The Government’s drive to switch patients to cheaper statins could put lives at risk, new research has shown.
A study indicated that one third of patients who were switched from a branded statin to a cheaper generic one received a less powerful equivalent.

Those switched from Lipitor, known as atorvastatin, to a generic simvastatin would see their levels of dangerous “bad” cholesterol rise by between five and six per cent.

This could increase their risk of suffering a heart attack or stoke by about three per cent, said experts from the University of Melbourne.

In Britain, about five million people are on statins, which combat cardiovascular diseases. The Government has encouraged doctors to switch patients to generic drugs for several years. It means hundreds of patients could be at greater risk because they have been put on a less potent drug.

“This is a warning not just to look at the cost of medicines. You might be saving money but you could be losing a life,” said Lieven Annemans, a professor of health economics, at the European Society of Cardiology Congress in Stockholm.

The NHS spends twice as much on Lipitor than it does on simvastatin, despite fewer people taking the branded drug. A month’s supply of tablets of Lipitor costs about £26 per patient, whereas the equivalent cost of simvastatin is £2.

Prof Danny Liew, of Melbourne University, who led the latest study, said some research suggested that a triple dose of simvastatin was needed to be equivalent to Lipitor. “We must be careful about non-equivalent switching because of the potential for increasing cardiovascular disease risk and patients need to be aware of the difference in potency of different statins,” he said.

Branded drugs can be made only by the company that holds the patent and Pfizer makes Lipitor. After the patent has expired, the drug becomes “generic” and can be made by any manufacturer, meaning the price drops substantially. About eight in every 10 drugs prescribed by GPs in England are generics and statins, in particular, have been targeted by policy-makers to reduce costs.

A 10mg daily dose of Lipitor produces a 38 per cent reduction in bad cholesterol, whereas 10mg of simvastatin produces a 28 per cent drop.

Many British doctors are reluctant merely to increase the dose of a generic drug because of the risk of side effects. Statins can induce muscle aches, dizziness and headaches, and have been linked to kidney and liver problems.

Prof Liew studied data from almost 40,000 patients in Holland who were switched from Lipitor to simvastatin in the first three months of 2009. One third of patients ended up with a lower equivalent dose of simvastatin. The study was funded by Pfizer.

Dr Jeremy Pearson of the British Heart Foundation said: “It is clear that GPs need to be informed that you cannot switch 20mg of one for 20mg of another.

“Switching cannot be done thoughtlessly, otherwise you are at risk of doing something that is not advantageous to your patient at all.”

From: http://www.telegraph.co.uk/Heart-patients-lives-at-risk-in-switch-to-cheaper-drugs

More than 3 million doctors have downloaded a 59p application – invented by Prof Peter Bentley, a researcher from University College London – which turns an Apple iPhone into a stethoscope.Last week, Bentley introduced a free version of the app, which is being downloaded by more than 500 users a day. Experts say the software, a major advance in medical technology, has saved lives and enabled doctors in remote areas to access specialist expertise.

“Everybody is very excited about the potential of the adoption of mobile phone technology into the medical workplace, and rightly so,” said Bentley, who initially developed the app “as a fun toy”.

“Smartphones are incredibly powerful devices packed full of sensors, cameras, high-quality microphones with amazing displays,” he said. “They are capable of saving lives, saving money and improving healthcare in a dramatic fashion – and we carry these massively powerful computers in our pockets.”

Bentley’s iStethoscope Pro application is not the only mobile phone programme lightening doctors’ bags and transforming their practices: there are nearly 6,000 applications related to health in the Apple App Store. The uptake has been rapid. In late 2009, two-thirds of doctors and 42% of the public were using smartphones – in effect inexpensive handheld computers – for personal and professional reasons. More than 80% of doctors said they expected to own a smartphone by 2012.

The trend looks likely to gain pace as younger doctors enter the workplace. Some medical schools issue students with smartphones. In America, Georgetown University, the University of Louisville and Ohio State University are among those requiring undergraduates to use one.

However, experts say they are being prevented from exploiting the technology’s opportunities. Bentley says that he is unable to launch a new range of applications because of out-of-date regulations.

“It’s much easier to develop technology than it is to get permission to use it,” he said. “I could create a mobile ultrasound scanner and an application to measure the oxygen content in blood, but the regulations stop me. We’re not allowed to turn the phone itself into a medical device, and what that precisely means is currently a grey area in terms of regulation. That’s the only reason we’re not seeing a flood of these devices yet.”

Professor Ian Wells, head of the scientific computing section in the department of medical physics at the Royal Surrey County hospital in Guildford, agrees that innovation is being hindered by regulations that are “still in their infancy”.

He said: “The approach of the regulators is not well worked out yet. There’s a wonderful new world out there but we need to find a way for regulators to protect patients and doctors, while not impeding innovation, research and development.”

The Medicines and Healthcare products Regulatory Agency (MHRA) – the government body with responsibility for standards of safety, quality and performance in healthcare – recently set up the Medical Device Technology Forum, a group of industry representatives, regulators, users and scientists, to help establish how to regulate novel technologies.

“This is such a complex area that we are currently looking at every application on a case-by-case basis,” said an MHRA spokesman. “We want to ensure that these new technologies are effectively regulated – thereby protecting health and avoiding unnecessary deterrents – while at the same time removing any unnecessary obstacles to manufacturers who wish to exploit new technologies for the benefit of patients.”

European regulators are also striving to bring their guidelines up to date. A group of regulators from Austria, Belgium, Denmark, France, Ireland, Sweden and the UK was set up last December to develop guidance for software under the European Medical Device Regulations. They are expected to report at the end of the year.

• Star Analytical Services has developed an app that allows patients to cough into their phone, and tells them whether they have a cold, flu, pneumonia or other respiratory diseases.

• OsiriX lets doctors look at x-rays, ultrasounds, CT and MRI images on handheld devices or mobile phones with special software, enabling radiologists, for example, to diagnose acute appendicitis from remote locations.

• ERoentgen Radiology Dx helps radiologists identify the most appropriate radiology exam for a patient by searching a large database of signs, symptoms and diagnoses to help them make quick assessments.

• Instant ECG is just one app that analyses the most common ECG results. It distinguishes the difference in various myocardial ischemia or injury patterns. Using the iPhone’s interactive touch screen, the app offers “real-time” films to make rhythm analysis similar to the clinical setting.

• AirStrip OB, an iPhone app, gives obstetricians real-time remote access to foetal heart tracings, contraction patterns, nursing notes, and vital signs. Obstetricians can monitor different stages of labour even when they are not by a patient’s side.

From: http://www.guardian.co.uk/technology/2010/aug/30/iphone-replace-stethoscope

A mother whose son suffered severe brain damage after being given the MMR vaccine as a baby has been awarded £90,000 compensation.
Jackie Fletcher has campaigned for compensation for her son Robert – now 18 – because she believed his severe epilepsy was triggered by the jab.

Now a tribunal has ordered that the payment be made, after concluding that it could be “no coincidence” that he suffered his first seizure 10 days after being vaccinated.

All injections carry the risk of extreme reactions, and in rare cases, children have been left brain-damaged by them.

The Vaccine Damage Payment Scheme does not examine the safety of particular jabs, but the likelihood that the process caused a reaction.

However, the payout for damage following a MMR jab the first to be known about since a major public scare about its safety, following research in 1998 that suggested the vaccine caused autism. The study, now discredited, provoked widespread public concerns about the safety of the vaccine.

The payment agreed by the Government compensation scheme is likely to reignite the debate over the safety of common childhood vaccines.

Robert Fletcher, from Warrington, in Cheshire, is unable to talk, stand unaided or feed himself. He suffered the effects after being given the combined measles, mumps and rubella vaccine when he was 13 months old.

In a six-page judgment, the panel which examined the case said: ‘Robert was a more or less fit boy who, within the period usually considered relevant to immunisation, developed a severe convulsion … and he then went on to be epileptic and severely retarded. The seizure occurred ten days after the vaccination. In our view, this cannot be put down to coincidence.”

The panel said the reaction only happened because the child had a genetic predisposition to epilepsy, but said that “on the balance of probabilities” the vaccination triggered the onset of the condition.

Mrs Fletcher said she believed the compensation award was the first to a surviving MMR-damaged person since controversy erupted in 1998 when the now discredited Dr Andrew Wakefield raised concerns about a possible link between the combined MMR injection and autism.

Mrs Fletcher runs pressure group JABS – Justice, Awareness and Basic Support. Around 2,000 families seeking compensation for their vaccine-damaged children are registered with the group, which provides advice and support.

‘My husband John and I have battled for 18 years for the cause of Robert’s disability to be officially recognised,’ she said.

‘We were told the vaccine was perfectly safe. Like most people, we trusted what the doctors and nurses were putting to us.

‘Robert is nearly 19 but mentally he is like a 14-month-old toddler. He can’t stand unaided and he is doubly incontinent.

‘He can’t speak except to say “Hi, Mum” or “Hi, Daddy”.

Her first application for compensation was rejected in 1997 on the grounds that it was impossible to prove beyond reasonable doubt what had caused Robert’s illness.

But Mrs Fletcher appealed and in a ruling delivered last week, a new panel of experts came to a different conclusion.

The one-day hearing last week was chaired by a barrister sitting with two doctors. While one said the child would have developed epilepsy regardless of whether he had been given the vaccine, he was overruled by his two colleagues.

The panel said that the judgement was specific to the particular case and should not be seen as a precedent. It underlined in particular that the ruling had no relevance to the question of a link between MMR vaccine and autism.

Dr Michael Fitzpatrick, a London GP whose own son is autistic, said: ‘It is a very important principle that parents should be compensated in cases of this kind.

‘But although a causal link has been established in law in this instance, exhaustive scientific research has failed to establish any link between MMR and brain damage.

This case should not make parents feel any different about the safety of the vaccine”.’

A spokesman for the Medicines and Healthcare products Regulatory Agency, which collects data on adverse reactions to drugs and vaccines, said although the vaccine could, on rare occasions, cause a temporary fever fit, there remained no confirmed evidence that these caused long-term brain injury.

He added: “The benefits of MMR vaccine in preventing serious and life threatening infections far outweigh any known side effects of the vaccine”.

From: http://www.telegraph.co.uk/Mother-wins-MMR-payout-after-18-years

The NHS in England faces a total bill of £65bn for new hospitals built under the private finance initiative (PFI)- six times more than the buildings cost.
Figures obtained by the BBC show that some NHS trusts are spending more than 10 percent of their turnover on the annual ”mortgage” repayments.

Under PFI, private companies win contracts to build and maintain new hospitals and mental health units and the NHS pays off the ”mortgage” over around 30 years.

The 103 schemes were valued at a total of £11.3bn when they were built.

But when rising fees and additional costs such as maintenance, cleaning and catering are taken into account, the NHS will have to pay back £65.1bn over the lifetime of the schemes. Some contracts are reportedly so restrictive that trusts are forced to pay hundreds of pounds just to get half a dozen pictures put up.

According to the data, the NHS currently pays back a total of £1.25bn each year but this figure is expected to increase until 2030 when it will hit £2.3bn, the BBC reported.

The final payment will not be made until 2048.

Professor John Appleby, chief economist at the King’s Fund health think-tank, said: ”It is a bit like taking out a pretty big mortgage in the expectation your income is going to rise, but the NHS is facing a period where that is not going to happen.”

Dr Mark Porter, of the British Medical Association, added: ”Locking the NHS into long-term contracts with the private sector has made entire local health economies more vulnerable to changing conditions.

”Now the financial crisis has changed conditions beyond recognition, so trusts tied into PFI deals have even less freedom to make business decisions that protect services, making cuts and closures more likely.”

Nigel Edwards, director of policy at the NHS Confederation, which represents trusts, told the BBC: ”They were planned for a different world. I’m sure that in some cases people feel their hands are tied.”

From: http://www.telegraph.co.uk/NHS-facing-65bn-mortgage-bill-for-PFI

Hospital waiting times have begun to rise again after years of decline following the introduction of European rules on junior doctors’ working hours.Waiting times in the NHS had been dropping since the 1990s but the rules limiting junior doctors to a 48-hour week, which were implemented last August, had reversed the trend.

Thousands more patients were now waiting longer than 18 weeks for surgery because of eu red tape.

Ministers were seeking to renegotiate Britain’s position on the European Working Time Directive, including a possible opt-out for NHS staff. The Royal College of Surgeons carried out the first comprehensive analysis of how the directive had affected waiting times.

According to the research, the proportion of NHS patients having to wait longer than the 18-week target for non-emergency surgery such as hip replacements had almost doubled from 1.5 per cent 18 months ago to nearly three per cent in March this year.

Waiting times reached an all-time low at the end of 2008, with patients waiting just a few weeks for surgery on average.

However, since the EU directive cut junior doctors’ hours from 56 to 48 per week, these gains had been wiped out, the Royal College said.

According to data from the Department of Health, the number of patients waiting longer than 18 weeks — from GP referral to being treated as an inpatient — fell steadily from April 2007, when almost 34,000 people were waiting, to 8,674 in December 2008.

The figure remained stable at about 10,000 until June 2009, just before the new rules came in, when the rise began.

In March this year, it had risen to 17,515, a level last seen in September 2007.

John Black, the president of the Royal College of Surgeons, said the increase was predictable.

“If you have the same number of patients, no more doctors and ask them to work less then it is inevitable that the time available for elective procedures will reduce and waiting lists grow,” he said.

Almost two thirds of consultants now frequently operated without assistants because departments were so stretched.

Mr Black said most European countries had bypassed the legislation by either not monitoring compliance or, as in Germany and Holland, finding ways around the directive.

“We look forward to this happening in the UK,” he said.

Sir Richard Thompson, the new president of the Royal College of Physicians, said the directive had been a “complete disaster” for both patient care and the quality of training for doctors.

“We are not providing the service or the training that we require,” he said. “I cannot overemphasise the damage to service provision and to training.”

According to the survey, 80 per cent of consultant surgeons and two thirds of surgical trainees said patient care had deteriorated since the directive was implemented.

Dr Matt Jameson-Evans, a spokesman for Remedy UK, a junior doctors campaign group, said the impact of the directive on services was inevitable.

“Patients are simply not being treated by as many doctors as before,” he said. “A second consequence of this and equally important is that doctors are not receiving as much training as they were and this has serious implications for the future quality of care.”

The Royal College of Surgeons has argued for an opt-out to allow trainees to work up to 65 hours per week because they were not getting enough practical experience on a 48-hour week.

The Coalition has abolished the 18-week target, saying it was not backed by evidence that it benefited patients.

Dr Mark Porter, the chairman of the British Medical Association’s consultants committee, said the drive for cuts within the NHS was also a factor in the rise in waiting times.

From: http://www.telegraph.co.uk/NHS-waiting-lists-rise-after-doctors-hours-cut

European rules are creating a generation of “lazy, clock-watching” junior surgeons who lack the skills to operate safely, their bosses have warned.
A year after the EU directive limiting workers to a 48-hour week was brought in for the NHS, 80 per cent of consultants polled by the Royal College of Surgeons said quality of care had already been damaged by the changes, with risks to patients who are repeatedly “handed” from one shift to the next.

The survey also found that two thirds of junior surgeons said their hours in training had been cut.

Children at risk through lack of training for doctors and nurses, report warns

Consultants who took part in the study were most damning about the impact of the changes on their trainees.

Among responses from more than 500 senior surgeons taking part were repeated warnings that the rules were creating a generation of “clock-watchers” with a “lazy work ethic” who no longer felt personal responsibility for their patients.

Trainees were now spending so little time in operating theatres that they would lack the “cutting skills” required to perform safely when they became consultants, many warned.

College president John Black urged the Government to take urgent action to address the concerns, having pledged in its Coalition agreement that it would work to limit the application of the EU rules in the UK.

He described the situation facing the NHS as “acutely urgent”.

Mr Black said: “Without action we are going to see a generation of specialists with less experience than any that have gone before.”

Many consultants responding to the survey said the changes – which began in 2007 when a 56 hour maximum working week was introduced, following EU legislation – were already changing the attitude of young doctors, who were becoming too detached from the patients in their care.

Marjan Jahangiri, Professor of Cardiac Surgery at St George’s Hospital in London said: “We have created a generation of surgeons who lack technical skills and operate within a “clocking off” culture where they do not feel personal responsibility for their patient.”

The surgeon said the change in attitude was “as fundamental and dangerous” as the lack of expertise among junior doctors, who now received far less training than their predecessors.

She said: “We have now got a system where trainees begin keen and motivated, become restless from a lack of training opportunities, and they will end up lazy and unskilled”.

The heart surgeon, 48, said that by the time she became a consultant, nine years ago, she had undertaken 900 cardiac operations. The current generation were likely to become senior doctors after performing less than 300, she said.

Consultants who used to do most of their surgery assisted by trainees said they were now often forced to operate alone.

While some juniors ignored the rules and came in on their days off, most had far less time in the operating theatre because of strictures limiting them to a maximum of 48 hours, including all time on call, as well as their night shifts, and time on wards and in Accident and Emergency departments.

One respondent to the survey described the directive as the “single most damaging factor affecting training and continuity of care”.

The surgeon added: “The most insidious problem is that it fosters the concept that you are responsible for a patient only for a shift.

“A consultant surgeon has a particular and continuing responsibility – we are training clock watchers whose work life balance is more important than anything else.”

More than half of the 982 consultants and trainees polled said they were not truly complying with the rules, with many saying they lied about the true hours they worked because of pressure from NHS managers.

Among consultants who did comply with the 48 hour limit, 56 per cent said they had only done so at the expense of patient safety.

Many of the risks came from the increased numbers of “handovers” from one shift to another, and the use of inexperienced locums to cover gaps in rotas.

While some respondents in the anonymous survey said only luck had avoided serious incidents, others described specific errors which they attributed to the new system – such as the removal of an eight year old’s ovary, instead of her appendix, by an inexperienced doctor.

Mr Black said the NHS was “skating on very thin ice” under the current system, given that most doctors said they were still working longer than the 48 hours,

Doctors described handover procedures between teams which were unsafe, inadequate and in some cases, non-existent.

Trainees also described despair about the system, with many saying their training had suffered, and others saying they were only managing to improve their skills by lying about their hours and working on their days off.

Estimates suggest the current generation of trainees will have spent about half as much time in training or on call as those who became consultants before the EU rules were introduced.

A consultant summed up the training problems as a “complete disaster”, adding: “I just hope my colleagues can look after me when I get old. The only problem is they are going to be getting old too.”

From: http://www.telegraph.co.uk/EU-rules-are-making-our-doctors-lazy-clock-watchers

Controversial US group UnitedHealth, which runs GPs’ practices and advises PCTs in UK reported a 30% leap in profits to $1.1bn.The company recently had to repay $350m to settle a US case in which it was accused of artificially depressing insurance repayments to customers.

A US health insurance company that recently won a multimillion-pound contract to advise primary care trusts (PCTs), has reported a surge in profits over the last three months.

UnitedHealth Group, which also operates five GP practices in Derbyshire and London, reported second-quarter profits climbed 30% on the same quarter a year ago to $1.1bn (£720m) on turnover of $23bn.

The stock market-listed firm said the bulk of its growth came in the United States after it signed up more members for the government-backed Medicare and Medicaid policies.

The company signed a contract with the Department of Health last month to advise PCTs on commissioning ahead of reforms that will give GPs the lion’s share of the NHS budget.

PCTs directly run GP practices and offer contracts to self-employed GP doctors and private firms to operate independent practices. GPs will be in charge of £90bn of the health budget under plans put forward by the health secretary, Andrew Lansley.

UnitedHealth will use its experience of private healthcare to bring efficiencies to the bidding processes.

US unions have complained about the company, which has come under fire for malpractice. In 2008, its former boss William McGuire was banned as a director and forced to repay $468m following a scandal related to backdated stock options.

In January the company agreed to pay $350m to settle a case brought by the New York attorney general, Andrew Cuomo, who accused the firm of boosting profits by artificially depressing insurance repayments to customers.

The company based repayments on “independent” assessments by a company called Ingenix, which was a subsidiary of UnitedHealth.

The company is based in Minnesota, from where it has grown to be the largest health insurer by sales in the US. The company, which has more than 50,000 staff and 60 million health plan customers, is expected to have annual revenues in excess of $80bn this year.

From: http://www.guardian.co.uk/business/2010/jul/20/nhs-health-firm-profits-surge

Finger on the Pulse- pointless and costly bureaucracy and ludicrous management salaries have no place in this era of austerity.
Several years ago, a friend worked as a temp in the NHS. She was the secretary to a group of middle management in a primary care trust (PCT) and spent the summer holiday before going to law school running their office. Within a few weeks, she quit. Not because she couldn’t do the job, but because she was disgusted with the waste she witnessed.

She was told not to work too hard. She would sit in meetings where the same things were discussed repeatedly without any decision being made. She was taken aside by a colleague when she attempted to improve efficiency and asked if she wanted to make everyone unemployed. It was shortly after this incident that she walked out.

All this was particularly galling to me at the time. I was working on a ward for elderly patients with dementia, and the ward didn’t even have its own resuscitation equipment. Instead, the clinical staff had to beg, borrow or steal from other wards. The amount of fruit that patients were given at lunchtime was cut.

I would sit in outpatient clinics and have to tell the families of people with Alzheimer’s that I wasn’t allowed to prescribe the anti-dementia drugs for their loved ones because the government had decreed that at £2.50 a day, they were too costly.

Frontline NHS staff look at the legions of paper-pushers in their offices and wring their hands in despair. Something needs to be done to prune this stratum in the health service, and last week there were the first signs that this might happen.

The Coalition government’s recent plans to improve the NHS will see PCTs and strategic health authorities scrapped. This is a bold move. In recent years, these organisations have morphed into unwieldy bodies that do little more than provide jobs for people who have no hard clinical skills, but who couldn’t quite hack it in the corporate sector.

While these organisations have responsibility for patient care, they are distant and detached, and it is difficult to see how they contribute in any meaningful way to the day-to-day care of patients. Yet, they cost millions to maintain. A report published last week found that more than 300 NHS executives have salaries larger than the Prime Minister.

Ian Miller, for example, worked as the interim director of finance and investment for South East Coast Strategic Health Authority and earned £310,000 for nine months’ work from April 2009 to January 2010. This equates to £400,000 a year, which would pay for 14 nurses. Financial experts have described these salaries as “unsustainable”.

The plans are not without potential pitfalls: will GPs, for example, be able to manage such large budgets effectively? But I wholeheartedly support the essence of these proposals, which is that pointless and costly bureaucracy and ludicrous management salaries have no place in this era of austerity.

I also believe that giving power to clinicians will benefit patients. It’s doctors and nurses who have a far greater understanding of what is needed and where resources should be directed than a person with an MBA sitting in an office well away from the action.

My friend, who is now a successful corporate lawyer, says that if the NHS wants to operate along corporate lines, it needs to heed corporate principles: no business would employ so many people who don’t do what the business is set up to do – namely to treat patients.

I hope the Government’s proposals address this once and for all, and that patients and those who care for them are put back at the centre of the NHS.

From: http://www.telegraph.co.uk/health/7895365/Banishing-the-NHS-paper-pushers.html

The rise in emergency admissions to hospitals is “overheating” the system in England and is “unsustainable” in the future, a health think tank says.
Analysis by the Nuffield Trust found there were now 4.9 million unplanned admissions a year – a rise of 12% since 2004-05 – costing the NHS £11bn a year.

It said a rise in patients who spent a day or less in hospital suggested many admissions could be avoided. NHS managers agreed action was needed to tackle the problem.

Emergency admissions include patients admitted through A&E units as well as direct into other parts of hospitals.
Ageing population

The think tank, which analysed a range of official NHS data during its research, found emergency admissions now accounted for more than a third of the total.

The rise seen since 2004-05 is costing the NHS an extra £330m a year alone and the think tank said the issue had to be a priority if the NHS was to prosper in the current economic climate.

Researchers found there was a range of factors behind the trend.

They pointed to the ageing population – the elderly were more likely to be admitted as an emergency – as well as financial incentives in the NHS which were motivating hospitals to admit more.

The report also noted there had been a significant jump in patients being admitted for one day or less.

It said this was partly related to advances in medicine which meant patients did not need to spend as long in hospital, but argued many could have been avoided with better community services.

While the report only looked in detail at the situation in England, it also noted rises had been seen elsewhere in the UK.

And it said the recent announcement by ministers that hospitals would be fined for readmissions would only have a limited impact as many of the cases did not fall into that category.

Nuffield Trust director Dr Jennifer Dixon said: “Reversing this unsustainable rise in emergency admissions must be the number one priority for the NHS – any reform to the health service that does not tackle this will fail. Our hospitals are overheating and are treating patients at great cost to the NHS.”

Nigel Edwards, acting chief executive of the NHS Confederation, which represents managers, said: “This report furthers the case for fundamentally reviewing the urgent and emergency care system.

“Hospital is often the right place for sick patients to be but we know that for many there are better, more convenient and more cost-effective alternatives to hospital admission.

Dr John Heyworth, president of the College of Emergency Medicine agreed there were pressures in the system, but questioned some aspects of the research.

“It is fundamentally incorrect to assume that admissions for less than 24 hours are unnecessary or financially inefficient. In fact, the opposite applies.”

From: http://news.bbc.co.uk/1/hi/health/10490508.stm

A policymaker’s dream. A pragmatist’s nightmare. That has to be the verdict on Andrew Lansley’s white paper “Liberating the NHS”, published on Monday.

In one sense it aims to complete the work of the last Conservative government – and much that the Blairites also wanted for the health service. The last Tory government tried to free NHS hospitals from direct management by health authorities.

It aimed to get GPs to buy patient care. And it briefly attempted to absolve ministers from responsibility for the day-to-day management of the NHS by creating a short-lived ministerial supervisory board with an NHS executive beneath it.

But it rapidly got cold feet over the likely impact of the quasi-market it had created, fearing the destruction it would cause would be anything but creative.

Labour, having first ditched much of this, recreated it earlier in the decade in a far more sophisticated form – with independent regulation and inspection and a tariff for NHS care that, in theory at least, encouraged purchasers to put quality above price.

It never quite sorted out who should do the purchasing – primary care trusts or GPs, who have been running a form of practice-based commissioning that, in most places, has been severely constrained.

But had the Blairite plans come to fruition, the purchasing of care would by now have been separated from its provision. All hospitals by 2008 would have been self-governing institutions, positioned part way between the public and private sectors.

Primary care trusts would have been solely commissioners, while their district nursing teams and therapists and community hospitals would now be independently run, either on a foundation trust model, or as social enterprises, or contracted out to the private and voluntary sectors.

There would also have been a more vibrant public/private/voluntary market from which purchasers could buy all sorts of care, with patients being able to choose between them.

What Labour – or more accurately Tony Blair and Alan Milburn, then health secretary – wanted is what Mr Lansley now aspires to create: a self-improving system run as a regulated market of competing providers driven by patient choice and commissioning in a way that no longer needs direct management from politicians and the health department.

From there, the step to an independent commissioning board, with ministers doing little other than continuing to raise the money for the NHS, setting its broad priorities, and then holding the board to account, would have been seen as an interesting evolution, not a revolution.

But the NHS is a long way from that. The Blairite reforms first slowed, then under Gordon Brown, pretty much stalled.

Half of hospitals are still directly managed and a chunk will never pass the financial viability test to become foundation trusts. PCT provider arms have still to be sorted out. Social enterprise in the NHS barely exists. Private suppliers have yet to demonstrate convincingly that they can consistently do things better and more cheaply than the NHS. And the best GP commissioners are still relative beginners.

Yet in a dirigiste decision that smacks more of old Labour central direction than anything else, the Conservative health secretary has decided not to allow GP commissioning to evolve into something demonstrably strong and effective but to require that all GPs – whether willing or not – do the job or acquiesce in their colleagues doing it for them. All in one big bang.

Mr Lansley’s plans amount to an NHS revolution. Virtually no part of the service will be untouched by his announcements on Monday, which aim, in barely three years, not just to complete Labour’s unfinished business but to go much further.

Issues Labour grappled with unsuccessfully, however, remain unanswered.

What, for instance, are the failure regimes for the new arrangements? And thousands of managers whose jobs are to go are expected to retain financial control throughout the upheaval while helping GPs take on their new role. The odds are many will bail out while they have the chance.

As Sir David Nicholson, the NHS chief executive, said on Monday: “The clarity of the vision is all very well. The big issue is how do we manage the transition.” With immense difficulty, is the answer. Mr Lansley, a man with a plan in a hurry, risks losing both financial control and performance.

From: http://www.ft.com/cms/s/0/7f3bc0e4-8def-11df-9153-00144feab49a.html