Thursday, May 17, 2007

The last of this series of long delayed entries. I’ve been catching up with events during the past few weeks on the flight back from Tallinn, in Estonia. Building on our work in Russia we have recently been awarded a major Wellcome Trust grant to study in more detail the causes of premature mortality in Russia and Estonia.
As readers will be aware, this is not the easiest of times to be conducting research involving both Russia and Estonia, given the recent tensions between the two countries. When I logged onto the BBC before breakfast this morning one of the
headline stories concerned an apparent attempt to block many Estonian internet sites (government ministries, banks etc.) with an avalanche of messages, some of which seem to originate from Russian state servers. Still, at least researchers can manage to transcend these political disagreements….
Given the easy availability in Russia of alcohol containing substances that, in theory, are not sold for drinking but in reality are, we had been interested to see whether they could also be bought in Estonia. In an earlier
paper we showed that this was the case. These substances, such as aftershaves and firelighting liquids, are cheap and easy to buy and, as we showed last year, contain very high concentrations of alcohol. Our more recent work sought to understand the nature of the market for these products. A major source are the kiosks that can be found on many Estonian streets. Aftershaves seem to be their main product line, although they also sell washing powder, pet food, and condoms, a rather eclectic mix. We think we can link them all together but we are still speculating. Watch this space!

May began with a trip to Hong Kong, where I was giving one of the opening speeches at the Hong Kong Hospital Authority’s annual conference (plus another one later in the programme). As the conference began on a Monday I managed to arrive a little earlier and meet up with Sian Griffiths, now Professor of Public Health at the Chinese University of Hong Kong. A former President of the Faculty of Public Health, Sian has managed to escape the chaos that the English Department of Health has visited on the public health workforce. Indeed, as I write this, the comparison between the governments successive waves of NHS re (dis) organisation and the biblical plagues comes to mind. The most recent reorganisation, in particular, has led to the early retirement of almost an entire generation of outstanding health professionals. (I have since been reminded by Angus Nicholl, now at the European Centre for Communicable Disease Control, that a similar loss of Area Medical Officers a few years ago was followed by an epidemic of whooping cough as those with the expertise to respond to public concern about the vaccine had been lost from the system.) I wonder what disaster we can now expect.
Anyway, back to Hong Kong. On the Sunday Sian organised an outing for myself , Paul Corrigan (soon to depart as our Dear Leader’s health advisor), and Selena Gray (University of West of England) to Lantau – until recently an island but now joined to the mainland as part of the developments linked to the new airport, which was built on reclaimed land on the shores of Lantau. I had forgotten how easy it is to escape from the bustle of Hong Kong to some amazing beaches and stunning mountain paths. Wonderful…. Oh, and I also managed to squeeze in a trip to the Hong Kong Museum of History. One of its many excellent exhibitions takes you from the opium wars to the 1997 handover, through streets recreated to represent different stages in Hong Kong’s history. Don’t miss it!
My first visit to Hong Kong was about 25 years ago and in the intervening years it has changed beyond recognition, not always for the better as the authorities have frequently shown a scant regard for their historical heritage. This time there was one change that was extremely welcome – on the 1st January Hong Kong had gone smoke free. Admittedly there are some exceptions, such as bars, so there is still work to be done, but restaurants, karaoke bars (not that I am likely to be seen in one) and most other public places (and many open spaces) are now free from a carcinogenic haze. Much of the credit for this must go to my good friend Judith MacKay who has worked tirelessly to expose the tactics of the tobacco industry in this part of the world.

By now, if you are still reading, you may be asking what about the conference. The organisation was a triumph, with everything running remarkably smoothly, due, in large part, to the work of Paul Hui, who seemed to be everywhere at once and totally in control. We began with the usual opening speeches from dignitaries, albeit somewhat more visionary than is usual at major conferences. Then to the opening lectures. Mine addressed the question of how health systems can maximise health gain. It allowed me to bring together a range of themes I have been talking about recently under five maxims (familiar to regular readers of this blog). These are:
Prevention is better than cure – the first step is to prevent disease arising in the first place
Timely investment pays off – you need a balanced programme of investment in people, things, and knowledge
You can’t leave it to chance (or the market) – delivery of health care needs to be planned
Anticipate change – the world is changing and so must the delivery of health care, but equally, permanent revolution (cf Trotsky, Mao, and Blair) is not a good idea
Trust but verify – learn from experience elsewhere but don’t assume that ideas are instantly transferable, Evaluate their impact.
These ideas seemed to resonate with the audience, fortunately!
To Brussels on the 26th and 27th April to participate in two of the four workshops we are organising on behalf of the European Commission to explore the impact of its proposed new strategy on health services. The idea was to prepare a document setting out the current situation in Member States and then invite a group of senior policy makers to consider the implications of the Commissions proposals – which would have been fine except that the Commission doesn’t actually have any concrete proposals yet. Still, it was a very good opportunity to thrash around some very difficult questions that have defied the combined intellectual might of Europe’s health policy community for at least a decade.
The two I was involved with were on quality of care and patients’ rights. I had also been involved in preparing the report on quality of care. This was a combined effort by three EU projects, Europe for Patients (focusing on patient mobility), MARQuIS (on quality of care, and SIMPATIE (on patient safety.
A key question we had to grapple with was who should be responsible for the quality of care provided when a patient from country A is sent by his or her health authority/ fund to country B. One thing was clear – it could not be the patient as, given the major asymmetries in information, patients are simply not in a position to assess whether the care they get is of good quality. There are far too many examples of smooth-talking charlatans helping vulnerable patients to part with their money. Even with the (totally unregulated) internet, except for a small number of people with longstanding chronic illnesses, the fully-informed patient remains an aspiration. There was considerable initial support for the authorities in country A taking the lead, until it was pointed out that this would mean that, potentially, a hospital would need to comply with the standards in place in each of the 27 Member States – hardly practical. What’s more, we were able to draw on the experience of the contracts between the English NHS and hospitals in France, Belgium, and Germany. This had never been a serious project anyway, but rather an attempt by ministers to show British hospitals that there were alternative providers so they had better do something about waiting lists. The English authorities sent a small number of patients abroad, with the first batch accompanied by almost as many newspaper reporters. They specified in excruciating detail how the patients should be treated, including access to English newspapers and afternoon tea. Given the abysmal quality of food in most British hospitals compared to those in France, the patients may have wished the authorities had not interfered. Anyway, as one might have expected, the foreign hospitals soon got fed up with the mass of bureaucracy, not to mention the lack of co-operation from English referring hospitals, who knew that the whole initiative was simply a way to get at them.
So the obvious answer is that quality must be the responsibility of the country where the health facility is situated. This is already implicit in EU law. However, it also implies that any country sending someone abroad should be assured that their patients will get high quality care. The answer seems to be some form of EU legislation to require countries to put in place mechanisms to ensure quality and then let them get on with it.

25th April – launch of our new project, EU-PREVOB. ‘Tackling the social and economic determinants of nutrition and physical activity for the prevention of obesity across Europe’. Led by my colleague Joceline Pomerleau, it brings together 14 partners from 11 countries, from the UK to Turkey and from Latvia to Bosnia. The aim is to develop a better understanding of the factors underlying variations in diet and physical activity across Europe. Of course we already understand many of these – most obviously people have tended to eat what farmers around them produce, explaining why Cretans eat Greek salads and Mongolians eat fatty sheep’s tails. Similarly, if you live in rural Nepal you have little alternative but to walk if you want to go anywhere while if you live in Los Angeles you risk being arrested for suspicious behaviour if you try to walk on the streets. The challenge, which links closely to our work on the PURE project (see earlier blog) is to locate other settings on these scales and to assess their direction of travel. For example, Ireland was once closer (gastronomically) to Mongolia than to Crete but is moving steadily towards the latter. If we can develop an appropriate instrument then we should be able to obtain some fascinating results.

I’ve spent a lot of time over the past month thinking about hospitals. Ever since I was a junior doctor I have been convinced that most hospitals were designed by architects trained in the Central School of Dismal Apartment Block Construction of the Soviet Union. I trained in Belfast, where the new Belfast City Hospital, which was conceived about the same time as I was, finally opened when I was 31. It provides the most perfect case study of how not to design a hospital, ranging from putting the dialysis unit on the top floor but forgetting to check if the water pressure up there would be sufficient or creating acres of underground parking without thinking of where the pipe work would go, so that the clearance was reduced to about 1 metre. The red rectangle in the picture highlights a grey (originally brown) bit that seems to have been put in as an afterthought – as it was. This is the university floor as the original designers overlooked that this was a teaching hospital. Then there was the need to replace all the heating ducts as the contractors forgot to put in portaloos so the builders urinated down the ducts causing them to corrode. I could go on.

Belfast City Hospital
Anyway, a few years ago Judith Healy and I published a book on the future role of the hospital. Our basic premise was that as the world was changing so must hospitals. They should be designed in ways that allows them to adapt flexibly to changing circumstances. Fairly obvious you would think. And of course it is – except to those in charge of the hospital building programme in the UK who happily sign expensive and complex contracts, under the Private Finance Agreement, that make it prohibitively expensive to change even the number of electrical sockets for a period of 30 years.
We also made the fairly radical suggestion that hospitals should be designed in ways that smooth the path of patients through them, so that they do not have to follow complex paths that would defeat an experienced jungle explorer, and that they should promote health.

These are issues we have returned to in a new book that will be published later this year.
This, then, was the reason why a disparate group of people came together in London on the 16th and 17th April. It was the latest of the Observatory’s authors’ workshops, in which those contributing to the book discuss what they are writing with those who make up its likely audience. As always, it was an extremely valuable few days, allowing people from very different backgrounds to understand where each of them is coming from. One of the main challenges, which I am working on, is how to create a system in which about 80% of activity is routine and predictable but the remaining 20% is anything but, and where what you are dealing with is often only clear after you have dealt with it. That should keep me busy for a few weeks!
A week later I was talking about hospitals again, this time at the annual conference of the
European Health Property Network, an organisation that does believe it is possible to build hospitals that actually make you feel better. They are partnering with us on the new book and their members have brought together a series of fascinating case studies from across Europe that give one hope that a better world is possible.
I was asked to set the scene for a debate on planning versus the market (in health care). I tried to be as balanced as possible, noting the great successes of markets compared with, for example, Soviet central planning. But of course the problems arise when you see the market as a panacea for everything, as the current British government does. As a consequence you get bizarre decisions such as that to break up the monopoly that was the perfectly acceptable British Telecom directory enquiries service. The result – dozens of new companies spending millions of pounds to advertise their services, which they then have to recover from far higher charges. Of course they can’t do this openly so they create cost structures that require the user to have a qualification in accountancy to understand them. Others simply cut costs by using voice recognition systems or untrained staff that give you the wrong numbers. A complete disaster. I won’t even begin to talk about the shambles that resulted from privatising the railways.
Unfortunately we never got to the debate. Even those who were meant to be speaking on behalf of the market didn’t do so, quickly conceding the need for planning. A pity as I was rather looking forward to the debate!