

In one case involving Barking, Havering & Redbridge Hospitals NHS Trust, a legal firm claimed nearly £78,000 in costs and fees, having won just £7,000 for a female patient. A Liverpool firm submitted a legal bill for £4.4m for a single case.

The figures for 2007-8 show that more than one in four NHS trusts are paying out more in legal costs than in damages. The clinical negligence scheme paid £264m in compensation in 2007-8 of which £90m was in claimants’ fees.

Compensation lawyers say the success fees help to cover the cost of fighting cases they lose.

BBC News : Plans to cut legal aid for medical negligence opposed (22nd September 2011)

Night lenses to spare children from glasses –

Tom Lamden in The Times 29th June reports: Night lenses to spare children from glasses

Coming from a family of many generation of myopic people, on both sides, I am excited by this research. Now will it be available to all, or only to a select few, and how will they be chosen? Myopic covert rationing could result in a two tier society where one class pays for early treatment, and the other is denied access – prioritization or restriction. This could also occur by region, and post code… But it is good news..

Children may no longer suffer from short-sightedness if they wear soft contact lenses at night that re-shape their eyes to prevent them from needing glasses, a study suggests.

More than 300 children in Britain and across the world took part in the trials, which showed that lenses could stop the eye becoming misshapen leading to myopia.

The research, which was recently presented to the British Contact Lens Association annual conference, comes after a recent study published by Ulster University which found that the rate of short-sightedness in Britain has doubled over the past 50 years.

Twenty-three per cent of British 12 and 13-year-olds now suffer from myopia, which causes distant objects to appear blurred, while close objects can be seen clearly — compared with 10 per cent in the 1960s. Some experts believe that this is because children no longer spend enough time outdoors.

As part of the new study, every child who wore contact lenses to bed during the three-year trial period experienced no change in their vision, while all the control groups rapidly deteriorated.

The lenses, which are removed each morning, control the shape of the eye so that it grows in the correct manner so that glasses are never needed, a practice known as orthokeratology.

“Parents who are worried about myopic progression in their children now have a viable option,” said Professor Pauline Chom, of the Hong Kong Polytechnic University, which carried out one of the trials.

“Orthokeratology has been shown to effectively slow the progression of myopia in children.”

In people with normal vision, the eyeball grows along with the rest of the body and is programmed to stop growing at a point that sustains clear vision. In people with myopia, the typically spherical eyeball becomes elongated, resembling the shape of a grape or an olive.

Jennifer Golden, co-founder and director at iGO Optical, which markets the lenses in Britain, said: “We have whole families using lenses with some children starting to wear the overnight lenses from as young as six years old and who are now aged 13 without experiencing any increase in their prescription. The children who wore overnight lenses suffered minimal deterioration in their eyesight over three years.”

Gordon Ilett, a representative from the Association of Optometrists and a specialist in children’s eyesight, raised concerns about the use of contact lenses at night and called for more testing of the lenses.

“It is emerging technology and there is lots of anecdotal evidence about how brilliant it is, but really we need large population studies to prove efficacy,” he said.

Healthcare Alert: “We could fall behind in health” – and yet ” Britain has the chance to be the world’s doctor” – REALLY…?

As an alert to Matt Ridleys article, there is a small insert reading: “The Government should review immigration policies or the British Health Sector could fall behind the rest of the world, a report by the all-party parliamentary group on global health says. Analysis by the group found that a rethink of visa laws might be needed to ensure that the best people could work on health and life sciences in the UK. NHSreality comments that this is true, but only because we have not trained enough scientists or doctors… Rationing by undercapacity means we now need to import if we are to care for the population properly.

In The Times 29th June Matt Ridley opines: Britain has the chance to be the world’s doctor

Health will be the booming industry of the 21st century and we need to cash in on our expertise in so many areas

If the 19th century saw extraordinary changes in transport, and the 20th saw amazing changes in communication, my money is on health as the transformative industry of the current century. It is already arguably the biggest industry in the world and it is growing at a phenomenal rate, especially in Asia, where India and China are expanding their health sectors at 15 per cent and 12 per cent a year respectively. And health is ripe for a series of revolutionary advances in biotechnology, digital technology, robotics and materials.

A new report commissioned by three parliamentarians, Meg Hillier, MP, Lord Crisp (former chief executive of the NHS) and the surgeon Lord Kakkar, and written by researchers at the London School of Hygiene and Tropical Medicine, makes the case that Britain is well placed to become the world’s “health hub”. Just as the City of London is the world’s financial centre and Wimbledon is the centre of tennis, so Britain is already a surprisingly dominant player in research, practice, policy and regulation when it comes to health, and widely emulated around the world. There is an opportunity here.

The sheer breadth of our dominance in global health came as a surprise to me. I was aware that Britain has played a prominent role in biomedical research. After all, “we” found or invented antibiotics, DNA’s structure, cloning, in-vitro fertilisation, mitochondrial donation and much more. But I had not realised how much clout — or “soft power” to use the fashionable term — we wield in health policy and regulation: in rules as well as tools.

Take, for example, the Cochrane Collaboration. In 1992 in Oxford, a group of health researchers set up a centre named after the Scottish doctor Archibald Cochrane, who had realised while treating fellow prisoners of war in Germany that there was “no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention”. He pioneered the use of randomised control trials.

Today that centre has grown into a network of collaboration in 120 countries whose database has reviewed the effectiveness of 8,700 treatments. The reviews are free from commercial sponsorship and are considered the gold standard in providing the evidence base to justify using a drug or procedure.

Or consider Nice International, the global offshoot of the National Institute of Health and Care Excellence — the body that decides, often to the fury of some pharmaceutical firms and patient groups, that some treatments are not cost-effective. It turns out that the Nice model is in demand around the world from countries keen to work out how best to spend limited health budgets. Set up in 2008, Nice International does not make a profit but charges fees to client countries as well as aid agencies and foundations.

Unlike in manufacturing or agriculture, we really are top of the league in health. We have three of the top five universities in the world for clinical, pre-clinical and health subjects. We have the top science journal and two of the top four medical journals. We have the world’s second largest charity (Wellcome) and the world’s largest cancer research charity (Cancer Research UK). We rank top among G7 countries for the quality of research in clinical medicine, pre-clinical and human biological sciences, and infection and immunology.

The world’s top-selling drug Adalimumab (for rheumatoid arthritis) came out of Cambridge. The stunning decline in malaria in recent years — global mortality down by 47 per cent since 2000 — though heavily funded by the Gates Foundation, is to a large extent down to British research, including the discovery of artemisinin therapy and promising trials last month of a malaria vaccine, both from Oxford University.

We also punch above our weight in health aid. We are the second largest aid donor in the world, and health is the top category of aid spend in most countries. Britain is the second largest donor to the Global Fight Against Aids, TB and Malaria and the largest state donor to the Global Polio Eradication Initiative. We dominate research in the battle against “neglected tropical diseases” such as blinding trachoma and Guinea worm.

Apart from patting ourselves on the back for this, what’s the opportunity? After all, London’s dominance in international finance leads directly to large fees, whereas a lot of our dominance of global health battles comes from our willingness to spend money generously — especially taxpayers’ money. Getting rid of tropical diseases is a good thing in itself, and it eventually must enrich our potential trading partners, which benefits us too. But it is not immediately profitable.

In fact, the one sector where the report finds we are not quite so dominant is the commercial sector. We have one big medical technology company (Smith & Nephew) and cannot match Switzerland’s and America’s dominance of the pharmaceutical industry. We have (only) the fourth biggest biotech pipeline in the world. It’s South Korea that is pouring money into data management for medical purposes.

That, says Lord Crisp, is where the opportunity comes in: to turn some of our soft power into commercial opportunities. DfID, anxious not to confuse aid with trade, still does too little to exploit the expertise of the NHS. Sierra Leone, where 800 British NHS workers volunteered during the ebola epidemic, is surely the place to start.

I have my doubts as to whether a centralised monopoly is the best way to deliver healthcare for Britons, but given that this is what we have, it’s worth noting that it brings certain opportunities that more fragmented health systems lack and other countries are keen to learn from: central accreditation of doctors, or the ability to share and analyse huge amounts of data.

We can train doctors from other countries, set up overseas campuses and market the services of the royal colleges and General Medical Council as model regulators and standard setters. This already happens to some extent: the Tropical Health Educational Trust has projects in 26 countries reaching 25,000 health workers, while Newcastle medical school has a campus in Malaysia and Moorfields Eye Hospital one in Dubai. The Royal College of General Practitioners accredits an exam for doctors in Bangladesh, India, Pakistan and Sri Lanka as well as other countries.

If America is the world’s soldier, Germany its engineer, Brazil its farmer, China its manufacturer and India its service provider, then Britain can be the world’s doctor.

OOH (Out of Hours) is very variable, and a disgrace. There is “No effective oversight”.

Nicola Walker and Richard Baker in the BMJ (2015;350:h2185 ) opine in their editorial: Satisfaction with out of hours primary care – Time to stop writing reports and start taking action

It’s very difficult to take action too late. The workforce are retiring, emigrating or electing a portfolio career which includes as little OOH as possible! Rationing by undercapacity, linked to over management of the GP contract has led to a perception of a “straightjacket” in Primary Care. Exactly what action will make any difference in the short term? Only rationing by co-payments.

In November 2014, the House of Commons Committee of Public Accounts concluded that patients’ experience of primary care out of hours in England varies considerably and unacceptably across the country, as does the cost.1 The committee criticised NHS England for its failure to provide effective oversight and, among other recommendations, urged NHS England to develop its understanding of reasons for the variations in experience and costs. In the July 2014 GP Patient Survey, 66% of respondents rated their overall experience of out of hours care as “very good” or “good,” but the trend is downwards, the respective ratings being 68% in December 2013 and 71% in December 2012.2 Providing evidence that NHS England will find helpful, a linked paper by Warren and colleagues (doi:10.1136/bmj.h2040) analyses results of the national GP Patient Survey and describes factors associated with poor patient experience of out of hours services.3

In recent years various steps have been taken to improve out of hours care. In 2006 the Department of Health published several National Quality Requirements that out of hours providers are obliged to meet.4 In 2010, after a series of high profile cases of substandard out of hours care, further recommendations were suggested after a ministerial review.5 Since 2012 the Care Quality Commission (CQC) has regulated the quality and safety of out of hours services. An overview of the initial inspections of out of hours care by the CQC identified many examples of good practice but also highlighted areas for improvement.6

Over the past decade, out of hours primary care in England has changed substantially. In 2004 an estimated 90% of GPs opted to transfer responsibility for providing such care to the Primary Care Organisations the NHS had at that time. Today, in areas where GPs have “opted out” of providing out of hours care, most care is provided by social enterprises that are generally not for profit organisations led or run by general practitioners. Common alternative providers include commercial services or other NHS run services such as walk-in centres. For any one individual patient there can be many ways to access care out of hours, which can leave people confused about where to get help.

The NHS 111 number was intended to provide a single entry point for patients needing urgent but not emergency care. It is therefore of particular concern that about a third of adults have either not heard of NHS 111 or have heard of it but do not know what it is for. Not only that, 26% of people have not heard of out of hours GP services.7 To complicate matters, presentations to in hours and out of hours general practice have become more challenging. The growing numbers of older people and those with multimorbidity can often require the assistance of the out of hours service, but they can find it confusing to navigate. They need greater continuity and integration of care during in hours care now more than ever.

Warren and colleagues investigated associations between individual patient characteristics (including ethnicity and the ability to take time away from work to attend a healthcare consultation), the provider of out of hours care (NHS, not for profit, or commercial), and the patient’s experience of clinical care (timeliness, confidence and trust in the out of hours clinician, and overall experience of the service).3 Commercial provider organisations were associated with reports of poorer patient satisfaction across all three outcomes they investigated. The explanation for this finding is unclear; it is possible that commercial providers are located in areas with more complex population needs, but it is also possible that patient experience is genuinely poorer. If confidence in commercial providers is to be preserved, further work is urgently required to understand the reasons for this finding.

Some ethnic minorities, particularly Asian (defined as Indian, Pakistani, Bangladeshi, other Asian, excluding Chinese, or other ethnic group)8 reported a poorer experience, especially when asked about timeliness of care. Poorer experience among ethnic minority groups has also been found for in hours GP care. Although higher expectations and communication issues could partly explain these findings, further qualitative investigation could help to account for potential inequalities in care and finally lead to approaches to delivering care that meet expectations and improve experience. Although more research might be helpful, however, action to change matters should not be delayed any further. In 2008 a Department of Health report concluded that many patients from minority ethnic groups are unable to exert real influence on improving local services and that communication and trust between the local NHS and ethnic minority patients needed urgent improvement.9

Warren and colleagues also found that patients in work who were unable to access their own GP reported lower satisfaction with out of hours care.3 People in work tend to report greater difficulty in accessing their preferred general practitioner in hours,10 and proposals have been announced to introduce seven day access to general practices. The practicality of this idea, however, is open to question, as GPs are already struggling to cope with current demand. In a recent survey of GPs conducted by British Medical Association, only 2% of respondents supported seven day working from their own practices.11 The case for bringing practices together into federations or other organisational forms to enable the scheduling of access beyond usual opening hours—as well as to create other efficiencies—is becoming urgent. The GP contract should be reviewed to promote federations. Although we need more research to better understand the experience of some patients and how we should respond, further reports are not needed; it is time for action that makes a real difference.

Whistleblowing in the NHS – The need to regulate non-clinical hospital managers

Mr Charlie Chan (Surgeon) writes in letters to the BMJ: Whistleblowing in the NHS – The need to regulate non-clinical hospital managers (BMJ 2015;350:h2769) NHSreality agrees.

Non-clinical hospital managers are the only group of NHS professionals without a regulatory body. Although clinical hospital managers are professionally accountable to their regulatory bodies (such as the General Medical Council, the Nursing and Midwifery Council), non-clinical managers are not.

Regulation 5 of the Care Quality Commission sets out “Fit and proper persons” standards for hospital directors,1 but no such standards exist for the vast cohort of senior and middle managers, who are not board members. So what sanctions might exist for hospital managers who repeatedly ignore issues about patient safety?2

Concerns about patient welfare are usually first raised with departmental managers, who are often non-clinical. If non-clinical managers were bound by a professional accountable body to act always in the best interests of patients, they would be more likely to listen and act. Doctors and nurses would be able to refer relevant hospital managers to an accountable body if the reformed NHS whistleblowing system ignored patient safety.

This regulatory change for hospital managers is long overdue and would give increased confidence to all who care for patients.

Rationed – Start of cheaper technique for breast cancer is delayed in UK despite adoption elsewhere. GP commissioners should be demanding intra-operative radiotherapy.

Nigel Hawkes in the BMJ News reports: Start of cheaper technique for breast cancer is delayed in UK despite adoption elsewhere ( 2015;350:h2874 ) This type of rationing by delay of approval is very common in the health services. Its the same for new drugs whose approval is delayed until they are nearly out of patent.. GP commissioners should be demanding intra-operative radiotherapy.

A new technique that substantially reduces the burden of radiotherapy in women with early breast cancer and could save the NHS millions of pounds a year has been approved in Australia by the Medical Services Advisory Committee—the Australian equivalent of the UK National Institute for Health and Care Excellence (NICE)—ahead of its UK counterpart. Not only has it been recommended for selected patients but it is also an item in the committee’s 2015-16 budget.

In July 2014 NICE published draft guidance recommending the use of intrabeam radiotherapy, which replaces a course of 15 postoperative radiotherapy sessions with a single dose, given at the time of surgery. A randomised controlled trial led by University College London (UCL), the TARGIT-A trial, was published in 2010,1 and a five year follow-up in 2014 showed that the outcomes were not inferior to the established approach.2

At that time Carole Longson, director of health technology evaluation at NICE, said that the technique had the potential to be a much more efficient form of radiotherapy. “Unlike regular radiotherapy, with the Intrabeam Radiotherapy System only one dose is required,” she said. “The single dose is given at the same time as surgery, eliminating the need for numerous hospital visits. Regular radiotherapy typically requires numerous doses over a three week period—although some people may receive it for longer—and is performed weeks or months after surgery or chemotherapy.”

But, after comments from what NICE referred to simply as professional organisations, the final recommendation has been delayed. This delay has blighted the use of the technique in the United Kingdom, where it was developed, but it continues to be enthusiastically employed elsewhere in the world.

“It’s a terrible and shameful situation,” said Jeffrey Tobias, consultant clinical oncologist at UCL and one of the original trialists. “It was invented here—we did the first case in 1998 at the Middlesex Hospital. Now it’s being done routinely in the US, Germany, Australia, France and elsewhere but not here. A number of our patients even have had to go abroad for this treatment—it’s such a pity.”

Jayant Vaidya, professor of surgery and oncology at UCL, said, “As professionals, we can’t give our patients the treatment that’s best for them. I had to send a patient to Italy last week to get the treatment there. It’s very frustrating.” He calculated that use of the technique would save the NHS £12m to £60m (€17m to €85m; $18.5m to $92m) a year.

The technique has been adopted worldwide. At the St Gallen Breast Cancer Conference in 2011 the consensus among more than 52 breast cancer expert panellists was that TARGIT alone could be used as the only radiation treatment in selected cases after breast conserving surgery or as a boost to the bed of the tumour instead of external beam radiotherapy boost.

At the Miami Breast Cancer Conference in 2012, 91% of the audience in the surgical oncology stream echoed that view. The 2015 update of German guidelines from the Association of Gynaecological Oncology includes TARGIT intraoperative radiation therapy (IORT) during lumpectomy as a recommended option for women with T1, grade I or II, ER positive breast cancer. Over 250 centres worldwide now use the technique for treating breast cancer in the United States, Europe, Australia, the Middle East, the Far East, and South America. Some 120 centres are in Germany and the US alone, and more than 8000 patients have now been treated.

NICE told The BMJ that its decision to call for more evidence does not mean that the technique cannot be used in England and Wales, but Tobias and Vaidya both said that this has indeed been the effect of the ruling, except for patients enrolled in the National Institute for Health Research’s Health Technology Assessment TARGIT-B trial in patients with higher risk disease. In a statement NICE said, “While this NICE appraisal is ongoing, intrabeam radiotherapy can continue to be offered to NHS patients who need it. Until NICE publishes its final guidance, decisions on whether or not to fund specific treatments are the responsibility of local NHS bodies.”

NICE requested further information from the trialists, which has been provided. The appraisal committee will meet in August to look at the new evidence provided and make a further recommendation on the use of intrabeam radiotherapy, NICE said.

The new approach would greatly reduce the burden on radiotherapy departments, since women would not have to return for repeated radiotherapy sessions. It requires investment in machines to deliver the intraoperative radiation but on balance would save substantial amounts of money.

Off patent drugs – Cheap drugs could get new lease of life. Watch and see if the MPs act..

It’s not about money – it’s about a proper debate on philosophy and overt rationing

The cheap drug anastrozole could save 4,000 a year from breast cancer

Thousands of prostate patients denied drug that can extend life by five months in watchdog U-turn

Cancer patients denied drug – restriction, prioritisation or rationing?

Anticoagulants to prevent clotting diseases.