Category Archives: pharmacists

Unfairness in infertility is symptomatic of a far more important unfairness – in survival and life expectancy.

£68m out of £122bn is significant when all other demands are considered. Ask the commissioners. Why should fertility be treated differently to stent insertions or stroke or cancer treatments? At least these are life saving. Every health system rations care. The debate should be about whether this rationing should be overt or covert, and whether different for different post codes/regions. Rationing by insurance differentials as in many EU countries is giving better overall outcomes and is less unfair than what we face now. Nobody knows in advance what will be rationed for them. Their future health demand results from the lottery of life, but the unfairness results from the lottery of where we live, and the dishonesty inherent in a lack of national debate. . The WHO will not in future report on an NHS: rather on 4 systems of covert rationing. A pragmatic and honest debate is needed on what the health services are for, and whether the founding principles outlined by Aneurin Bevan (in place of fear, chapter 5) need to be reassessed and rewritten. Meanwhile our denial is bringing back fear, especially to those without the means to make a private choice.( Politicians often go privately….) 

 The hearts and minds of the coalface workers are disengaged from the politics because of this denial. They are also concerned that the media may be colluding in the denial, so that things get worse. 

 Three MPs write a letter to the Times revealing their state of denial and poor understanding of the rationing decisions commissioners are having to take to keep within budget.. The Times then follows up with a leader which is equally banal. “Unfairness in Infertility”. There will be fewer staff now that we are leaving Europe, and Katie Gibbons reports 30th October that “Staffing crisis will put NHS care at risk, says charity”. The Kings fund report is more circumspect but they really agree. Rationing by not having enough people with sufficient skills is a disgrace, and reflects more on our politician and political system than anything. Unfairness in infertility is symptomatic of a far more important unfairness – in survival and life expectancy. Of course genetic selection IVF should be a choice for those with inherited diseases, but in other cases we need to question priorities. (See Letter from Richard Childs in the Times 2nd November 201& – posted at the end, followed by another letter on cost and perverse incentives from Prof Nargund)

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Image result for infertility cartoon

NHSreality ‘ response to the Times is:

“£68m out of £122bn is significant when all other demands are considered. Ask the commissioners. Why should fertility be treated differently to stent insertions or stroke or cancer treatments? At least these are life saving.

Every health system rations care. The debate should be about whether this  rationing should be overt or covert, and whether different for different post codes/regions. Rationing by insurance differentials as in many EU countries is giving better overall outcomes and is less unfair than what we face now.

Nobody knows in advance what will be rationed for them. Their future health demand results from the lottery of life, but the unfairness results from the lottery of where we live, and the dishonesty inherent in a lack of national debate. .

The WHO will not in future report on an NHS: rather on 4 systems of covert rationing.

A pragmatic and honest debate is needed on what the health services are for, and whether the founding principles outlined by Aneurin Bevan (in place of fear, chapter 5) need to be reassessed and rewritten.

Meanwhile our denial is bringing back fear, especially to those without the means to make a private choice.( Politicians often go privately….)

The hearts and minds of the coalface workers are disengaged from the politics because of this denial. They are also concerned that the media may be colluding in the denial, so that things get worse.

CUTS TO IVF CYCLES – The Times letters 31st October 2017
Sir, This month marks the 40th anniversary of the creation of the embryo that went on to become Louise Brown, the world’s first IVF baby. This medical breakthrough has brought joy to countless people.

In England, the provision of IVF treatment on the NHS is now reaching crisis point, with clinical commissioning groups (CCGs) decommissioning services, and several areas in the southeast offering no service at all. Research carried out by Fertility Fairness shows that the number of CCGs offering the Nice-recommended three IVF cycles to eligible women under 40 has halved in the past five years so that only 12 per cent now follow national clinical guidance. CCGs need to be held accountable for these cuts but neither the government nor NHS England seem to have the powers or the appetite to do this. Even when CCGs consult their local population, and the latter support retaining fertility services, the CCGs cut them anyway. Surely the time has come to consider commissioning this service centrally in England, as they do in the devolved nations, so that the provision of fertility treatment is equitable.
Steve McCabe, MP (Lab); Tom Brake, MP (Lib Dem); Ed Vaizey, MP (Con)

Unfairness in FertilityAfter 40 years, IVF treatment on the NHS is unacceptably patchy

Whether couples have children should not depend on where they live. Forty years into the age of in-vitro fertilisation, those who could benefit should have access to it on a roughly equitable basis. Unfortunately, they do not. Huge variations in the availability of IVF on the National Health Service have emerged since local doctors’ groups were given new control over how NHS money was spent in the Lansley reforms five years ago. This is an injustice that the government has helped to create and that the government can help to end. It should do so without delay.

National guidelines on how many cycles of IVF should be available on the NHS are being ignored at the local level, and especially in the southeast. As of this year, couples having trouble conceiving in Cambridgeshire and Croydon have no chance of IVF except by paying for it themselves, while those in most of Greater Manchester are still assured of three cycles on the NHS as long as the would-be mother is under 40.

This is unfair. It is especially galling for couples trying unsuccessfully to have children for want of enough IVF treatments, who through their taxes are subsidising effective treatments for others for no better reason than their postcode.

Such a lottery is avoidable. Since April this year, commissioning of IVF in Scotland has been centralised so that all couples who could benefit are guaranteed three cycles. Commissioning has also been centralised in Wales and Northern Ireland, although the provision there is less generous. MPs are demanding a similar centralisation of IVF provision in England.

Four decades ago, Patrick Steptoe and Robert Edwards pioneered the laboratory fertilisation of a human embryo and its successful re- implantation into the womb of the egg’s donor, Lesley Brown. Later knighted, Sir Robert was also awarded a Nobel prize for his work in reproductive medicine. Mrs Brown’s daughter, Louise, the world’s first IVF baby, is this week attending a fertility conference in Texas at which she has said the heartache of couples denied access to the treatment that gave her life can be devastating.

More and more people hoping to conceive in this way are being affected. National guidelines recommend up to three IVF cycles for women under 40, but these are not binding. Replies to Freedom of Information requests sent to clinical commissioning groups (CCGs) by a fertility pressure group reveal that the number following the guidelines has halved in the past five years to one in eight. Thirteen CCGs have stopped offering IVF in the past year. Nationally, one in 30 offers none at all.
For a given locality, the arguments against generous provision can seem compelling. IVF is not strictly a health treatment. Its effectiveness falls steeply as women approach 40. It is expensive, and resources are finite. At the national level, however, these arguments carry less weight. The NHS funds IVF for roughly 20,000 couples a year at a cost of about £68 million — a small fraction of the service’s overall budget of £122 billion. Guaranteeing three IVF cycles for all women who might benefit from it would carry an extra cost, but so would withholding the treatment. This cost might be measured in sadness and loneliness in later life, but would be no less real for that.
The lottery of fertility is harsh enough. There is no reason for government to make it harsher still.

Image result for infertility cartoon

Letter from Richard Childs in The Times:

Sir, Susan Seenan, of Fertility Fairness, suggests that IVF is a “medical need”. Cancer treatment and tumour surgery are medical needs, IVF is not. It is a personal or social “want” — a very different thing. Financially the NHS is only able to provide funding for genuine medical needs. I do agree with her, though, that whether someone receives treatment of any sort should not be dependent on a postcode. A fair solution for IVF is, therefore, that irrespective of postcode no one should receive it on the NHS. Ever more scarce resources could then be diverted to addressing real medical needs.
Richard Childs

Collingham, Notts

Letter from Prof Nargund:

Sir, Your report “First test tube baby Louise Brown warns over ‘devastating’ impact of IVF cuts”, Oct 31) covers increasingly familiar and depressing ground. However, the continued reporting of IVF funding cuts misses the crux of the issue. The scale of the NHS budget is not the problem; the existing budget could easily fund the required IVF treatments in accordance with National Institute for Health and Care Excellence guidelines. The real problem is twofold: first, there is a fundamental deficit of IVF pricing knowledge within the NHS and among NHS commissioners. Simply put, a lack of awareness as to the various methods of IVF delivery, treatment and drug doses is resulting in a flawed (and highly expensive) procurement process.

Second, and more worryingly, the problem is compounded by the vested interests of the drug companies and IVF providers, where both enjoy a lack of transparency on IVF costs and profit at the expense of NHS patients.

If these challenges were to be sufficiently addressed we could halt the NHS rationing of treatment and help those denied treatment by virtue of their postcode.
Praful Nargun
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CEO, ABC IVF, Harley Street

 

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The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

David Epstein in propublica (Atlantic) on 22nd Feb 2017 writes/asks: When Evidence Says No, but Doctors Say Yes = Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments. (Such as Bisphosphonates)

Image result for bad pharma cartoon

You can listen to the article  HERE, and the importance of evidence based medicine, study replication and critique becomes vital. In the UK we see the over prescribing of anti-depressants to elderly people (BMJ 2011;343:d4551 ) when over 90% don’t work and 7% cause side effects (At present unpublished data). In orthopaedics we were given the solution to cross infections and waiting lists in 1983, but have moved in the opposite direction, closing cold orthopaedic hospitals or denying them as choice options to patients. In addition, clips closing skin wounds have been shown to increase infections by 300% but are still used because they are faster! The article covers heart disease, hypertension, knee injuries and other conditions that need systematic evidence review. What has never been measured is morbidity and mortality for patients who wait longer for operations (Hips and Knees especially) as there is no public database, and big pharma are not concerned. Indeed, waiting lists mean more drugs, prescriptions and side effects. Proposed legislation to reduce efficacy thresholds (USA) could increase the influence of “pharma” when the opposite is needed…

For a summary read from this link. When Evidence Says No, But Doctors Say Yes

Summarising:

Stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all.

Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died.

The consultants approach: “Just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account’s not going to be upset with you for doing the surgery.”

When looking at cross-over trials for cancer: “If the treatment were Pixy Stix, you’d have a similar effect. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment.”

When distinguishing between relative and absolute risk: “Relative risk is just another way of lying.”

The article ends:

In 2014, two researchers at Brigham Young University surveyed Americans and found that typical adults attributed about 80 percent of the increase in life expectancy since the mid-1800s to modern medicine. “The public grossly overestimates how much of our increased life expectancy should be attributed to medical care,” they wrote, “and is largely unaware of the critical role played by public health and improved social conditions determinants.” This perception, they continued, might hinder funding for public health, and it “may also contribute to overfunding the medical sector of the economy and impede efforts to contain health care costs.”

It is a loaded claim. But consider the $6.3 billion 21st Century Cures Act, which recently passed Congress to widespread acclaim. Who can argue with a law created in part to bolster cancer research? Among others, the heads of the American Academy of Family Physicians and the American Public Health Association. They argue against the new law because it will take $3.5 billion away from public-health efforts in order to fund research on new medical technology and drugs, including former Vice President Joe Biden’s “cancer moonshot.” The new law takes money from programs—like vaccination and smoking-cessation efforts—that are known to prevent disease and moves it to work that might, eventually, treat disease. The bill will also allow the FDA to approve new uses for drugs based on observational studies or even “summary-level reviews” of data submitted by pharmaceutical companies. Prasad has been a particularly trenchant and public critic, tweeting that “the only people who don’t like the bill are people who study drug approval, safety, and who aren’t paid by Pharma.”

Perhaps that’s social-media hyperbole. Medical research is, by nature, an incremental quest for knowledge; initially exploring avenues that quickly become dead ends are a feature, not a bug, in the process. Hopefully the new law will in fact help speed into existence cures that are effective and long-lived. But one lesson of modern medicine should by now be clear: Ineffective cures can be long-lived, too.

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

The physiotherapists research: Toby Smith & Debbie Sexton, and two consultants (Donell and Mann) in 2010:  Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis (BMJ 2010;340:c1199 ) – found a 3 fold or 300% increase in infections

Blunders. Iatrogenesis continues to be very important – for us all. It may become more so…

The nation hooked on prescription medicines – no more than many others actually..

 

 

 

 

 

 

Moral duty and Moral Hazard. Woeful lack of control and supervision on pricing of pharmaceuticals by department of health…

After Thatcherism, everyone for themselves, and there is “no society” it is not surprising that British Citizens feel they can arbitrage the generic pharmaceutical system. Surely they do have a duty to report the loopholes they have exploited, and it is not “against the law”; just against their moral duty as a citizen and potential consumer. What is the opposite of rationing – profligacy?

Billy Kember reports in The Times 4th June 2016: Drug ‘profiteers’ face fines – Times investigation prompts government inquiry into £260m NHS rip-off

Drug companies that raised the price of medicines by up to 12,500 per cent could face multimillion-pound fines after the government called in the competition watchdog.

Jeremy Hunt, the health secretary, asked the Competition and Markets Authority (CMA) urgently to examine evidence uncovered in an investigation by The Times, which revealed that a select group of entrepreneurs had made a fortune exploiting a loophole in NHS pricing rules.

The companies face limited competition on long-established, off-patent drugs, which they bought from large pharmaceutical companies. By dropping the brand name, the medicines are taken outside NHS profit controls and suppliers are free to oversee “extortionate” price rises…..

You might argue that they are not ever going to be consumers, but NHSreality replies that their emergency infarct or stroke will not happen in a place or a circumstance when they have an option. The A&E departments of the Regional Health Services are safety nets for all of us.

A letter from Ian Bennett in The Times summarises nicely:

Sir, While suppliers are criticised in your report, the real blame must lie with the Department of Health for its woeful lack of control and supervision on pricing. It is not difficult to determine that some generic prices are far above those of the original patented products and also well above generic prices in other EU countries.

Many generics, marked as manufactured in the UK, are imported in bulk, repacked and packaged with a UK address. To avoid the risk of a UK supplier demanding excessively high prices, the NHS and the wholesale network should be free to obtain supplies elsewhere in the EU, under current mutual recognition procedures of product registration. This might involve some changes in labelling requirements but that would be a price worth paying to have an effective price structure for these older generic products supplied
to the NHS.
Ian Bennett
Lymington, Hants

 

Cutting pharmacists may be possible in cities, but it will be very inconvenient in rural areas. Who is off their trolley?

Rationing numbers of pharmacies may be possible in cities, but it will be very inconvenient in rural areas, unless GP restrictions are lifted. The rural “on cost” is never clearer than in pharmacies. Our town has three, but technically one could do the job of all of them…( Lack of competition may then result in diminished service.?.). None of the links below gives an indication of the increased load that might result on GPs. Actually the evidence for this is very thin, and it may be more of a fear than a reality: but politicians need to be aware that an already creaking service might implode further. Like the poor retired major, Mr Hunt and his team might well be off their trolleys..

Sean Poulter in The Mail reports 30th May 2016: Local Chemists threatened by supermarkets and Sophie Borland reports 28th May 2016: £170m cuts could kill off a QUARTER of our chemists – prompting warning of even more pressure on A&Es
Previously on 4th May Ian Strachan in the Huffington Post, opines: Why the Government Plans for Pharmacy Make No Sense

Despite the uproar BBC news reported 23rd May: Thousands of pharmacies in England ‘at risk of closure’

and Mark Whitehead in Local Government News 23rd May opines: Closure of local pharmacies would be ‘catastrophic’ for public health

Chris Sloggett in Pulse reported 23rd March: RCGP launches new initiative for pharmacists to work in GP surgeries, but this implies an expansion. Mr Hunt really wants to save money somehow, without co-payments and overt rationing. A bit on honesty might help..

 

 

 

 

GP shortages now so bad that pharmacists will be drafted in to treat patients in surgeries

Lizzie Parry and The Press Association report for The Mail 17th March 2015: GP shortages now so bad that pharmacists will be drafted in to treat patients in surgeries 

The Rationing of numbers of doctors is evident to all, and the risk is that Pharmacists might be tempted to make a diagnosis. If this happens there will be more litigation… But Dr Porter is correct, and pharmacists could take away a lot of the trivial consultations that GPs are forced to do. Work expands to fill the time available (Parkinson’s Law), and NHSreality predicts that the good suggestion will make no difference in the long run… without co-payments. It might impact badly on the litigation funds, and needs no-fault compensation to be financially “safe”..


Kat Lay in The Times reports: Pharmacists drafted in to help at GP surgeries

Pharmacists will be drafted in to GP surgeries to help combat the dearth of family doctors under plans to be unveiled today.

The proposals could see patients — particularly those with long-term conditions such as asthma or diabetes — offered an appointment with a pharmacist when they ring their surgery.

The move would cut the time patients have to wait to get an appointment and could address a current oversupply of pharmacists, experts said.

It would also combat problems caused by a rapid rise in patients on multiple drugs by using pharmacists’ expertise to ensure combinations of medicines were not allowed to become harmful or ineffective, according to the Royal College of General Practitioners and Royal Pharmaceutical Society….

Dr Mark Porter for the BMA comments:

I think this is a great idea. Despite numerous attempts over the years to integrate pharmacists into the primary care team, it has never quite worked out and their expertise remains under-used by the health service.

A significant proportion of my daily workload centres on medication and prescribing issues and it would be great to have a pharmacist to help me. Not only would it free me to see more patients, it would almost certainly lead to better medicine management and happier patients experiencing fewer side-effects.

The role of pharmacists in managing illness is less clear-cut. There is plenty that they could offer here — as many already do in high street pharmacies and on hospital wards — although it may require a change of mindset for some.

Many retail pharmacists have been brought up in an environment where evidence-based practice takes a back seat to commercial pressures. They may deny it, but why else would they peddle so many products (from cough medicines to flower remedies) that simply do not work?

Not everything needs a remedy, and not all remedies help. If they get behind that NHS mantra, pharmacists could become an even more important asset than they already are.