Martin McKee's blog

2012-01-30T14:12:00.001Z

I'm grateful to Lucy Reynolds for additional analysis of the latest YouGov poll on attitudes to the Health and Social Care Bill. The survey was of 1601 NHS staff and was conducted between 17th and 20th January 2012.

If you take out the don't knows, the figures work out like this:

Of those who expressed an opinion:

80% expect the new system to be more costly, 89% think it will increase bureaucracy, and 78% think it will be more fragmented. 84% expect quality of care to deteriorate as a result of the passage of the Bill.

91% think the reform will introduce too much competition, and 87% expect privatisation of services to increase. 83% expect there to be loss of access to healthcare services for some of the population and 68% are expecting it to lead to the introduction of user fees.

80% consider that the Health and Social Care Bill should be withdrawn entirely.

71% think that Andrew Lansley is failing in his role as Secretary of State.

77% feel that it is in the public interest for the Risk Registers that the government has been told to produce to made available.

Raw data (before correction to remove don't knows):

72% expect the new system to be more costly,

83% think it will increase bureaucracy, and

68% think it will be more fragmented.

74% expect quality of care to deteriorate as a result of the passage of the Bill. 81% expect privatisation of services to increase.

Two-thirds of people polled think that the Lansley reform will make the NHS worse (66%) and that the Health and Social Care Bill should be withdrawn entirely (65%).

84% think it will introduce too much competition.

78% expect there to be loss of access to healthcare services for some of the population and 68% are expecting it to lead to the introduction of user fees.

71% think that Andrew Lansley is failing in his role as Secretary of State.

77% feel that it is in the public interest for the Risk Registers that the government has been told to produce to made available.

See the detail on:

http://library.constantcontact.com/download/get/file/1102665899193-831/YouGov+NHS+survey+results.pdf

2011-10-07T08:08:00.000Z

Lucy Reynolds and I offer our views on the provisions for competition in provision in the Health and Social Care Bill

“It is not from the benevolence of the butcher, the brewer or the baker that we expect our dinner but their regard to their own self-interest.”

Adam Smith, 1776[1]

“That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg is enough to make one despair of political humanity.”

George Bernard Shaw 1913[2]

EXECUTIVE SUMMARY

Without basis in any solid evidence, the NHS is about to undergo a market reform which may well be, for all practical purposes, irreversible. It is likely to cost the country much more than the existing system, because of extra bureaucracy, loss of economies of scale and full bargaining power with suppliers, maintenance of redundant capacity, and the need to cover return to capital and the costs of commercial borrowing. It will deliver less, not just because of the diversion of effort into the copious administration of commissioning and contracting, but because the embedded incentives of market-based healthcare will lead to physician-induced demand (unneeded tests and treatment undertaken to increase provider income, which may harm patients subjected to them). More effective regulation will be needed to control the problems to which this system is prone, again elevating costs. Overall, the reforms will reduce the quantity of front-line care which can be provided for each pound of the NHS budget spent. This paper comments specifically on the theoretical weakness of the Cooper and Propper econometric studies which are being used to justify the reform.

In conclusion, the proposed market-based reform to the NHS will be an expensive step in the wrong direction. It was rushed through the Commons and its content needs to be carefully scrutinised: in addition the policy consequences of adopting a market-based reform should be examined.

FIGURE 1

FIGURE 2

Introduction

This market-based reform (see Figures 1 and 2 above for the financial changes involved) has been presented to the electorate as essential in the interests of cost-saving for the taxpayer. It has been justified on the basis of saving money and improving outcomes, neither of which hold up to more than cursory inspection.

The only “evidence” that competition can benefit healthcare performance is at best debatable

After a quarter of a century of assertions that competition benefits healthcare[3], lobbyists finally, in 2010-11, found three UK-based studies which purport to test and prove this theory. They areknown as the Cooper et al paper[4] and the Propper et al [5]^,[6] studies.

As these authors could not measure competition per se they used the density of service provision as a proxy, comparing it with routine health service data on heart attack mortality. These three papers stand against a background of many other studies which do not find a positive association (as noted in a review of the literature in one of them⁵) and in contrast to the theoretical case for why market-based competition in healthcare would be harmful, as set out by the Nobel Laureate Kenneth Arrow and explained in section 4 below. While the three papers contain elaborate mathematical models corrected for many relevant confounding factors including distance to hospital, they suffer from a basic scientific error, the confusion of association and causation: they document the former and impute the latter. A small but perceptible difference in the outcomes before and after the introduction of small-scale competition mechanisms in the NHS is present, but the authors do not offer any convincing mechanism for how reduction of heart attack mortality might result from higher hospital density (which, as noted, they treat as a proxy for greater market competition between providers). Instead they postulate a general “halo” effect of greater operational efficiency arising from bidding for some types of work in the same hospitals that treat heart attacks, via a more “competitive” culture. Alternative explanations for the outcomes generated from the models they have devised exist, such as under-correction for the time taken for ambulances to drive heart attack patients to the nearest hospital. They also ignore the possibility of “upcoding”, although this exaggeration of the gravity of illness in incoming patients is a well-known consequence of paying hospitals according to the quantity and type of cases they treat [7], a change which is part of the competitive internal market introduced in the NHS. If hospitals are judged on mortality and outcome data there is an incentive to record medical problems as more severe than they are, a practice that is hard to detect even by tracking back to case notes. For this overlooked explanation both motive and mechanism are evident, and so is much precedent⁷. Even if there is a true effect, these studies provide no evidence that it was competition that brought it about: it could as easily have been due to other changes taking place at the same time. None of these papers actually provide any evidence that the market competition reform proposed will in any way improve the NHS, and their citation as the best proof available tells its own story.

Contrary to the government’s line, the new arrangements will be much more expensive than the Beveridge system that they replace [8]. The change will benefit only corporate market entrants, many of them foreign. The main reasons for the extra costs are:

1. Fragmentation of purchasing among more entities

The single purchaser system that the NHS has moved away from in recent years can provide excellent value for money. This is demonstrated by the success of the PHARMAC single purchasing agency in New Zealand[9]^,[10], and the contrasting failure of cost control in many parts of the American health care market[11]. The arrangement we are moving to, with purchasing decentralised into hundreds of consortia, involves multiplication of procurement arrangements, reducing the bargaining power of each purchasing entity, and requiring creation of extra bureaucracy to enable this more costly arrangement.

2. Competition between providers involves redundant capacity and loss of economies of scale

Government insistence on trying to run the system through “consumer choice” (a nonsense in this context, as explained in section 4 below) involves the need for redundant capacity; providers will need to charge more for the services they do provide in order to cover the costs of having capacity lying idle in order merely to allow creation of a competitive market. In addition, market competition generally involves spending on marketing. Obviously, unification of provision as in the Beveridge-system NHS allows services to be supplied more cheaply because of economies of scale, avoidance of redundant capacity and no need to spend money on marketing.

3. Shift to individual billing to facilitate competition between providers multiplies bureaucracy

To facilitate competition between providers, the future arrangement in the NHS will be that “the money follows the patient”, in the words of the White Paper. This results in a shift from efficient pooling of cost and risk across the nation toward the use of individual healthcare budgets. The change will require both providers and commissioning groups to maintain administrative capacity to set up and monitor individual billing. Again this requires a multiplication of unnecessary bureaucracy which provides no benefit to patients, while increasing costs to the taxpayer.

4. The structural problem of supplier-induced demand results from competition in healthcare

Henceforth all hospitals will be required to generate their income from selling services to private patients or to Clinical Commissioning Groups (CCGs: composed of GPs and others). This is to occur through what is known in general as fee-for-service and in the NHS as “payment by results”, although in fact it is activity not results which is rewarded. Except for a few facilities which offer essential services which are otherwise unavailable, they will need to cover their costs from such sales or face insolvency and closure. The government has explicitly rejected calls from the Chief Executive of the NHS to maintain the mechanism for a failing hospital to be taken back into public ownership[12]. Hospitals will be permitted to retain any profits they make, for reinvestment or payment to their shareholders or partners. This arrangement ensures that hospital staff are keen to provide services, and is represented as encouraging them to maximise efforts to provide patient-friendly service of high medical quality so as to generate repeat custom and patient recommendations. However, it also incentivises clinicians to recommend and provide services that are unnecessary or of marginal medical benefit, and hospital managers to overprice services where this can be arranged. In this era of light-touch regulation[13], both of these undesirable options would be much easier and cheaper to arrange than genuine improvements in service provision, and would more reliably boost the bottom line. One corporation that is now offering commissioning services to our CCGs[14] has previously found it necessary to compensate the US government following allegations of its fraud against the Medicare scheme[15].

The setting of a fixed tariff for each procedure is intended to block over-pricing, but experience in countries which use this system shows that the profit-making provider’s response to this form of control is to miscategorise patients’ conditions, so that they are registered as suffering a more severe medical condition than is actually the case, “upcoding” or“DRG-creep”[16]. A patient miscategorised in this way could be treated more aggressively than is appropriate to their condition, so might for instance undergo unneeded surgery or suffer side-effects from treatment with stronger medication than appropriate. The patient may thus be harmed in order to generate money for the provider.

The planned new system will be vulnerable to this sort of malpractice because the rationalisation for this market based reform (welfare economics and its offshoot public choice theory[17]) relies on a consumer versus supplier model which does not fit healthcare. In this model, providers wishing to sell more services at higher prices to generate more profits oppose customers trying to acquire the services they need in adequate quantities at lower prices, and the two come to a mutually agreeable arrangement. This model relies on a number of assumptions including one which is rarely met in the case of medical services, as explained in 1963 by the economics Nobel Laureate Kenneth Arrow[18], the possession by both buyers and sellers of complete information about the nature and quality of the services to be supplied. Such symmetry of information allows a balance of power between buyer and seller to facilitate a fair negotiation process between these two principals in the transaction. However, this is evidently not the situation where medical services are concerned. Few patients are medically qualified, and they visit doctors in order to ask what is wrong with them and how it may be treated. That is, the patient relies on the clinician to provide advice as their agent. When the clinician is also allowed or required to act as a seller of services, the two roles of agent for the patient and principal in the transaction can come into direct conflict, resulting in an increase in demand (through an upward shift of the demand curve in economist’s jargon) induced by the physician’s inclination to increase income by maximising services provided[19].

Where the survival of the service and the owners’ requirements for financial returns put pressure on clinicians to increase the money they bring in by selling more services to patients, the stage is set for systematic exploitation of patients’ ignorance through unneeded billable tests and investigations, diagnosis of minor problems as severe, unnecessary treatment, and over-aggressive treatment[20]. The ability of a patient-consumer to assess the quality of medical services received is for many types of treatment limited to such peripheral issues as waiting time, comfort of waiting rooms and wards, and friendliness of staff, while the clinician-seller is able to exploit their inability to detect profit-led over-treatment, possibly at the cost of subjecting the patient to the side-effects and risks of unnecessary procedures. In the future NHS, the proposed use of “fee for service” payment arrangements for clinical services adds a dimension of moral hazard, incentivising this form of abuse. Where exploitation does not ensue, it is because the professional ethics of the medical profession constrain it. But unnecessarily creating such a temptation is surely unwise.

The more market-driven the health care system the more it is prone to this problem:

Comparing two societies of similar economic and cultural status, in 1993 doctors in the US performed hysterectomies two and a half times as often as doctors in Sweden, and caesarean sections twice as often. And doctors in the US performed 4.4 times more coronary bypasses than doctors in Canada.

Another revealing comparison can be made between certain professions and everyone else. The American Medical Association conducted a study of medical intervention in cases of stage II prostate hypertrophy. They asked urologists what they would do if it were their own case. Just 40.5% of urologists asked said they would opt to have a transurethral prostate resection, yet for the population as a whole the rate of transurethral resections actually carried out in cases of stage II prostate hypertrophy was 80%.[21]

The Economist calculated that the market-driven, corporate-dominated US health care system in 2009 generated between $250 and $325 billion of charges for unnecessary care; this comprised 10-12% of US healthcare spending that year[22].

5. The proposed means of controlling the extra cost of supplier-induced demand involves a second layer of profit-taking and incentivises denial of needed care

It is well-known by health economists that fee-for-service medical provision causes inflation of medical spending [23]. This is the reason why the US medical system provides such poor value, consuming 18% of GDP (compared to our 8%) and yet leaving a high proportion of the population without access to decent medical care (according to the Commonwealth Fund report comparing seven developed world health systems[24]). Because medical providers in the USA are too politically powerful for the government to be able to introduce the universal coverage the population[25] and the President[26] would prefer, other means have had to be found to try to contain soaring medical costs. A mechanism, “managed care”, was devised to oppose the incentive for providers to over-treat with another which uses the profit incentive to motivate limitation of the amount of care provided. This is the arrangement which the Health and Social Care Act would move us to, with commissioning at GP level used to restrain overcharging by hospitals through gate-keeping of referrals.

In this model, managed care is undertaken by health maintenance organisations (HMOs) which invite members of the public to pay an annual insurance premium in order to access treatment for any new illness that befalls them (in our new system this premium will initially be fully replaced by an allowance from the NHS budget, which will for now also cover treatment for pre-existing conditions). The HMOs employ doctors who diagnose and recommend referral to hospitals as appropriate (as our GPs do). The HMOs keep any difference between the total of the premiums they receive and the care they pay for (as our CCGs will). This creates a financial incentive for the HMO (or CCG) to reduce total referral cost. Proponents emphasise that this deters referrals undertaken more to keep the patient happy than for any medical benefit, and that it creates a financial incentive for referring doctors to control the amounts charged by referral services. Both are good goals if provision is under fee-for-service arrangements, which encourages excessive charges, as explained above. Medically qualified HMO employees are more knowledgeable customers than are patients, and can better control supplier-induced demand, also clearly beneficial. Unfortunately for patient welfare, the crude use of the profit motive also incentivises refusal to refer patients for services justified on the basis of medical need.

Criteria for assessing efficiency in medical service provision should involve the correct and timely treatment of medical conditions which are amenable to treatment. Instead, managed care applied to profit-making provision simultaneously gives rise to both under-treatment (exclusion from medically needed care because of denial of referrals[27]) and over-treatment (medical procedures undertaken for the benefit of providers not patients [28]).

These mismatches occur because the choices triggered by the profit motive map poorly on to the priorities set by the meeting of medical need. It is known that financial incentives raise doctors' activity levels[29] but this does not translate to better health outcomes unless doctors paid this way are underprovided in a community, in which case more activity might improve outcomes. If they are oversupplied and competing for business, then providers’ need to make a living incentivises overtreatment²⁸^,[30]. Since no treatment is devoid of adverse effects, poorer outcomes ensue²⁸. If the market competition that the government insists is central to the reform[31]^,[32]is introduced throughout the system, we will be in the second situation, where competition between providers for enough patients to cover their fixed costs (rent, salaries, etc) will create motive and opportunity for exploitation of patients. As noted by a concerned QC, it is also likely to create stresses on staffing caused by cost-cutting which could result in many more medical errors[33].

In contrast, the Beveridge system does not encourage overtreatment, overcharging or denial of needed care, because doctors are under no financial pressure to over-treat patients. It scores highly on value for money⁸^,[34], quality of health outcomes[35]^,[36], and patient satisfaction[37], and produces a system where clinician efforts are expended on addressing medical need not on generating income. The proposed reform involving two extra layers of profit and a great deal of unnecessary administration being extracted from the NHS budget for hospital treatment appears to be in the interests of neither patients nor taxpayers; it may however produce a bonanza for foreign corporations[38] and plenty of new work for accountants and lawyers[39]^,[40].

6. Privatisation will increase the costs of regulating adequately; failure to do so will result in abuse of patients

It should be noted that once the reform has loaded our health system with incentives to over-treat patients, deny referrals, falsify or withhold information on patient outcomes and to maximise corporate profits, the cost of regulating adequately will rise. Failure to do so will save money on “red tape” but at the cost of harming vulnerable people and squandering taxpayers’ money. We can see how this works in practice from the poor record of the Care Quality Commission, for example at Winterbourne View[41] , mainly due to an underfunded regulatory system which operated largely on the basis of self-certification and not inspection. It should be noted that recruitment advertising for the CQC over the past year has not required any medical qualification for any post[42].

Conclusion

While it is clear that ways exist to improve the Beveridge system NHS, it is equally plain that replacing it with a market-driven health system is a move in the wrong direction which is likely to harm patients and waste scarce resources.

Market competition in healthcare does not produce desirable results, a conclusion evident from inspection of medical systems which rely upon it and also from economic theory. Despite the highest spending in the world both as a proportion of GDP and as a per capita figure, health outcomes achieved in the USA are mediocre: for instance, in 2010, the US was 44^th/193 in the world ranking for the probability of dying by age five³⁴. In the past decade, the American health care system has made minimal progress in reducing deaths from causes amenable to medical care (the UK Department of Health’s chosen high level indicator of health system performance), falling increasingly far behind other industrialised nations; in the UK, progress on this measure has been among the fastest[43].

This “reform” serves only corporate interests. They will gain new profit opportunities, as recently explained by Earl Howe to an audience of private sector investors[44], and by past NHS Director Mark Britnell to a group of US private equity companies[45] as follows:

“In future, the NHS will be a state insurance provider not a state deliverer. In future ‘any willing provider’ from the private sector will be able to sell goods and services to the system. The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.

GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate this process.

The monolithic arm of state control will be relaxed which will provide a huge opportunity for efficient private sector suppliers.”

We believe the Bill as presently worded is largely unworkable, while attempts to implement it are likely to increase costs and reduce the level and quality of care that is provided. It is laden with incentives for opportunistic behaviour. Furthermore, as noted by the House of Lords Constitution Committee,[46] it is potentially unconstitutional. The Secretary of State has condemned his critics for relying on anecdote rather than evidence. In this paper we have presented the evidence that, we argue, he must respond to if he is to make a convincing case that his Bill should be passed.

REFERENCES

[1] Smith A. An Inquiry into the Nature and Causes of the Wealth of Nations. 1776

[2] Shaw GB. Preface on doctors. The doctor's dilemma: a tragedy. Baltimore: Penguin, 1913: 9

[3] Reynolds L. Competition and the 1987-2011 NHS reform. BMJ 2011 http://www.bmj.com/content/343/bmj.d4136.full/reply#bmj_el_267122

[4] Cooper Z, Gibbons S, Jones S, McGuire A. Does hospital competition save lives? Evidence from the English patient choice reforms. 2010. http://eprints.lse.ac.uk/28584/1/WP16.pdf.

[5] Gaynor M, Propper C, Serro RM. Death by market power: reform, competition and patient outcomes in the NHS. 2010. www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdf.

[6] Bloom N, Propper C, Seiler S, van Reenen J. The impact of competition on management quality: evidence from public hospitals. Centre for Economic Performance discussion paper No 983, 2010. http://cep.lse.ac.uk/pubs/download/dp0983.pdf.

[7] Pitches D, Burls A, Fry-Smith A. Snakes, ladders, and spin: How to make a silk purse from a sow's ear—a comprehensive review of strategies to optimise data for corrupt managers and incompetent clinicians. BMJ 327 : 1436 doi: 10.1136/bmj.327.7429.1436 (Published 18 December 2003)

[8] Pritchard C, Wallace MS. Comparing the USA, UK and 17 Western countries' efficiency and effectiveness in reducing mortality. J R Soc Med Sh Rep 2011;2:60; doi: 10.1258/shorts.2011.011076

[9] New Zealand Government http://www.pharmac.govt.nz/

[10] Cumming J, Mays N, Daubé J. How New Zealand has contained expenditure on drugs. BMJ 2010;340:c2441. http://www.bmj.com/cgi/content/extract/340/may18_1/c2441

[11] 2011 Milliman Medical Index: healthcare costs for American families double in less than nine years. May 2011. http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2011.pdf

[12] Watt N. NHS chief challenges Andrew Lansley's foundation hospitals plan. URL: http://www.guardian.co.uk/politics/2011/sep/28/nhs-chief-challenges-andrew-lansley

[13] Editor’s Blog. Health Policy Insight 14 September 2011. http://healthpolicyinsight.com/?q=node/1227

[14] http://www.unitedhealthuk.co.uk/WhatWeDo/GPCommissioning.aspx

[15] http://www.justice.gov/opa/pr/2004/December/04_civ_788.htm , http://www.californiahealthline.org/articles/2004/8/13/travelers-unitedhealth-settle-medicare-fraud-lawsuit-for-206-million.aspx

[16] Simborg DW. DRG creep: a new hospital-acquired disease. N Engl J Med. 1981 Jun 25;304(26):1602-4.

[17] LeGrand J. Motivation, Agency, and Public Policy: Of Knights and Knaves, Pawns and Queens. OUP 2003

[18] Arrow, Kenneth J. (1963). "Uncertainty and the Welfare Economics of Medical Care". American Economic Review, 53 (5)., pp. 941–973

[19] Shafrin J. Cutting Medicare reimbursement increases the quantity of medical care. Healthcare Economist 5 May 2008. http://www.mylot.com/nr/viewframe.aspx?id=764058&url=http%3a%2f%2ffeeds.feedburner.com%2f~r%2fHealthcareEconomist%2f~3%2f283721314%2f&type=Blog

[20] Wennberg JE, Barnes BA, Zubkoff M. Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med 1982;16(7):811-24. PMID 7100999.

[21] Deppe H-U. The nature of health care: commodification versus solidarity. In Panitch L. and Leys C, Morbid symptoms: Health under capitalism. (Eds.). 2009 New York: Monthly Review Press.

[22] The Economist. Waste Measurements: US healthcare spending. 17 June 2011. http://www.economist.com/blogs/dailychart/2011/06/us-health- care-spending, plus 2009 OECD spending figures and 2010 US Census data

[23] Tussing AD, Wojtowycz MA. Physician-induced demand by Irish GPs. Soc Sci Med. 1986;23(9):851-60.

[24] Davis, K.; Schoen, C. and Stremikis, K. (2010). Mirror mirror on the wall: How the performance of the U.S. health care system compares internationally 2010 update. The Commonwealth Fund.

[25] Steinmo S, Watts J. It’s the institutions, Stupid! Why comprehensive national health insurance always fails in America. Journal of Health Politics, Policy and Law Summer 1995;20(2):329-372

[26] Sirota D. Obama for Single-Payer Before He Was Against It: How Political Elites Have Made Single Payer "Politically Impossible" Alternet 11May 2009. http://www.alternet.org/health/139959

[27] Potter W. Health Insurance Corporate Profits Spiked Despite Dire Predictions of Health Care Reform Wreckage. 25 April 2011. http://wendellpotter.com/2011/04/health-insurance-corporate-profits-spiked-despite-dire-predictions-of-health-care-reform-wreckage/

[28] Gawande A. The cost conundrum. Annals of Medicine. The New Yorker. http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

[29] Gaynor M, Pauly MV. 1990, "Compensation and Productivity in Partnerships: Evidence From Medical Group Practice," Journal of Political Economy, 98, 544-573.

[30] Bennett D, Lauderdale TS, Hung CL. Competing Doctors, Antibiotic Use, and Antibiotic Resistance in Taiwan. September 16, 2008. http://chess.uchicago.edu/events/hew/fall08/bennett.pdf

[31] Lansley A. Extract from: 'The Future of Health and Public Service Regulation' Speech 09 July 2005. http://www.andrewlansley.co.uk/newsevent.php?newseventid=21

[32] Johnstone R. Lansley stands by his NHS competition plans. CIPFA Public Finance. 18 May 2011. http://www.publicfinance.co.uk/news/2011/05/lansley-stands-by-his-nhs-competition-plans/

[33] Whitting J. The hidden cost of NHS reform. New Statesman 23 June 2011 http://www.newstatesman.com/blogs/the-staggers/2011/06/care-nhs-health-clinical

[34] World Health Organization Global Health Observatory. http://apps.who.int/ghodata/?vid=1320 Accessed 26 September 2011

[35] Appleby J. Does poor health justify NHS reform? BMJ 27 January 2011; 342:d566 doi: 10.1136/bmj.d566

[36] Desai M, Nolte E, Karanikolos M, Khoshaba B, McKee M. Measuring health system performance: amenable mortality and the achievements in the UK. J Roy Soc Med (in press)

[37] Helm T. Andrew Lansley accused of burying poll showing record satisfaction with NHS: Ministers are said to be withholding survey results that undermine health secretary's case for urgent radical reforms Guardian 19 March http://www.guardian.co.uk/society/2011/mar/19/nhs-andrew-lansley-healthcare-reform

[38] Player S, Leys C. The people behind ‘Liberating the NHS’ reform. Part 3. Hospital Dr 22nd November 2010 http://www.hospitaldr.co.uk/features/the-people-behind-liberating-the-nhs-reform-part-3

[39] Munro R. Emergency Service. Accountancy Magazine. June 2011. http://www.accountancymagazine.com/croner/jsp/Editorial.do?BV_SessionID=@@@@1340474970.1308684704@@@@&BV_EngineID=cccgadfdljdkkfgcflgceggdfnfdgfg.0&channelId=-305535&contentId=1571525

[40] Reynolds L, McKee M. GP commissioning and the NHS reforms: what lies behind the hard sell? Journal of the Royal Society of Medicine, in press

[41] The Press Association. CQC publishes critical report of Castlebeck abuse failings. Nursing Times19 July, 2011. http://www.nursingtimes.net/nursing-practice/clinical-specialisms/public-health/cqc-publishes-critical-report-of-castlebeck-abuse-failings/5032741.article

[42] Bousfield A. The Care Quality Commission and Turkeys. Medical Harm. September 15, 2011. http://medicalharm.org/uncategorized/the-care-quality-commission/

[43] Nolte E, McKee M. Variations in amenable mortality ‑ trends in 16 high‑income nations. Health Policy 2011; doi:10.1016/j.healthpol.2011.08.002

[44] Pulse Online. ‘Big opportunities’ for private sector in health bill, says minister PULSE 7 September 2011 http://www.pulsetoday.co.uk/newsarticle-content/-/article_display_list/12663018/big-opportunities-for-private-sector-in-health-bill-says-minister

[45] Apax Partners conference, Opportunities Post Global Healthcare Reforms, October 2010 http://www.powerbase.info/images/f/fe/Apax_Healthcare_conference_2010.pdf

[46] Ramesh R. NHS shakeup poses threat to political control, Lords committee claims URL: http://www.guardian.co.uk/society/2011/sep/30/nhs-shakeup-political-control-warning

2011-06-22T16:23:00.000Z

Some time ago we wrote a widely cited Lancet paper setting out what we considered a reasonable way forward for public health in England. However, it was clear that the Secretary of State rejected our arguments and he said so, very clearly, in a letter to the Lancet in response to our paper. We then responded to his letter and expected to see both in print very soon. unfortunately he has decided to withdraw his letter, so neither will appear in the pages of the Lancet. Obviously we can't publish his now withdrawn letter, but we thought you might like to read our reply:

Dear Editor,

We were surprised by the Secretary of State‟s summary dismissal of our arguments for an alternative approach to public health in the reformed NHS in view of the government's decision to “pause, listen and engage”. Mr Lansley states that our concerns around fragmentation of the service as a consequence of his plans are unjustified. Yet our apprehension is supported by detailed evidence and our proposals have been endorsed explicitly in responses to the Public Health White Paper consultation by professional bodies, 1,2,3,4 all raising specific concerns about fragmentation. The Secretary of State provides no evidence as to why all these concerns are wrong; nor does he clarify how his plans overcome the problems we describe arising from the division of public health between the Department of Health, local authorities and, potentially, commissioning consortia.

Although he re-affirms the independence of Public Health England, he does not respond to the widespread scepticism this claim has generated or explain how it will be achieved.

His assertion that public health budgets will be ring-fenced within local government is difficult to reconcile with the speech by his cabinet colleague Eric Pickles that the government is “scrapping ring-fencing”.5 We know that some councils, such as Westminster, have already identified cuts from 2012-3.

We are disappointed that he has not „engaged‟ with our clearly thought through concerns about the capacity of public health teams in small local authorities, the trading activities of the Health Protection Agency, training and loss of workforce expertise.

In grasping “the unique opportunity to prioritise public health and work in partnership with [the government] to realise it,” we have built upon the government‟s proposals to suggest modifications to address the adverse consequences we have highlighted.

We hope to continue to engage constructively in this process.

Yours sincerely,
Martin McKee
Robert W Aldridge
Rosalind Raine
Louise Hurst
Ingrid Wolfe

1 Academy of Medical Sciences. Response to the consultation on the public health

white paper ‘Healthy lives, healthy people’ URL:

http://www.acmedsci.ac.uk/p100puid215.html (accessed 3rd May 2011)

2 UK Faculty of Public Health response to Healthy lives,

healthy people: our strategy for public health in England URL:

http://www.fph.org.uk/White_Paper (accessed 3rd May 2011)

3 Association of Directors of Public Health – response to consultation on White Paper

Healthy Lives, Healthy People: strategy for public health in England URL:

http://www.adph.org.uk/downloads/ADPH_response_Healthy%20Lives_Healthy_People_W

P.pdf (accessed 3rd May 2011)

4 BMA response to Public Health White Paper URL:

http://www.bma.org.uk/healthcare_policy/public_health_white_paper/index.jsp (accessed

3rd May 2011)

5 Eric Pickles: We will let councils make their own decisions. URL:

http://www.conservatives.com/News/Speeches/2011/03/Eric_Pickles_We_will_let_councils

_make_their_own_decisions.aspx (accessed 3rd May 2011)

2011-05-22T17:13:00.000Z

David Cameron is right. The NHS must change as the population and its health needs change. Yet this is what it has been doing since its inception. Once orthopaedic (literally child straightening) surgeons spent their days treating young people misshapen by polio and spinal tuberculosis. Now they replace the joints of old people disabled by arthritis. Cardiac surgeons once treated hearts damaged by rheumatic fever; now they treat hearts damaged by poor diets and smoking. These and many other health professionals and managers have never had any illusion about the need to change and even, when called upon, to do so quickly. The emergence of AIDS in the 1980s gave rise rapidly to new approaches to infection control, data protection, and patient involvement, as well as major reconfigurations of hospitals, first to open new dedicated AIDS wards and then, as treatment became available, to close them. The question is not whether the NHS must change. Rather it is what it must change into.

The government’s current proposals provide little clarity. The 450 page Health and Social Care Bill is written in a way that would deter all but the most persistent, with its seemingly endless list of changes to words in previous legislation making it almost impossible to understand what is being proposed. Inevitably, many people simply assumed that it would reflect what was set out in the preceding White Paper. That made many reasonable points, such as the need for more clinical engagement. Yet, when a few dedicated individuals did manage to plough through the text of the Bill it was clear that what was being proposed was very different indeed. Many will agree with Liberal Democrat MP John Pugh who described a "vision of a bill being drafted during the daytime by a sane, pragmatic Dr Jekyll-like minister, but during the night some … Mr Hyde jumps in with a rightwing ideology, breaks into Richmond House and changes many of the sentences." It was not even clear what problem the reforms were trying to solve as the government’s “dodgy dossier” on cancer and heart disease that sought to justify change was rapidly discredited.

So what are the challenges facing the NHS in the future? The Prime Minister has now abandoned his claim to have ring-fenced the NHS budget and admits that his main goal is to cut it by £20 billion, much of which must go before his reforms can be implemented. He sees his task as complicated by an ageing population, which he blames for driving costs upwards. Yet he overlooks how we are living longer in good health and that the main driver of expenditure is how close we are to death, whenever it occurs, rather than how old we are. The real challenges posed by an aging population are how to promote healthy aging through lifestyle changes and how to manage the combination of chronic disorders that we will accumulate, but which advances in treatment now allow us to control. A typical 80 year old may have five or six conditions each requiring specific treatment, involving a wide range of health professionals in different facilities, all of which must be co-ordinated. But this is only the start. We can begin at the other end of the age spectrum, where again we see the effects of medical advances. No longer do we have wards full of children with jaundice and chest infections. The NHS must now look after children with chronic diseases, such as diabetes and genetic disorders, cancer, and a wide range of behavioural disorders and must manage their transition to adulthood. Then there are those whose numbers are likely to increase as a direct consequence of the government’s other policies. These include homeless people, hit by a combination of rising unemployment and reduced welfare benefits, and those with mental illness. Suicides are already up almost 8% from 2007. One word, complexity, encapsulates the needs of all of these groups. The NHS of the future must be able to provide a comprehensive, integrated service through which those with complex disorders are able to navigate with ease.

So how can the NHS create such a system? A first step is to achieve integration. This requires some organisation responsible for ensuring a comprehensive package of care for everyone living in a geographically defined population, whether they live in a home or on the streets, and whether they have registered with a GP or not. That organisation, even if it is no longer called a Primary Care Trust, must work with health care providers to ensure that appropriate, evidence-based services are in place and must monitor the results they are achieving. This will often mean the establishment of networks, such as those that have achieved major advances in cancer care but which have been threatened (their recent reprieve raises enormous questions about how this is compatible with the free market envisaged in the government’s reforms). These networks must include all providers, avoiding imposing artificial divisions between general practitioners and hospitals. It will require clarity about training, to ensure that skilled staff are available. It will require embedded public health expertise, with efforts devoted to prevention as well as to cure. Finally, it will also mean avoiding quick fixes, such as primary care walk-in centres and Independent Sector Treatment Centres that may undermine the viability of specialist services.

A second step is to build in the flexibility required to respond to changing circumstances. This means finding some solution to the ruinous Private Finance Initiative deals that have locked hospitals in stone for 30 years or more. It also means revisiting the idea of Foundation Trusts. At present, to transfer services from one hospital to another it is seems necessary to merge them into a single Trust. When circumstances change again, as is already happening in London, it may be necessary to break them up and merge them with other Trusts. Yet we know that organisations on this scale take several years to recover their previous level of performance. It will exclude the big corporations with their one size fits all approach but it does allow involvement by non-profit organisations that have brought responsiveness and innovation into niche areas, such as palliative care and substance abuse. And it requires avoidance of disruptive large-scale reorganisations that divert managerial attention from the real problems. Just like football teams, hospitals do better when they have managerial stability.

Unfortunately, the proposed reforms take us in the opposite direction, to commissioners responsible only for those who register with them, purchasing only those services they think appropriate while avoiding anyone whose problems are “difficult”, and to providers competing for whatever services are most profitable. We don’t need a crystal ball to see the consequences. We need only look to the USA, where such a system is in place. There it is those with complex needs who suffer. Someone with diabetes is five times more likely to die before the age of 40 than in the UK. And it won’t save the money the Prime Minister wants. The American health system costs almost twice as much as a proportion of national income as the British one yet still fails to provide coverage for over one in seven people.

Unfortunately, there is now a danger that the model that will emerge from the current listening exercise will be a political compromise between the two coalition parties, designed to avoid either loosing face with their supporters. This is no way to design a health system. The only sensible course is to go back to the drawing board, agree what problems we are trying to solve, and design a system that is fit for purpose in the 21^st century. Paradoxically, it may turn out to look rather like what was in place in the 1980s, before an internal market was even thought of, but with the possible inclusion of social care. And once the new system has been put in place, then perhaps it can be left alone, so that those working in it can get on with adapting successfully to changing health needs, just as they have done in the past, rather than to changing political whims.

2010-09-01T09:45:00.000Z

25 years ago the Rockefeller Foundation convened a group of scholars to explore the concept they termed Good Health at Low Cost. It was somewhat of a misnomer, as it was less about cheap health care and more about the ability of countries that had limited resources to achieve good health outcomes. The group met at the Rockefeller Centre in Bellagio, Italy, and examined in detail the experience of four jurisdictions, China, Costa Rica, Sri Lanka and the Indian state of Kerala. Cuba would have been included but wasn’t, for political reasons. The project identified several key features of the successful countries. These included a strong political commitment to health as a social goal, a social welfare orientation in development policies, widespread political participation, a commitment to equity, and intersectoral linkages.

Last week, another group of scholars came together in Bellagio to revisit this concept. The team, led by my colleague Dina Balabanova, has been updating the experiences of the original jurisdictions, which have had mixed fortunes, and has looked at the experiences of five new ones. These are Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu. Although diverse, each stands out from its neighbours in one or other aspect of health system development. For example, Kyrgyzstan, despite (or perhaps because of) lacking the natural resources of some of its neighbours, has achieved a single payer system, reduced informal payments, and made major strides in improving the quality of care. It has done so even though it has undergone several quite turbulent changes of government. Ethiopia has overcome the challenges of a highly fragmented country to develop a Health Extension Programme that has already had major success against malaria. Tamil Nadu stands out for its progress in maternal health. And so on....

So what lessons can we learn from these examples. We are still working through the rich discussions that took place but initial thoughts highlight the role of:

individuals, especially politicians with vision and drive;
institutions, that can support a process of change and, in particular, learn from experience at home and abroad;
events, such as political changes or even natural disasters, which those with vision can take advantage of to bring about change; and
context, which includes the system of political representation, culture, and beliefs.

We will be presenting the initial findings at the Global Forum on Health Systems Research, in Montreux in November, and will be publishing a book in the New Year.

For further reading, check out the blog by Tracey Koehlmoos, one of the Bangladesh team members, on the BMJ website.

2010-08-16T08:42:00.000Z

I was born in Belfast on the 12th of July, famous in Northern Ireland as a day of marches. A colleague writing from Belgium today, on another matter, asked: "does the fact there is now fighting on the streets of Ulster mean I have forgotten your birthday?" At my age, I am perfectly happy to forget birthdays, but it did remind me, in the light of the current upsurge in violence, of some words of Winston Churchill's in 1922.

“Then came the Great War: every institution, almost, in the world was strained. Great Empires have been overturned. The whole map of Europe has been changed. The position of countries has been violently altered. The modes of thought of men, the whole outlook on affairs, the grouping of parties, all have encountered violent and tremendous changes in the deluge of the world. But as the deluge subsides and the waters fall short, we see the dreary steeples of Fermanagh and Tyrone emerging once again. The integrity of their quarrel is one of the few institutions that has been unaltered in the cataclysm which has swept the world.”
Unfortunately, we have two groups of people living side by side, but with elements of each group not recognising the other as part of the same human race. Until that changes I fear that we will simply continue to have a resurgence of violence with each generation. One thing that might help would be to educate children of both religions together. Falling birth rates may help as many existing schools, in rural areas, are no longer viable and are even (shock...) merging boys' and girl's schools. the few inegrated schools remain largely the preserve of the middle class, who when I was growing up there mixed socially anyway. But it will take at least another generation....

2010-08-13T08:39:00.000Z

Why we need effective government

The coalition government in the UK is engaging in an unprecedented dismantling of government functions. We are constantly told that nothing is sacred (although when the public health minister suggested removing free milk for toddlers, the Prime Minister, recalling the reaction to Margaret Thatcher’s axing of milk for older children, quickly stopped her). Yet it is easy to forget why we need government until it is too late. In an excellent blog on the BMJ site, Vassilly Vlassov describes how the Moscow forest fires followed Putin’s cutbacks in the state forestry service. After Hurricane Katrina, Pail Krugman wrote in the NY Times (5th Sept 2005) “…the federal government's lethal ineptitude wasn't just a consequence of Mr. Bush's personal inadequacy; it was a consequence of ideological hostility to the very idea of using government to serve the public good. For 25 years the right has been denigrating the public sector, telling us that government is always the problem, not the solution. Why should we be surprised that when we needed a government solution, it wasn't forthcoming?. “ Also a few years ago, I wrote an article in the Medical Journal of Australia entitled “What are governments for?". It may be worth a re-read.

2010-08-12T16:17:00.002Z

At first I thought I must be wrong. Why would any government pursue policies it must realise would create a recession? Every time there is a major policy development, like the emergency budget, forecasts of growth are reduced further. Yet, day by day, I have searched for an explanation and failed to find one that makes sense. Over the past few months the new coalition government in the UK has been pursuing policies that seem inexplicable.

There are clearly two messages being promoted. First, we have an unprecedented deficit that has to be reduced. Fair enough, but the question is over how long? Much of the deficit is temporary, as a consequence of the bank bailouts, a policy that the two governing parties supported when in opposition) yet ignores the fact that our debt is much lower than most other industrialised countries and the average period before it reaches maturity is about twice as long (we have a paper out soon in the Journal of Public Health explaining all this). The second is that all of this is the fault of teh last government. Again, fair enough – New Labour blamed everything on the conservatives for years after they came to power in 1997. But it is difficult to explain why forecast growth is falling as the government sets out its policies and not rising.

In fact, it seems totally uninterested in growth even though it is one of the most important ways that it could reduce the deficit. It is explicitly pursuing the same policies seen in Ireland and Greece that have arrested economic growth there.

Another way to promote growth would be to provide targeted support to British industry through export guarantees and the work of the regional development agencies. All that is going. Worse, it seems to celebrate the fact that countries like Germany are retrenching when it should be horrified. Where does it think we will export to?

Growth will certainly not come from domestic demand, as it is planning to put about 1.3 million people out of work (about half each in the public and private sector), increasing the cost of welfare payments (and it must know that, for many of those over 50, the chances they will ever work again are remote). The chances of significant job creation are limited given the shortage of credit, and it seems unwilling to act to make the banks lend more.

It is also abolishing as many QUANGOs as possible, bringing key functions within government departments. They will no longer be able to profit from their trading activities – the Health protection Agency will lose the third of its budget that comes from this source. Will the government pick up the bill or will it just allow health protection to weaken?

Then there are the short term costs, of redundancy and redisorganisation. Kieran Walshe, in a BMJ editorial, estimated that the (incomprehensible) redisorganisation of the NHS would cost at least £3 billion, as well as paralysing it for 3 years.

The only explanation I can find is that the government’s true aim is the ideological one of cutting the size of the state to that in Victorian times. The view that George Osbourne is now the “minister for cuts”, as suggested in today’s Guardian, is supported by his decision to maintain the independence of the Bank of England, so denying him any say over monetary policy, and to give many of his remaining powers to the soon to be leaderless Office for Budget Responsibility. Most of the traditional economic levers have been passed to the governor of the bank of England whose main quality is consistency, in being wrong. The rest have gone to a totally untried body, unsure even of who it reports to. All that the Chancellor has left is to chair a competition among ministers to see who can wear the hairiest of hair shirts.

We see the evidence every day. The government seems to have gone to war with its civil servants, publicly humiliating them at every opportunity. Yet, one thing finally convinced me that there was a single ideological goal to cut the size of government. Surely they must know that the creation of a generation of school leavers with no prospects of employment, with reduced university places, and without even the possibility of joining the armed forces is very likely to lead to civil disorder? Remember the early 1980s? In such circumstances, surely it is madness to reduce the police force?

Of course, there may be a better explanation, in which case could someone let me know.

2010-06-29T10:31:00.000Z

1-11th June – Brussels

I’m speaking at a major conference on global health, organised by the European Commission, in a session on health research (organised by DG Research). Some great presentations in the session, expertly organised by Kevin McCarthy and Jan Paehler from DG Research, looking at what research has contributed to global health. My task is to talk about what Europe can offer the world. The answer is – a lot. Our strength is our diversity. The observation that heart disease is so much lower in southern Europe than in northern Europe led to the research identifying the importance of the Mediterranean diet. That led on to the EPIC study that has done so much to advance our understanding of the role of diet in cancer. Another is the EUROTHINE study, providing important new insights into health inequalities. Then there is the diversity in policy responses. Research such as that in the EUROCARE project, showing marked differences in cancer survival, has contributed greatly to how we deliver cancer care in several countries. And finally, there is the European expertise in developing capacity for health research, drawing on experience in central Europe in the 1990s and in the former Soviet Union more recently. There are relatively few opportunities for researchers in rich and poor countries to meet together. This was a rare and valuable example.

2010-06-29T10:17:00.000Z

7th June – Rotterdam.

I’m giving one of the opening speeches at the European Congress on Healthcare Planning and Design. We often hear that the hospital is doomed as healthcare moves into the community. Yet, rather like Mark Twain, reports of its death seem greatly exaggerated. Our two books on hospital design have attracted far more interest than we could ever have imagined, with a seemingly endless list of requests to speak at conferences and write papers in scientific and professional journals. I made a three points. First, many existing hospitals are essentially dysfunctional, designed and built with little thought for what they have to do. The long period between conception and birth, coupled with the pace of change in health care, means that many are obsolete by the time they open. Second, we need to understand why and how hospitals are changing, taking account of changing patterns of disease and emerging therapeutic options, many of which have blurred the boundary between hospital and community. Third, hospital design must respond to the needs of those who are in them, both patients and staff. We often forget that it is the staff who spend most time in hospitals and, while we constantly urge them to find new ways of working, in multi-professional teams that communicate with one another effectively, we create buildings that do little to facilitate this process.
These factors have three important implications for the hospital. The first is the importance of adaptability. The hospital has changed throughout its existence and will continue to change but many of those changes cannot be predicted so we should make change as easy as possible. This affects how we pay for hospitals, such as avoiding failed experiments like the UK Private Finance Initiative that locks hospitals into contractual straightjackets, and how we build them, ensuring that we can change the configuration of the buildings without knocking them down. There are some excellent examples of good practice, such as the variable acuity beds pioneered in Indianapolis, where which the patient stays in the same bed while modules are added or removed to take account of his or her changing needs. The second is design. Hospitals involve a lot of people on the move, from one department to another. In this respect they are like an airport. Yet in an airport the flow is in one direction. In hospitals they move in different directions, they loop back on each other, many have disabilities and some are confused. We recognise that the flow is erratic, and we even create places to store patients to stop them getting lost (waiting areas and wards). The challenge is to find ways to design hospitals that make these flows as easy as possible, something that a number of innovative designs (described in our book of case studies) are doing. The third issue is capacity. It would be nice if the demand for hospital care was entirely predictable but it is not. The hospital must have the ability to accommodate peaks, troughs, and surges. It is clear that there is an audience for these messages. Let’s just hope that they can turn them into reality.

2010-06-11T05:52:00.000Z

OK, it had to happen. I've been persuaded by my good friend Eddie McCaffrey, owner of JooseTV, the excellent company that runs the website 3four50.com and that has managed the webcasting of some of the major public events in recent years, to sign up to twitter - I'm @martinmckee. No idea whether I'll manage to keep it up but it's a lot less work than adding all the hyperlinks to a blog! Let's see!

2010-05-31T20:19:00.003Z

To Pécs, in Hungary, last week for the 3rd Conference on Migrant and Ethnic Minority Health in Europe. I had been invited to give a keynote lecture by my old friend István Szilárd, the conference organiser. István and I first met in 1992 when we were working together to develop a new system of public health training in Hungary. It was therefore especially gratifying to see so many high calibre presentations at the conference by Hungarian public health researchers.

The conference was excellent, both in terms of the practical organisation and the quality of the presentations. I was very impressed by the remarkable growth in research on this topic, from a very low baseline, in the past few years. This research remains concentrated in a few centres, in particular Amsterdam, Copenhagen, and Edinburgh, but there is also a growing number of very good young researchers in other centres. Some of the highlights were a superb plenary by Aldo Morrone, who has done an enormous amount to help the boat people arriving on the Italian island of Lampedusa (you can see a presentation of his work on YouTube), Raj Bhopal’s presentation on the many initiatives to address the needs of minority ethnic populations in Scotland, and a series of individual presentations on topics such as expectations of Poles obtaining health care in Scotland, outcomes of diabetes in Belgium, and patterns of hospital care for minority populations in The Netherlands.

My interest in the topic began some years ago with a book that Judith Healy and I edited on delivering health services to diverse populations, including migrants and indigenous populations. We are now in the process of editing a new book on health and health care for migrants in Europe, due out in 2011.

I have to confess that, a few days before the conference, I had no idea what I was going to say. I was speaking to an audience that, collectively, knew an enormous amount about migrant health, but who also had extremely diverse interests, covering different health disorders and different migrant populations. The word cloud that I created to set the scene illustrates the huge diversity of topics at the conference. What on earth could I say that would be relevant to all of them?

I eventually decided not to talk about health at all but to focus on migration. But who are the migrants? Are they the tens of thousands of elderly northern Europeans retiring to the Mediterranean? Are they the footballers from across Africa being paid millions of pounds/euros to play for premier league clubs in Europe? Or are they the global elite who live in hotel rooms and on planes, exemplified by George Clooney’s character in the recent film Up in the air? (a character that I empathise with!) In fact, much of the conference focuses on other groups, at the other end of the wealth spectrum. They include those risking their lives to get to Europe, often in extremely dangerous conditions, and those who have made it to Europe but are subsisting in low-paid jobs, often being exploited by unscrupulous employers and facing multiple obstacles to basic services.

Those we are talking about, therefore, are only a sub-group of the globally mobile population, defined primarily by their inability to cross borders legally. So why do they try? There are the obvious answers, fleeing persecution and searching for a better life. But if we are to understand migration properly, we need to look at the underlying reasons. These relate to the fundamental inequalities of power and resources in a world that permits free movement of goods, capital, and services but not of people. This creates a situation in which those with power and resources (the ones who can glide through borders) can benefit from cheap, and increasingly, skilled labour in poor countries (for example, in telephone call centres or software companies) and cheap unskilled, and often illegal, labour in rich countries (such as the fruit pickers in California). This is the fundamental issue in understanding migration.

2010-05-31T11:32:00.001Z

Two weeks ago I went to Madrid for the mid-point evaluation of the Registered Nurse Forecasting (RN4CAST) project. I’ve been involved in research on the contribution of the nursing workforce to hospital performance for some years, working with Linda Aiken at the University of Pennsylvania in the International Hospitals Outcome Study. In the English arm of the study we showed that hospitals with the best patient-to-nurse ratios had consistently better outcomes than those in hospitals with less favourable staffing, with substantially lower mortality, while the nurses in those hospitals were about twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals. RN4CAST is now expanding this work to 11 European countries (Belgium, Finland, Germany, Greece, Ireland, Poland, Spain, Sweden, Switzerland, The Netherlands, and the UK), the USA and three International Cooperating Partner Countries of the European Union (Botswana, China, and South Africa) plus one reference group (Norway). I’ve been asked to be one of the evaluators of the project and I was delighted to see the tremendous progress so far. This study will provide invaluable insights that go beyond its original aims, to shed light on the processes and quality of care in European hospitals.

I was also asked to give a plenary lecture at the conference that was linked to the meeting. The project places a high priority on engagement with policy makers and had brought together a large number of key stakeholders from Spain and the rest of Europe. I focussed my talk on the challenges facing the nursing profession in the future.

The first set of challenges arise from the changing nature of health care. These include changing demographics, disease patterns, and professional roles. This has profound implications for the general nurse who faces:

• Loss of much of traditional caring role (to health care assistants)

• Increase in the need for clinical knowledge (of drugs, interactions, side effects)

• Increase in the need for technical skills (new equipment for patient monitoring and treatment, information technology)

• Increase in the treatment co-ordination role (among many more actors, and with a much more mobile group of patients)

• Increase in need for vigilance to identify patients deviating from the expected clinical trajectory

• Increase in working in different settings, often involving greater autonomy

Unfortunately, health systems do not always rise to these challenges, exemplified by a paper in J Health Serv Res & Pol in which a researcher described their stay in a hospital: ““Care was being delivered by a group of professional and semi-professional workers, each of whom occupied their own silo, occasionally picking up information from others to initiate some action, or acting in ways that triggered actions by others, but who were unable to see how they formed part of a whole system”

A second challenge is the recruitment and retention of nurses, with many industrialised countries far too dependent on recruitment of nurses from developing countries that can ill afford to lose them.

The third challenge is how to get the balance right between curing and caring. Too often we focus on the technical aspects of care, encouraged by the focus in some countries on what can be measured, while ignoring the human aspects.

Fourth is the need to strengthen professionalism. In some countries professionalism needs to be developed, where nurses are still viewed as doctors’ handmaidens, but in others professionalism needs to be defended from politicians who endorse George Bernard Shaw’s description of professions as “a conspiracy against the laity”, seeking to micro-manage and infantalise them.
Finally, there is a need to address the challenge of life-long learning, although hopefully not going down the incredibly prescriptive, bureaucratic, and probably unworkable model of revalidation being developed for doctors in the UK.

2010-05-31T09:49:00.000Z

At the end of April I was in Warsaw, to participate in a meeting of the European Science Advisory Network for Health (EuSANH). This is a network of national science advisory bodies working which in the field of health that promotes independent scientific advice and evidence-based health policy. We have been contributing by preparing reports on bodies fulfilling this role in the UK, including LSHTM’s on-call facility for the Department of Health, the Academy of Medical Sciences, and NICE (with thanks to those involved for providing the necessary information).

The meeting was combined with a conference discussing the role of scientific advice for policy, at which I gave a keynote lecture. I began by reflecting that the world is complex (helpfully illustrated by a diagram published in the New York Times the previous day in which the US Department of Defense sought to represent the challenges it faced using a diagram that had the appearance of an upturned bowl of multi-coloured spaghetti), before looking at the different stages of communicating information. One problem is that researchers too often take pride in the obscurity of their messages, viewing anything comprehensible as lacking intellectual rigour, although an alternative view (which I prefer) is that this is simply an opportunity to defend the status of their discipline. I was therefore delighted, when researching the lecture, to come across a paper from 1968 entitled “Are sociologists incomprehensible? An objective study”. It cited an earlier paper which argued that “A few sociologists write the best English they are capable of writing.... Others, however – and a vast majority – write in a language that has to be learned almost like Esperanto. It has a private vocabulary which, in addition to strictly sociological terms, includes new words for the commonest actions, feelings and circumstances. It has the beginnings of a new grammar and syntax, much inferior to English grammar in force and precisions. So far as it has any effect on standard English, the effect is largely pernicious. “ A more recent paper, reflecting on economics, said “We have all had the experience. You start a new job, be it academic or corporate. You walk into a presentation by a colleague. Before the third slide comes up on the screen, you find yourself totally lost in a morass of method, terminology, and tradition beyond your comprehension. You know the speaker is brilliant and you have full confidence in the conclusions; however, you find it impossible to follow the logic that takes the work from beginning to end.”Enough said!

However, much is being done to redress this situation and I argued that anyone seeking to make a difference should read the excellent series of articles recently published by John Lavis, Andy Oxman, Simon Lewin, and Atle Fretheim in Health Research Policy and Systems, which takes the reader through all the stages, from creating organisational structures that support the use of evidence, through identifying evidence needs and finding and assessing the evidence, to making evidence-based decisions.

Yet, no matter how hard researchers try, they need to confront the biases that exist in the minds of recipients of evidence. David Stuckler and I were thinking about this in the run up to the recent UK general election. At one stage, when it became clear that he was trailing in the public response to the televised debates between the party leaders (among those watching on TV, not those listening on radio, echoing an earlier debate between Nixon and Kennedy), Gordon Brown called for a focus on substance, not style. This was a complete waste of time. As we showed in a paper in the BMJ reviewing new research from neurosciences, once the electorate have come to a judgment on an individual, it doesn’t matter what they say. Research using fast magnetic resonance imaging shows that they automatically discount your messages, while ignoring obvious contradictions from politicians they admire. These biases influence how objective evidence on health policy is interpreted. An elegant American study published in late 2009 looked at how political allegiance shaped interpretation of evidence on the causes of diabetes, presenting news stories that were identical except for what they said was its main cause (not mentioned, genes, individual lifestyles, or social determinants, such as the obesogenic environments in which many of us live). Democrats and Independents reading the last of these were more likely than those whose news item mentioned no cause (controls) to agree that social determinants were important, while there was no effect among Republicans. However, while reading the explanation invoking social determinants made Democrats and Independents more likely than controls to support collective social responses, Republicans were less likely to.

Then there is the effect of the media. Ben Goldacre has drawn attention to some of the more bizarre stories in the British tabloid paper the Daily Mail, including its apparent campaign to place every object in the world in the categories of causes or cures for cancer, and in some cases both simultaneously (indeed, so numerous are its claims that there is a website specially for those who wish to keep up with them, helpfully listing them in alphabetical order). However, it has an equally vociferous campaign against what it calls the “nanny state”, in which most of us would include the spectrum of public health policies that have rendered death in childhood a rarity in Britain and have contributed to a steady gain in life expectancy. But does the media matter. Sadly, yes, as was shown in a study that tracked the roll-out of Fox News to cities on cable channels in the USA between 1996 and 2000. Its appearance in a city was associated with a significant electoral shift to the right.

Finally, there is the role of vested corporate interests. Marshalling vast financial resources, and using remarkably sophisticated marketing techniques, they have developed tremendous experience in influencing how we think. A now notorious example is the use of product placement in movies by tobacco companies.

So, in summary, if we as researchers are to have an impact on policy, then we need to get our own house in order, finding out what it is that policy makers want and giving it to them. But as citizens, we should also demand that our policy makers recognise their responsibilities to be aware of the biases they bring (and the forces that influence them) and at least try to be objective.

2010-05-29T22:22:00.000Z

It’s back. At last. It’s been a year and a half since I last posted an entry on this blog and I reckon it’s time to restart it. The problem was that I didn’t know how to restart. Most of my postings were written on the plane back from somewhere, but I was finding that that time was being used up by writing meeting reports, preparing the next talk to give somewhere else, editing papers, or simply catching up with the journals. There was just no time at all. I felt I needed to offer some explanation for why I hadn’t been writing on the blog, but couldn’t find the words.
So what has changed? Well, nothing really. The volume of work remains at a completely unsustainable level, but then it’s been like that for years and I’ve managed to sustain it .... just. But just for once I’m on a plane and have no immediate deadlines – well, not quite true – I still have to prepare two lectures that I’m giving next week and the week after. But I’m not going to manage to finish them up here so I just thought – let’s do it.

I’m sorry I haven’t kept an on-line record of the last 18 months, as there was plenty to write about. Some of the highlights included:

• Speaking at the Global Ministerial Forum of Research for Health, in Bamako, Mali in November 2008. Health ministers from almost 60 countries committed to developing and funding health research strategies, including research infrastructure (ethical review procedures, clinical trials registries, and open access to data) and knowledge translation. As I argued in a BMJ editorial, this is an ambitious agenda and it will be important to hold governments to their commitments.

• Participating in the WHO global Advisory Committee on Health Research, in which I’m privileged to work with some outstanding colleagues from across the world as we develop an ambitious and exciting agenda to support research for health. In November 2009 we had a joint meeting in Panama with the PAHO regional committee, chaired by John Lavis from McMaster University, which really sets the benchmark for the other regions.

• Setting out an agenda for health research at the WHO’s European Regional Committee in September 2009, which will pave the way for action to begin to address the severe under-representation of some European countries in projects undertaking research for health.

• Starting a new EU funded (Framework 7) project, Health in Times of Transition) to study health and lifestyles in nine former Soviet countries. This builds on our earlier Lifestyles, Living Standards and Health study that provided a wealth of comparative analyses of eight countries in this region. The new project adds Azerbaijan. Field work is well under way and we should have the first results this autumn. An added strength is that, this time, we are adding community profiles, so we can understand the environments that shape the decisions that people live in. This will be the first time this has been done in this region and, at a recent meeting in Minsk there was real excitement as the different research teams worked together to address the not inconsiderable challenges.

• Making progress on the Prospective Urban and Rural Epidemiology (PURE) study. This remarkable project is led by Salim Yusuf at at McMaster and has now recruited almost 150,000 people in 17 countries worldwide. Again, we are collecting data on the circumstances in which people live and the early results presented when we met in Beijing in November 2009 indicate that it will yield some very important new findings.

• Making progress on our Rockefeller Foundation funded project updating the study on Good Health at Low Cost published 25 years ago. Their report then identified several countries and regions that were achieving much better health outcomes than would be expected given their level of economic development. They included Sri Lanka, Costa Rica, and Kerala, in India. This time, as well as seeing how the original countries have fared since that report was published, we are looking at another five that are now viewed as doing better than expected: Thailand, Bangladesh, Ethiopia, Kyrgyzstan, and Tamil Nadu. At our last team meeting in Bangkok, in April this year, provided an invaluable opportunity for the research teams from these somewhat different countries to exchange experiences.

• Preparing a report on the implications of ageing for health systems for the Czech EU Presidency, with mu colleagues Bernd Rechel, Yvonne Doyle, and Emily Grundy, subsequently published in summary form in the BMJ. This is one of the most important issues facing European governments and I hope we have been able to dispel some of the many myths.

Several projects have come to an end. The EURO-PREVOB project has provided new instruments for assessing the extent to which the environments in which people live influences their diets and levels of physical activity and the IMAGE project has succeeded in developing and publishing European evidence-based guidelines for the prevention of diabetes in those at risk.

Then there have been the papers. Early in 2009 David Stuckler, Larry King and I published a paper in the Lancet showing how the scale and speed of mass privatisation in the former communist countries correlated with the increase in mortality that occurred at the same time. We thought that this was fairly uncontroversial and saw our most important contribution (besides quantifying the relationship) as identifying the role on community support (measured as membership of organisations) in protecting people. That fitted with another study we published last year showing how measures of social capital were associated with better health in the region. We never expected the response from those who had been advocating rapid privatisation. The Economist used a leader article to dismiss our results (doesn’t everyone know that privatisation is the only thing to do....), using a graph purporting to show trends in Russian life expectancy but looking nothing like anything we’ve ever seen before. Eventually we discovered what they had done. Despite life expectancy fluctuating rapidly from year to year, they took five year averages! This had the effect of making the Russian mortality crisis disappear! Just as Stalin caused millions of deaths at the stroke of a pen, The Economist brought similar numbers back to life. And they never apologised .... Over the course of the next year, we engaged in seemingly interminable (and often frankly bizarre) exchanges, via Richard Horton, with some of the supporters of mass privatisation. The final words can be read in two letters from our critics in the Lancet, which work very hard to show that our results were wrong, along with our letter in response, in which we invoke the criteria of data torture to try to understand how they managed to get our findings to disappear. I would encourage everyone to read all three letters and make up their own minds. Unfortunately, as we have since discovered, no matter how well we rebut our critics, it has become clear that some people will never be convinced.

To coincide with renewed attention to progress in achieving the health-related Millennium Development Goals (MDGs), which focus very largely on deaths in childhood, we looked at whether adult mortality was important. Chronic diseases in adulthood have attracted much less attention than childhood illness (as we showed in an analysis of WHO expenditure prepared for the Bamako forum and published in the Lancet) yet we reckoned that the death or serious illness of a parent must be bad for their children. Our study confirmed this, showing that high rates of disease burden from non-communicable disease, such as cardiovascular disease, stroke and diabetes, were indeed associated with slower progress towards the MDGs and we were delighted when it was cited at the UN General Assembly.

And then the books… The main ones in the past year have been our two on the hospital of the future, one bringing together a series of case studies from some of the most innovative developments in Europe and the other drawing together the many issues facing hospital design in the future. These have, to our slight surprise, attracted enormous attention and have spun of a considerable number of papers as well as numerous presentations and policy dialogues.

So there we are. The blog is back. The challenge will be for me to keep it up!

2008-09-21T22:32:00.001Z

20th September 2008, Liverpool
I had been invited by Michael Marmot to speak at the annual meeting of the Academia Europaea. Michael had organised a session on Health and Wealth so I was presenting our work on the contribution of health to economic growth in Europe. It was my first opportunity to hear Michael speaking since the publication of the Report of the Commission on Social Determinants of Health, which he chaired.
The report begins by documenting, in great detail, the scale of the problem we face. Life expectancy at birth ranges from 54 to 82 years, not in the world as a whole but within a single city, Glasgow. The Commission states very clearly that "social injustice is killing people on a grand scale" and sets out a vision for closing the health gap between rich and poor in a generation.
The Commission made three broad recommendations:

Improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and die Equity from the start; healthy places, healthy people; fair employment and decent work; social protection across the life course; universal health care;
Tackle the inequitable distribution of power, money, and resources—the structural drivers of the above conditions of daily life—globally, nationally, and locally Health equity in all policies, systems, and programmes; fair financing; market responsibility; gender equity; political empowerment—inclusion and voice; good global governance;
Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

This is an ambitious but achievable agenda. The real question is whether the governments of the WHO’s member states will have the courage and determination to take it forward.

2008-09-21T22:24:00.005Z

18th September 2008, Stockholm
To the European Centre for Disease Prevention and Control. This was my first visit to ECDC, although we do work closely with colleagues there, most recently in our new book on the health system response to complex communicable diseases (primarily, but not only, HIV and TB). Unusually, this time we looked beyond Europe, drawing lessons from both Europe and another region undergoing political and economic transition, Latin America and the Caribbean.
I was there as a member of an expert advisory group on migration. The 2007 Portuguese EU presidency placed the health aspects of migration on the policy agenda and the ECDC is in the process of preparing a report on its consequences for communicable disease.
In some countries, in particular the UK, migration has become a highly politicised issue. Even though the UK has benefited enormously from migration (whether as assessed by the number of foreign born “British” Nobel Prize winners or the army of unrecognised workers who care for the elderly and disabled in our society), there are still shrill voices calling for ever tighter restrictions. These calls have, regrettably, been heard by the current government which has put in place a draconian process to limit the number of highly skilled migrants, as well as quite disgraceful treatment of asylum seekers fleeing persecution in other parts of the world. It has come under particular criticism for its inhumane treatment of children in families seeking asylum. These points are worth recalling as it is easy to overlook the reality that the major threats that migration poses to health are to the health of the migrants themselves.
The report is due out at the end of the year. It will focus on three areas, TB, HIV, and vaccine-preventable disease. However, what became clear from our discussions was the need for an extensive preamble, defining and categorising different types of migration and providing a conceptual framework to understand the health consequences of migration.
A major challenge will be collecting the necessary data. In part reflecting differences in laws on citizenship (at the risk of over-generalisation, there are two approaches – jus solis , where citizenship depends on where you were born, and jus sanguis, where citizenship depends on the nationality of your parents) and constraints arising from data protection legislation.
At the end of our meeting I gave a lecture on migration and health, entitled threats and opportunities. You can see a short video on the ECDC website. It was an opportunity to recall that, even after the breaking down of barriers in Europe in 1989-91, we still live in a divided continent, inhabited by young and old and native-born and migrants. The European social system is, however, based firmly on solidarity. This solidarity owes much to the experiences of the 1940s, where even the most wealthy could be reduced to ruin when they became caught up in the conflict. Two recent books remind us that people of all nationalities suffered. These are Norman Davies’ Europe at War (in which he once again reminds us of the extent of Europe, in this case recalling the carnage on the Eastern Front), and Giles MacDonogh’s After the Reich (where he describes the horrors of the retributions visited on Germans after May 1945). The knowledge that you could go to bed rich but wake up poor ensured that the generation that survived would put in place arrangements to protect their fellow citizens from the consequences of illness and unemployment. This contrasts with the the USA, which has never managed to achieve universal health care coverage. There, those in power, who were overwhelmingly white, could be confident that they would never wake up black. The question we must face up to is whether our belief in solidarity is strong enough to survive the pressures of aging populations, increased migration (by those who are visibly different) and economic downturns. Unfortunately there are some worrying signs in many countries, with growth of extreme xenophobic parties. As Martin Niemoller reminded us over 60 years agoin his famous poem (First they came for...), this challenges everyone who believes in solidarity to speak out before it is too late.

2008-09-21T22:23:00.000Z

17th September, 2008 Rotterdam
In Rotterdam for the initial meeting of our new EU-funded project Avoidable mortality in the European Union: towards better Indicators for the effectiveness of Health Systems (AMIEHS). Jointly led by Johan Mackenbach at Erasmus Medical Academy and us at LSHTM, with partners from France, Germany, Spain, and Estonia, it seeks to understand how the concept termed “amenable mortality” can be used as an indicator of health system performance.
The concept of amenable mortality was developed by Rutstein and colleagues in the 1970s. It was based on the premise that deaths from certain causes, and certain ages, that should not occur in the presence of timely and effective care. Subsequent work has expanded the list of causes of death considered amenable, reflecting advances in health care, and increased the upper age limit for these deaths, reflecting improvements in life expectancy. The concept has also been refined to include differentiation of causes amenable to the health care system and those to public health policy, while specific causes have been partitioned into the proportion to which reductions are attributable to primary, secondary, and tertiary actions.
In recent years, amenable mortality has undergone something of a renaissance. In part this reflects the much greater interest in performance of health systems, stimulated by the 2000 World Health Report, with improved tools being sought avidly by policy-makers seeking to determine whether they are getting value for money. An example was our study showing that deaths from amenable mortality in the USA around the year 2000 had hardly changed at a time when other industrialised countries were experiencing substantial declines.
In its original conceptualisation, amenable mortality included some conditions where medical care could do little to prevent death once the disease process had occurred but where the onset of the disease could be prevented by health promotion activities. This is exemplified by lung cancer, where, it was argued, health professionals could be effective in preventing people smoking or encouraging them to quit. However, assuming they were successful, the deaths that would then be avoided would occur several decades later. Clearly, this is incompatible with the idea that contemporary rates of amenable mortality reflect the current performance of health systems. Hence, only those deaths than can be prevented by contemporary interventions should be included. The definition of contemporary is inevitably somewhat arbitrary but a period of five years has the attraction of consistency with the period used to assess what is popularly considered as “cure” in analyses of cancer survival.
The original list of amenable causes included causes of death that could be prevented entirely by health care and those from which some deaths would be inevitable but the number could be minimised. The former is exemplified by vaccine preventable diseases such as measles; the latter by ischaemic heart disease, where even in the best performing health care system, some deaths will be sudden and unobserved. However, there are also many causes of death not considered to be amenable where, in some circumstances, health care can be life-saving. This is true of many cancers for which a small proportion may be identified early, making possible curative treatment. An example is cancer of the pancreas. This begs the question of what proportion of deaths from a specific cause should be preventable for the cause to be considered amenable. This issue has previously been addressed only implicitly but it is now time to make it explicit. The figure is, again, somewhat arbitrary but we propose that a 50% reduction has the benefit of simplicity.
There are, however, a number of considerations to be taken into account. In some cases, reductions in mortality in this scale will be achievable with a single intervention. The term “magic bullet” recalls the dramatic benefits of penicillin when it was first given to patients with severe staphylococcal infections in the 1940s. More often, health care will prevent deaths through a combination of interventions that were introduced incrementally, perhaps over decades. In these cases it will be necessary to look at changes in death rates over considerable time, introducing the problem of attribution as it is necessary to exclude other explanations for observed changes.
It will be necessary to draw on a variety of sources of evidence. In some cases, there will be randomised controlled trials. However, these are most likely to exist for single interventions; they are much less likely where a combination of interventions is involved. Randomised controlled trials also face the problem of external validity, as they often exclude both children and older people, those with co-morbidities, and historically, women. Hence, it will also be necessary to draw on natural experiments, where it is possible to determine when new treatments were introduced. An example is the introduction of HAART for patients with AIDS, where death rates fell very rapidly. In other cases, even where detailed data are unavailable, it may be possible to infer the impact of health care where there has been wider system change. An example is the political transition in eastern Europe around 1990. The opening of borders to modern pharmaceuticals and ideas of evidence-based medicine made it possible to provide treatment that was previously denied to sufferers from many chronic diseases. Thus, in countries such as Estonia, there was a rapid decline in mortality from stroke, almost certainly as a result of better treatment of hypertension, at a time when such deaths were increasing in neighbouring Russia. It may also be necessary to look at historical evidence. Thus, conditions such as acute appendicitis became amenable to health care once the introduction of asepsis and anaesthesia made intra-peritoneal surgery possible in the late 19th century. Treatment of hypertension has a shorter history but has still been possible since the late 1950s.
In all previous studies, the definition of amenable deaths has had an upper age limit, reflecting the view that “everyone must die of something”. The age limit has increased over time, from 65 to 75, but this creates certain problems. The first is that it is explicitly ageist, as it devalues curative care for those aged over 75. The second is empirical, first because life expectancy in some countries now exceeds this figure but, second, as there is growing evidence that many types of health care are very effective in older people. If, however, the definition of an amenable cause is one where health care can reduce the death rate by 50% or more, then there is no intrinsic reason to have an upper age limit. Yet, while conceptually attractive, this also poses problems of obtaining evidence, first because older patients are often excluded from trials but, second, because the absence of an observed decline in mortality at older ages at a time when an intervention was being introduced may simply mean that this population was not offered treatment.
So far we have not addressed one of the most difficult definitional issues in assessing health system performance, how to define the borders of the health system. The 2000 World Health Report adopted an essentially pragmatic definition as it was necessary to include all of the WHO’s 193 member states, the majority of which had no functioning system f vital registration and certainly no possibility of ascertaining causes of death. As a consequence, it defined the health system extremely broadly. This included a range of inter-sectoral actions. It is, however, difficult t justify holding the health system to account for actions that others must take. For this reason, we propose that the boundaries must be drawn more tightly, to include interventions delivered by those working what is unambiguously the health care system but also those developed by public health agencies, such as immunisations and screening for cancer.
This is a three year project. What I have described above is only the first step, as we then need to show whether changes in amenable mortality actually do correlate with innovations in health care. If we are successful, this should be a valuable contribution to the debate on health system performance.

2008-09-21T22:21:00.001Z

16th September 2008, Velden, Austria
Carinthia is a stunningly beautiful part of Europe. Its lakes, mountains, and traditional towns and villages make it an ideal holiday destination. Unfortunately my stay was for just over 12 hours but long enough to put it on the list for future visits. Situated in the south of Austria, it borders Italy and Slovenia and, since the 2004 enlargement of the European Union enlargement, links across these borders have strengthened greatly. This is especially true in the health sector, with the Carinthian authorities establishing a formal system of collaboration with colleagues in Slovenia and in the Friuli and Veneto regions of Italy. I was speaking at the Austrian Health Economics Forum, sharing a session with my colleague Luigi Bertinato from the Veneto region. I was talking about the three way relationship between health systems, health and wealth (see Tallinn Conference) while he was discussing the changing nature of international health tourism. Veneto Region has been developing links with Dubai, where an international “medical city” is being built with the intention of attracting patients from across the world to what will be a first class medical facility.
Two weeks before I had been speaking about the Dubai venture on BBC World Service TV. I confess that I was not entirely optimistic. There is no doubt that there is a growing market for medical tourism but I’m not sure that Dubai can compete with the much lower costs in countries such as South Africa, India and Thailand. There is, of course, a potentially large American market, given the increasing unaffordability of care even for those Americans who have coverage. However, I’m not sure how many will be prepared to fly to he Arabian peninsula in the current political climate, especially when they can get care for rather less in Mexico.
Both in the presentations and discussions over coffee a key issue to emerge was that of quality of care. In Austria, as in many other countries with social insurance systems, it has proven extremely difficult t get the medical profession to engage in effective mechanisms to assess and improve the quality of the care they provide. There are, of course, lots of small scale individual efforts but there is still a lot of opposition to anything more systematic. As we have shown in our new book reviewing the mechanisms to promote quality in all 27 EU Member States, Austria is not alone.
This is becoming an important issue at a European level. The proposed framework directive on patients’ rights in relation to cross-border care will require that each country establish systems to ensure quality of care, and while they will be free to decide how to do this, future work is planned to monitor whether they are doing it (See our recent BMJ editioral). A further issue is the introduction, in a few countries of revalidation of the right to practice medicine. Again, this is something we have looked at in a recent paper and, in some more a detail, in a policy brief. Clearly this is an area where some discussion at a European level is needed, not least to ensure that the arrangements are workable (but also to ensure that they are not hijacked by bureaucrats who believe that the larger the pile of paperwork, the better the system (as seems to be happening in the UK)). Unfortunately, and as usual, the Commission’s DG Internal Market doesn’t agree. It invariably sees any attempt at regulation that would protect the public as a constraint on free movement. It is essential that its views are not allowed to prevail.

2008-09-21T22:15:00.002Z

10-11th September, 2008 Tiberias, Israel
I was in Israel for a meeting of the International Advisory Board of the Israel National Institute for Health Policy and Health Services Research and for the international conference that followed it. The conference was on the Public-Private mix in health care. The discussions were fascinating, reminding us of the many semantic difficulties in health policy. Specifically, could we agree on what we meant by public and private? This is of particular relevance in Israel, where the sickness funds are private bodies but operating within a statutory framework. Most of those representing them do not claim to be private organisations, rather seeing themselves as fulfilling a public role. Perhaps the only way to resolve the issue is to accept that some organisations have public and private dimensions and which predominates depends on the specific circumstances!
All health care systems are a product of history and, if one was starting from scratch it is unlikely that anyone would design them as they are now. Much of the discussion inevitably focused on issues facing the Israeli health system. Revital Gross provided a remarkably clear explanation of a highly complex financing scheme, where everyone is covered through the social insurance scheme yet where 80% purchase supplemental insurance from the sickness funds while 38% also pay for complementary private insurance. However, this was simplicity itself compared with the new Dutch insurance system, presented by Wynand van de Ven, which left many of us relieved that we didn’t have the choice that it offered, as the complexity of the many packages on offer seemed to test the comprehension of most of those present, that vast majority of whom had the benefit of tertiary education!
The conference was held in Tiberias, on the Sea of Galilee Its banks are steeped in history, from biblical times to the 20th century (it is overlooked by the Golan Heights). Over 200 m below sea level, the surroundings are beautiful and the warm water is fresh and clear (and I did manage to find some time to swim in it). Yet it also provides a warning. It is surrounded by jetties and harbours whose walls now tower over the stones that line its shores. Although it is difficult to tell, it seems to be about 8m lower than it once was, serving as a reminder that, ultimately, the survival of this region is dependent on one scarce commodity, water.

2008-09-21T22:08:00.003Z

18-22nd August, 2008. Auckland and Wellington, New Zealand
New Zealand holds a great deal of interest to anyone interested in health policy and living in the UK. In both countries the executive has almost unchallenged power to introduce laws, with no need to build supportive coalitions at other tiers of government or with civil society organisations. This has many attractions for politicians – after all, why explain your decisions if you don’t have to. However, the absence of detailed scrutiny also makes it easy to enact unworkable laws, and then to revise them with ever increasing rapidity.
New Zealand acted as a health policy laboratory in the 1980s and 1990s, introducing market reforms that went well beyond those then being contemplated in the UK. The word “hospital” was no longer acceptable, being replaced by Crown Health Enterprises. They were intended to work like businesses but to continue to be socially responsible. Inevitably, those running them failed to resolve the contradictions. Many chief executives left. Costs increased rapidly, as did waiting lists. By 1996 the Treasury concluded that ““The health reforms have yet to yield the original expectations. By a range of measures … the pace of performance seems, if anything, to have been weakened since the reforms.” However, lessons were learnt. Those bits of the system that had worked were retained, especially Pharmac, the pharmaceutical purchasing scheme that ensures that New Zealanders get low cost drugs. However the purchaser-provider split was abolished and a new system was put in place in which health care was delivered by 21 district health boards. The most important lesson was the destructive effects of what can seem like endless attempts at reform. Reform fatigue set it and even though there is widespread agreement that the current system is not perfect, there is little appetite for structural change.
I was in New Zealand for a series of meetings, concluding with a conference entitled “Building tomorrow’s health services”, held in a spectacular community and conference centre built in the form of an upturned Maori boat.
My trip included several meetings at the Minstry of Health in Wellington and a masterclass in Auckland. New Zealand’s health system faces many familiar challenges, including an aging population and the rise of complex non-communicable diseases, as well as some that are less familiar, such as a long-term redistribution of population, away from the South Island and into the greater Auckland area. It also experiences a high level of emigration of health professionals although, as we learnt, the emigration rate is not significantly different to other graduates. There is, however, a remarkably clear vision of what needs to be done, embracing prevention (and especially action to reduce the persisting inequalities between Maori and European populations) to integrated delivery systems.
In 1948 Aneurin Bevan, when asked to speculate about the forthcoming introduction of the National Health Service replied “do I need a crystal ball when I can read the book”. He was referring to the successful introduction of a health service in New Zealand a decade earlier. Could it be that English politicians will once again learn a lesson from New Zealand and place major structural chage on hold for a while to allow people to just get on with the job of delivering better care. Somehow I doubt it, but we can but hope.

2008-09-21T18:53:00.000Z

3-8th August 2008, Venice
This year’s European Observatory summer school is on the “Hospital re-engineering: New roles, tasks and structures”. It draws extensively on our forthcoming book and we have, once again, been able to assemble a first class team to teach on the course, which is held in the idyllic setting of the island of San Servolo, close enough to Venice to be inspired by the view but far enough away from crowds of San Marco to allow for the reflection and contemplation necessary to exchange and absorb new ideas. As always, one of the greatest assets is the range of participants, collectively bringing a vast range of experiences that they are willing to share.

2008-09-21T18:52:00.000Z

3rd July, 2008, London
Among the hundreds of thousands of words written about different health systems (and I confess that I can account for quite a few thousand alone) there is remarkably little describing what health professionals in different countries actually do. Although we have statistics on how long patients stay in hospital (themselves increasingly meaningless in a world dominated by ambulatory care), we know very little about what happens when a patient with a common medical or surgical problem comes into a hospital. Well, we know what happens in our own country but unless we engage in participant observation, either as health professionals or as patients, in a hospital in another country, we know almost nothing about how things are done elsewhere. Yet without this crucial information, it is difficult to see how we can say anything meaningful about how different health systems perform.
This was what prompted the organisation of a meeting by the NHS Confederation and the European Observatory that brought together health professionals from countries such as Sweden, Finland, France, Germany and Italy to talk through a series of scenarios such as acute myocardial infarction and deep venous thrombosis. As expected, there were many similarities in how patients are managed but also quite a few differences, reflecting the organisation of care in each country. In particular there were differences in the extent to which care was centralised in specialised hospitals or dispersed, in the roles of different health professionals, and the extent to which quality of care was monitored. This is only the beginning of what will be a long process. We will next be using this approach to understand the delivery of child health services at a workshop at the EUPHA conference in Lisbon in November. I hope anyone that is interested in these issues will join us there.

2008-09-21T18:37:00.003Z

25-27th June, 2008, Tallinn
At last, the culmination of over two years’ work. Health ministers and their representatives from the 53 Member States of the European Region of WHO have come together in a major conference to discuss the links between health systems, health, and wealth. I’ve been involved in many aspects of this process, including writing some of the background reports, but here my task is to give one of the opening speeches, along with Mary Robinson, former UN High Commissioner for Human Rights and President of Ireland, and Uwe Reinhardt, from Princeton University. Both extremely hard acts to follow. If you want to see whether I succeeded you can watch a webcast of the speech on the conference website.
The framework underpinning the conference is a series of reciprocal relationships between health systems, health, and wealth. The first set of relationships are between health and wealth. It is obvious the greater wealth, whether at the level of the individual or a country, provides greater opportunities for health. People with more economic resources can make healthier choices in terms of what they eat, where they live, and how they spend their leisure. Countries with more economic resources can provide healthier environments. However, there is now a large body of evidence that healthier individuals and healthier populations contribute to greater economic growth. Healthy individuals are more productive and more likely to remain in the labour force. Historical studies show that much of the wealth of countries today is due to improvements in health over the last 200 years.
Health systems contribute to health, by preventing death and alleviating suffering. We can I quantify this through research using the concept of avoidable mortality, which measures the number of deaths that should not occur in the presence of timely and effective care. However better health also contributes to health systems, as healthier people have less requirement to use health care. This was the basis for at the analysis conducted by Sir Derek Wanless in his report to the UK Treasury, when he was asked to look at future expenditure on the National Health Service.
Wealth can contribute to health care as wealthier countries clearly have more resources to spend on modern medicine. On the other hand, health care systems can contribute to economic growth, especially at a regional level, where the provision of high-quality health care and support inward investment. Investment in health facilities can benefit the local economy, reducing unemployment, and thereby improving the health of the population, but only if it is structured in a way that enables local companies to bid for tenders on a level playing field with multinational corporations.
What we were trying to convey at the conference was not the detailed prescription for action, but rather a vision of where policy should be heading. We believe that it is possible to create a virtuous circle, with benefits for everyone.
Although there was a large attendance at the conference, and the background material is available on the Internet, we had recognized that there was a need to reach out to a much wider audience. Fortunately, as at the Oxford Health Alliance meeting in Sydney in February, we were able to enlist the invaluable support of Eddie McCaffrey and his team at JooseTV, who not only webcast the entire conference, but also produced a series of news bulletins at the end of each session and in-depth interviews with some of the key individuals who were at the conference. If you watch nothing else, check out the film shown at the end of the conference that really captures the atmosphere of excitement and enthusiasm there. Once again, I conducted many of the interviews and you can watch them on the conference website. The opportunities provided by webcasting also allowed us to connect with the European Health Management Association conference, taking place at the same time in Athens, with a specially tailored interview. If we really want to communicate messages to a wider world, this is definitely the way to go forward.

2008-09-21T18:35:00.003Z

20th June, 2008 Leiden, The Netherlands
I was privileged to be asked to speak at a conference of the EUPHIX consortium. This team, led by colleagues at RIVM in The Netherlands, has done a remarkable job in creating a portal for information on health in Europe. In my speech I asked, somewhat tongue in cheek, whether with EUPHIX we needed Interail to see Europe’s rich diversity. The portal is much more than a directory of information. It includes software for mapping data (down to regional level) and manipulating it graphically. However, crucially, it is supported by extensive guides, helping users to understand the strengths and limitations of the data they are using.

2008-09-21T18:34:00.002Z

18th June, 2008 Belfast
In Belfast for the launch of the new Centre of Excellence in Public Health, led by Frank Kee at Queen’s University, Belfast. As a graduate of Queen's University, have been delighted to see the remarkable progress in academic public health under Frank’s inspired leadership. I was particularly delighted to see that the launch conference was opened by Northern Ireland’s Deputy First Minister and Health Minister, two individuals from different political parties who, not so many years, would not have spoken to one another. The Centre’s research programme recognises the importance of interlinkages between different disciplines and the need to translate research into policy. This is just what Northern Ireland has needed for a long time and it is certainly something to watch.

2008-09-21T18:34:00.001Z

8-10th June, 2008 Washington DC
This year’s AcademyHealth conference was held in the sweltering heat of Washington in June, a city where summer is always hot and sticky but which this year was experiencing what was, for it, a heatwave. A strong disincentive to leave the conference venue! With my colleague Bernd Rechel, we had organised a session based on our forthcoming book on hospital. This is the product of a collaboration between the European Observatory and the European Health Property Network.. After introducing the scope of the study, which draws on the most innovative ideas in hospital configuration and design from across Europe, we looked in detail at some of the most interesting examples. One was Northern Ireland’s regional hospital plan, which will create a network of hospitals offering different levels of care, primary care and rehabilitation facilities, and care in patients’ homes. Another was the Orbis Medical Park, near to Maastricht, in The Netherlands, where a new hospital is being designed to support clinical pathways and processes rather than, as is more usual, ignoring them. The third was the Alzira Hospital in Valencia, Spain, which has implemented a new financing model that was initially quite problematic but is now working well, in contrast to the UK’s Private Finance Initiative, which is now suffering what seem to be terminal death throes.
As always, many of the presentations at the conference focused on the problems that arise when you fail to provide universal health coverage. A growing number of states are now taking initiatives themselves, typically by requiring people (and their employers) to purchase insurance schemes. However, for a European the overwhelming impression is of just how complex these schemes are, and also how many holes there seem to be in them. It is difficult to see how any of them will ever really work without addressing some of the reasons why health care is so expensive in the USA, in particular the high cost of pharmaceuticals and the huge administrative costs of maintaining a multi-payer system.
There is, of course, an election coming up but it is not obvious that either candidate has a solution. What’s more, we heard that health reform is not high on the concerns of ordinary Americans, and is training far below where it was when Hilary Clinton attempted to do something in the early 1990s. Instead they are concerned about the economy and the wars in Iraq and Afghanistan. Yet this may change, as manifest by the growing evidence that people are having to cut back on expenditure to meet health care costs. Something must be done sometime, but I suspect things will have to get a lot worse before they get better.

2008-09-21T18:33:00.001Z

4-5th June, Izhevsk, Russian Federation
Izhevsk, a city on the European side of the Urals, is the setting for a major Wellcome-funded study we are undertaking to understand the high level of adult mortality in Russia. Readers of this blog will be familiar with our earlier work highlighting the role of alcohol. In our current work, and in previous work in other parts of Russia, it has become clear that we are facing an enormous problem of untreated hypertension. The Soviet Union never managed to deal effectively with chronic diseases. It never developed a modern pharmaceutical industry and, even if it had, it would never have been able to distribute the drugs that those in the west take for granted and which, when taken regularly, can be life-saving. Now the drugs are available and the distribution system is in place, but we still face two problems. First, those taking drugs as outpatients have to pay for them. As they are often much more expensive than in the west because of mark-ups along the supply chain they are often effectively unaffordable. Second, there are very low expectations as to what can be achieved, so that physicians seem content to leave patients untreated even with what we would consider dangerously high pressures. This should be an entirely soluble problem but I suspect it will take some time to resolve it.

2008-09-21T18:21:00.001Z

27th May 2008, Lausanne
This was my second year teaching on the course run by Alberto Holly in Lausanne. The title of this year’s course was “Mastering the new challenges of health care”. There is a wonderfully diverse mix of students, making the discussions especially rich. My sessions were on health system performance and the future of health care. These are both topics I have spoken about many times before. Predicting the future is never easy. A few have managed it successfully, such as Jules Verne and HG Wells, but even they recognised their limitations and, as far as I know, never staked their fortunes on the outcome of a horse race! Yet there is one thing that we can be fairly certain about, and that is that health care in the future will be much more complex than it is now, with aging populations suffering from multiple disorders, each interacting with one another, with their ability to function secured by a complex mix of medicines that have never been tested in combination, and especially in people with impaired liver and kidney function. This poses real challenges for modern health systems, something Ellen Nolte and I will be looking at in our new book on the health system response to chronic disease, due out in September.

2008-05-07T06:02:00.000Z

I’ve been thinking a lot about two words, governance and stewardship, recently. In part this is because, with Josep Figueras, I’ve been working on the text for the Tallinn Ministerial Conference but also because I’ve been teaching about it to our MSc students. I’m grateful to one of my PhD students and to my MSc seminar group for the examples I’m going to use in a minute.
The problem with both of these words is that everyone seems to use them differently. A quick search on Google reveals dozens of definitions of governance; stewardship, a term that came into widespread use following publication of the 2000 World Health Report, has received less attention but it is also clear, listening to it being used, that it can mean all things to all people. As always with health policy, I take comfort from Lewis Carroll’s book, Alice’s Adventures in Wonderland, where Humpty Dumpty says “words mean what I choose them to mean”.
Yet maybe we can turn it round. We may not know what (good) governance and stewardship are but we do know when they are absent. Hence the two examples from my students. One concerns a new EU member state. As with any newly acceding country, its accession was conditional on putting in place an extensive body of modern laws. One of these laws concerned mental health. Yet although the law was passed, no resources or personnel were made available to implement it. No-one was accountable for failing to implement it. Indeed, it was very clear that it was never meant to be implemented. Simply passing it served a purpose and it could now be ignored. This is a failure of governance.
The second example is from the UK. A previous English Secretary of State for Health was confronted with a situation where, having put in place a new system of postgraduate medical training, it was clear that a flood of applicants from outside the UK would leave several thousand British doctors with no job. She issued an instruction that non-EU doctors would be ineligible to apply. The British Association of Physicians of Indian Origin sought judicial review and in a scathing judgement the Law Lords supported them. They noted that the Secretary of State had it within her power to change the rules by bringing a motion before parliament. Clearly wanting to avoid controversy, she failed to do so, instead simply placing a notice on a web site of the NHS Employers organisation. This, Lord Bingham noted “was to suggest a degree of official formality that was notably lacking”, going on to state that “it is for others to judge whether this is a satisfactory way of publishing important government decisions with an impact on people’s lives”. This too is a failure of governance (and as I have argued before, far from exceptional in the UK in recent years).
Of course, these are not unique, and maybe we need to think about assembling a collection of such examples from across Europe. Even if we are unable to define what good governance and stewardship are, we will at least be able to know when they are missing.

2008-05-06T22:52:00.002Z

Copenhagen, 30th April

To Copenhagen, for the European consultation on the forthcoming Ministerial Conference on Health Research that will be held in Bamako, Mali, this November. I’ve been engaged with this process for a while, through WHO EURO.
The conference follows on from one held in Mexico City in 2004. It will be important as it will contribute to the agenda for global health research in the next number of years. Hence, it is essential to get it right.
My concern is that we risk losing sight of the fact that it is a global conference, albeit one that is, in part, focused on Africa. I don’t want to diminish for one second the enormous need for health research in Africa and, in particular, the importance of building research capacity there, but we should not forget the needs of the rest of the world.
Last November, we organised a consultation on European priorities for Bamako at the conference of the European Public Health Association (later published in the Eur J Public Health). We highlighted three priorities for research in Europe (on top of the ones that will be included anyway because of their global reach, such as tobacco and HIV). These were migration, aging, and alcohol, while we also flagged up the contribution that Europe could make to the rest of the world in research on complex chronic disorders, which will be the real challenge for everyone in the future, whether we are talking of diabetes or HIV or something else.
This time we were looking more widely, and the Danish Foreign Ministry had brought together what seemed to be over 100 people in their very attractive conference on the sea front in Copenhagen. I was arguing, in a panel discussion, that the health systems framework we will be using in the forthcoming Tallinn conference bears closer inspection. It highlights the beneficial reciprocal relationships between health systems, health, and wealth. Beyond that, I think we have three questions about capacity that are of concern to those of us working in Europe.

First, how can we get the basic data in place, by which I mean regular health examination and health interview surveys, that are comparable across all of Europe? These are being developed but we are already so far behind the USA.
Second, how can we establish better links between research and policy? Obviously I would say that the European Observatory is a good model but we also need to learn much more from the Canadians with their knowledge brokers.
Third, how can we build up research capacity in our own neighbourhood. Research capacity in many parts of the former Soviet Union or in the Middle East or North Africa is far weaker than in countries like Uganda or Tanzania.

So at Bamako I hope that Africa does get attention – it deserves it. But we should not forget the rest of the world.

2008-05-06T22:18:00.000Z

April 29th
To the Royal College of Physicians for their conference on Global Health. I was asked to speak about international trade and health so I chose as my title “Opium, tobacco and alcohol: the evolving legitimacy of international action”. My argument went as follows. We all agree that, in most cases, international trade brings great benefits. Each country does things where it has a competitive advantage. I enjoy mangoes but it would be a bit silly of me to try to grow a mango tree in my garden in north London (although with global warming you never can tell). Yet there is a down side. The problems arise when what are being moved around the world are not the usual “goods” but rather “bads”. Few people really think that flying tons of AK-47s into the Democratic Republic of Congo is a good idea (except of course those doing the flying and those supplying them from places like the Trans-Dneister republic – see Misha Glenny’s new book - McMafia: Crime Without Frontiers ). Similarly, landmines are now fairly universally regarded as a “bad”. But what is it that changes a “good” into a “bad”?
I began by looking at one of the best known examples. In the middle of the 19th century British forces went to war with China (twice) to protect our right to sell opium to China. China certainly didn’t want it – it realised that it was causing harm to its population and even threatened to retaliate by banning exports of rhubarb to Britain, in the hope that this would inflict widespread constipation. Yet it was the opium harvest that lay behind the economic success of now British Bengal. Over a century later we were still at it, as Christopher Bayly describes in his excellent book on the British withdrawal from SE Asia, as we imported massive amounts of opium to ensure that the Malayan population kept working even though there was no food. Yet now the Royal Navy patrols the high seas, interdicting cocaine smugglers in the Caribbean (and anywhere else it can find them). What turned us from a trafficker to a policeman?
The same sort of change is taking place with tobacco. Here we have a product that has killed more people than all the wars of the twentieth century yet we (or at least our political leaders) still treat the manufacturers and distributors in the same way as people who make things that actually benefit us. It really is remarkable. These people are peddling their deadly products to children all over the world in a way that is really no different to the traffickers who hand around school gates trying to hook kids on heroin. Yet while no-one would invite the drug traffickers to be photographed with our political leaders, there seems to be no barriers for tobacco company executives. In the past, when countries such as Thailand stood up to the USA and said that they didn’t want tobacco imports, the USA threatened trade sanctions. Imagine what would happen if Bolivia took the USA to the World Trade Organisation for blocking exports of cocaine (although, again, anything is possible).
Except, there are some signs of hope. The Framework Convention on Tobacco Control does make clear that tobacco is not just another product and that governments can put in place a range of measures to counteract the aggressive marketing of tobacco without being accused of erecting non-tariff barriers. So tobacco is steadily being transformed from a bad to a good.
What of alcohol? Obviously this is more difficult as moderate consumption is clearly good for you, providing you are at risk of heart disease (if you are under 40 you are just kidding yourself – the net effect is harmful, sorry). Yet the alcohol industry seems to be doing everything possible to move into the corner with the makers of “bads”. Recently (as I described in an editorial in the BMJ) when discussions on a European alcohol policy were taking place, the Brewers of Europe published a remarkable report purporting to show that there really was very little evidence that alcohol was at all harmful. They commissioned it from the Weinberg Group, a consulting firm that had previous tried to convince us that the health effects of smoking were exaggerated and that Agent Orange was not such a bad thing after all. Their report argued that that "there is not enough evidence to substantiate a link between alcohol advertising and consumption," raising the question of why the industry spends so much money promoting its products, and that "violence is a subjective term which is fairly nebulous and elastic," a view unlikely to be shared by someone scarred by a bottle wielded by a drunk. Clearly, if the alcohol industry continues with tactics such as this, it cannot be surprised if we begin to consider the need for concerted international action, building on the experiences with narcotics and tobacco.

2008-04-27T09:17:00.003Z

My second trip to Brussels this week. I was with my colleagues Christian Haerpfer and Alexander Chorostov to begin negotiations with the European commission on our new FP7 project, Health in Times of Transition: Trends in Population Health and Health Policies in CIS Countries. This is a follow-up to our earlier project entitled Lifestyles Living Standards and Health. In it, we conducted household surveys in eight former Soviet countries, providing important new information on topics such as tobacco and alcohol consumption, access to safe water, and use of health services. In the new study, we will be expanding the household surveys to 11 countries, covering the entire Commonwealth of Independent States with the exception of Turkmenistan. We will also be undertaking a number of community profiles to understand better the circumstances in which people live, in particular their access to different forms of food, the extent and nature of tobacco marketing, and their access to healthcare. We are hoping that the project will begin in November 2008 with the first survey data being collected in early 2010.

Footnote: I read that the UK government is planning to introduce a new facial recognition system “to reduce delays at immigration in British airports”. This news simply confirms to me that the Home Office is viewed as an incredibly soft target by anyone with a computerised gizmo that no-one else is stupid enough to buy. When it was introduced, I enrolled in the IRIS system, which was a complete waste of time. The system is frequently out of order and, even when it is working, it is so slow that it is quicker to use the ordinary queue. I was reading about the new system as I was getting on the Eurostar at Brussels, where one must show one’s passport to Belgian officials and then again, about 10m further on, repeat the entire process with the British (only more slowly as it is clear that their computers are creaking under the weight of data from the new biometric passports. If the government really is interested in reducing queues at immigration, there is an obvious solution. Join the Schengen Agreement like the rest of Europe!

2008-04-27T08:42:00.006Z

To Brussels, for a meeting of the steering committee of the European Observatory. It has been an incredibly busy year, beginning with the publication of our book on cancer in Europe and continuing with intensive preparations for the Ministerial Conference on Health Systems in Tallinn in June.

It is always nice to know that one is appreciated, so it was a great pleasure for us all when the Observatory was recognized in an award schema that had been launched by the World Bank for initiatives that improve the lives of people living in Europe and Central Asia. A total of 19 awards were made, most for projects within countries, such as the restoration of the famous bridge in Mostar, in Bosnia, that was destroyed during the war, or an AIDS control project in Moldova. The Observatory was recognised by a multi-country award. The picture shows Armin Fidler, who had previously accepted the certificate from the president of the Bank, in Washington, handing it on to Charles Normand, the chair of our steering committee, and accompanied by Josep Figueras, Director of the Observatory.

2008-04-18T19:29:00.002Z

17-18th April 2008, Riga, Latvia
We are here for a meeting of the EURO-PREVOB project. This is seeking to develop a methodology to map policies, both “on the books” and “on the streets”, that can address the increasing problem of obesity in Europe. We are interested in policies that influence both energy intake and expenditure, in other words, nutrition and physical activity. With support from the WHO, we were joined by many of the leading experts on food and physical activity from across Europe, who provided extremely valuable inputs into our thinking.
We began with a series of presentations that brought us up to date with developments in this field. Liz Dowler reminded us that, as we think about access to healthy food, we need to think about whether it is culturally appropriate food in an increasingly multi-cultural Europe. Mike Rayner reminded us that marketing involves 4 Ps: product, promotion, place, price. Effective action must address all of these. A key issue we need to address is food labelling. Although almost everyone has signed up to the need for labelling to inform the public, some companies are working hard to avoid the use of traffic light systems – red for danger, green for healthy – for the obvious reason that their products would have a line of red splodges. Instead they are pushing for more complex labels, often on the back rather than front of packs, that the public finds confusing (see link for UK Food Standards Agency evaluation). Mike also reported some very interesting evidence on the effects of so-called “fat-taxes”, or more generally increased taxes on unhealthy foods. In fact, in the EU, many foods are already taxed – in the UK there has been a very interesting legal action recently to decide whether a marshmallow is a cake or a biscuit, with very considerable financial implications for the Treasury. The question is whether the existing somewhat confused and contradictory regime can be refined to incorporate a health dimension. What the research showed was that simply taxing unhealthy foods would actually increase deaths. What is needed is an integrated policy that is linked to subsidies for healthy foods.
Tim Lobstein then took us through the tactics that are being used increasingly to market food to children. He reminded us of a study that looked at the range of foods marketed to children. Some products were low in fat (but high in sugar), some were low in sugar (but high in salt), so that only 1% of products were actually low in salt, saturates, fat and sugar. In other words, virtually all food aimed at children is junk.
Any parent will be familiar with some of the more obvious methods used to persuade children to consume energy dense foods, such as McDonalds’ Happy Meals, otherwise known as “edible entertainment”. Many of these products give away sets of toys, with the sets changing regularly to encourage children to eat enough to get the whole set. Then there are the links to “good causes” where companies distribute tokens that can be exchanged for school sports equipment and the like. We were reminded of Cadbury’s tokens, whereby, if one managed to consume 20,000 kcal of chocolate, one could get a netball. Then there are the companies offering free logos and ringtones for mobile phones, and of course once the numbers are logged, the children can be bombarded with advertising text messages. Or the books where children learn to count by placing M&Ms on pictures, no doubt eating a few as they do. It is clear that the regulators are many steps behind the industry.
So what is to be done? We were meeting in Latvia, a country where, unusually, the government has taken a strong stance against additives and colouring in food aimed at children. Leaving aside the emerging evidence that some additives may have harmful effects on children’s behaviour, we are faced with a situation in which colourings are used very extensively simply to make otherwise unattractive (and unhealthy) food attractive to children. There seems a strong argument for banning their use in food aimed at children.
So back to the project. Essentially, if we want to understand existing policies in a country, how they relate to needs, and the scope for further development, we need quite a lot of information. We will be focusing, first, on the “law on the books”. The idea is to identify a national focal point in each country who can convene a group of knowledgeable informants who can tell us about what policies are in place. Of course, that is just the first step, so we need them to tell us not only whether a policy exists but also whether it is written down , whether there are financial and human resources identified to implement it, and whether there are systems for monitoring, evaluation and accountability. The second focus is on “law on the streets”. Here we have to develop a means to capture what is happening in reality. Do the foods on sale in shops have nutritional labels? Can people afford to eat a healthy diet (and can they get to the shops that sell it)? Does the layout of the streets force people to use their cars or to walk of cycle? Finally, drawing on Marx’s comment that “the philosophers have only interpreted the world, in various ways; the point is, however, to change it”, we need to identify who the key stakeholders in a potential new policy might be, what their positions are, their interests, and their influence. We have a lot of work ahead of us!

2008-04-18T19:06:00.000Z

17th April 2008, Flying from Tallinn to Riga
A short flight down to Riga. The Baltic States are now in the Schengen zone so no need to go through immigration, unlike the ridiculous situation when entering the UK, whose government continues to emphasise its semi-detached relationship with the rest of Europe.
I read in the in-flight magazine an article by Bertolt Flick, the CEO of Air Baltic, that there is some prospect that the EU might get rid of the ban on liquids in hand baggage. He writes that he has serious doubts that they ever contributed to safety. So he should. As anyone with a moderate knowledge of chemistry will know, this policy is devoid of any basis in evidence (surely if it was so easy to make explosives from household liquids we would be seeing bombs going off in European capitals every week?). We must thank the European Parliament, whose members have been asking some quite penetrating questions (even if the European Commission has failed to answer them, citing secrecy – the argument of the truly desperate). The Parliament is pushing through long-awaited legislative measures to bring some basic common sense to the often bizarre array of security measures that simply serve to make air travel in Europe even more awful than it would otherwise be. However, I am not holding my breath. This will involve some governments admitting that they got it seriously wrong and, given that some still believe there are WMD in Iraq (and also presumably fairies at the bottom of their gardens), this may take some time.

2008-04-18T19:00:00.002Z

15-16th April 2008 – Tartu, Estonia
Estonia has, in many ways, had a very successful transition from communism. Its economy is growing rapidly (somewhat faster than its neighbours Latvia and Lithuania), it has maintained a high level of fiscal stability, and its markets are now closely integrated with the rest of the EU. It has made remarkable progress in reforming its health care system, introducing a very effective system of primary care, it has managed to restructure its hospital system very successfully, and has a health insurance system whose income and expenditure are in balance. These largely reflect the efforts of a number of extremely talented young Estonians (hope you are reading this, Maris and colleagues). Their achievements stand out in a region that has struggled, often unsuccessfully, to bring about much needed changes to health care systems.
Yet there is still some way to go, both in terms of economic progress but more importantly in terms of health. Life expectancy at birth for Estonian women lags behind that in Sweden by over 4 years; for men the corresponding figure is a massive 11 years!
Things are improving. Indeed, Estonia has managed to achieve sustained increases after 2005 at a time when Latvia and Lithuania have experienced what are hopefully only temporary setbacks. One area where there has been a marked improvement is in deaths from stroke, almost certainly reflecting the reform of Estonian primary care and resulting improvements in the treatment of high blood pressure. This is at a time when Lithuania has actually seen a slight worsening in death rates. There have been other achievements, most notably the successful implementation of a ban on smoking in public places (something I argued for in the Estonian paper Eesti Päevaleht in December 2004 (Tubakasuits tuleb laiali ajada. Eesti Päevaleht). Yet there is one area that stands out because of the complete absence of a policy – alcohol. Like all countries that emerged from the USSR in the early 1990s Estonia has long had a problem with alcohol. Spirits are cheap and easily available (despite some local efforts to reduce the possibility of buying them late in the evening). As we showed in a recent study, aftershaves and medicines containing high concentrations of alcohol are sold widely, in the knowledge that they are being drunk. In a second study we showed that the main outlet is street kiosks, which sell an eclectic mix of aftershaves, pet food, washing powder, and condoms. One result is that, at a time when mortality overall has been falling, deaths from liver cirrhosis have been rising, to a level that is now three times higher than in 1990!
This provides the rationale for one of our research projects in Estonia. Working with Katrin Lang, Marika Väli, and Kersti Pärna and other colleagues at the University of Tartu, we are trying to understand better the role played by alcohol in premature deaths in Estonia and, in particular, the role of alcohol in sudden cardiac death, something that is still imperfectly understood. We should begin to have enough data to draw some conclusions in about 18 months.

2008-04-09T19:28:00.007Z

Five years ago the University of Crete established a postgraduate training course in public health. I’m here at the invitation of the course director, Professor Anastas (Tassos) Philalithis, to join in a review of the course, accompanied by colleagues from the UK, Sweden, and Canada.
Public health has not, traditionally, been strong in Greek universities (the Athens School of Public Health is part of the Ministry of Health, not Education). The creation of the course was therefore a very welcome development. In the short time that it has been going, it has attracted large numbers of students (and also attracted some very talented staff who had been working abroad). The Medical School here at the University of Crete has a spectacular modern campus, with a view of the mountains and sea that must inspire great thoughts! Although we are only half way through the process, we have had a chance to talk to the extremely motivated students and to look at their dissertations , all of which are very impressive.

Crete has a special place n the geography of public health. Cretan researchers participated in the landmark Seven Countries Study. The study recruited men aged between 48 and 59 and followed them up from 1958 to 1970. At that time, remarkably little was known about the causes of cardiovascular diseases. The Seven Countries Study was far ahead of its time, using standardised data instruments and analyses. It included countries with some of the highest and lowest mortality rates known anywhere at that time. By comparing risk factors in Karelia with those in Crete, the research team discovered the key role played by diet, in particular lipids, in the genesis of this disease. In due course this study, along with others, would confirm the status of the traditional Cretan diet, with its olive oil and high levels of fresh fruit and vegetables, now considered the healthiest anywhere in the world.

Of course, Crete is a Mediterranean island, benefiting from the Mediterranean climate and culture. The main square in Heraklion has a reminder of this shared culture, with a bust of one of it’s most famous sons, Doménicos Theotokópoulos, better known as El Greco. Although born here, he spent time in Venice and Rome before finally settling in the Spanish city of Toledo, where many of his greatest works were painted.

Unfortunately, as in other parts of the Mediterranean, the traditional Cretan lifestyle is under threat from the forces of globalisation. The diet is giving way to fast food, the growth of motor vehicles is reducing the amount of physical activity that people take (and leading to an enormous number of premature deaths from traffic injuries, in part because of a widespread rejection of the concepts of seatbelts and motorcycle crash helmets), and obesity rates are increasing rapidly. However, perhaps the greatest problem, and the one that can be addressed most easily, is the high rate of smoking.

I watched someone smoke three cigarettes, one after the other, at breakfast in the hotel yesterday morning. Every bus shelter has large advertisements for cigarettes, clearly designed to attract new smokers among Cretan adolescents. As the pictures here show, there are health warnings but they are very difficult to see. The result – death rates from cardiovascular disease and cancer are now rising in Crete and, as we showed in a recent paper looking at regional patterns of mortality in the Mediterranean countries, in many other places that traditionally had a health advantage.

The tragedy is that many Greek politicians do not seem to have understood what is happening to the health of their population. The public health service remains focussed on traditional hygiene. There is still no proper career structure for public health professionals. Although there are some world class public health researchers, they have so far had to go abroad for their postgraduate training and many have not returned. There are few funds for research training, except those available from the European Union. The health insurance funds, that might be expected to show some interest in preventing illness and ensuring that the care they pay for is effective, take little interest as, when faced with rising costs, they simply increase their deficits and from time to time ask the government to bail them out. Until now the gods have been kind to the Greeks, blessing them with a long life expectancy. It was easy to believe that a modern public health workforce was a luxury. Hopefully, before it is too late, Greece’s political leaders will realise that it is not. When they do, the University of Crete is well-placed to rise to the challenge.

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One of the things I enjoy about Greece, as a non-Greek speaker, is spotting the many words of Greek origin that have made it into English. The emergency exits in the university bear signs labelled “exodus”. The labels on the fire extinguishers begin with “pyros”. The wings of the university building are Pteriga (as in Hymenoptera – bees and wasps – or Pterodactyl (wing/ fingers)). I was therefore fascinated to learn from Tassos that, back in the 1950s, Xenophon Zolotas, an eminent Greek economist, had developed the art of making speeches to the international financial bodies, ostensibly in English but using virtually entirely words of Greek origin. One of his speeches, to the IBRD, is reproduced here. Another can be found by clicking on his name above.
I always wished to address this Assembly in Greek, but realized that it would have been indeed "Greek" to all present in this room. I found out, however, that I could make my address in Greek which would still be English to everybody. With your permission, Mr. Chairman, l shall do it now, using with the exception of articles and prepositions, only Greek words.
Kyrie, I eulogize the archons of the Panethnic Numismatic Thesaurus and the Ecumenical Trapeza for the orthodoxy of their axioms, methods and policies, although there is an episode of cacophony of the Trapeza with Hellas. With enthusiasm we dialogue and synagonize at the synods of our didymous organizations in which polymorphous economic ideas and dogmas are analyzed and synthesized. Our critical problems such as the numismatic plethora generate some agony and melancholy. This phenomenon is characteristic of our epoch. But, to my thesis, we have the dynamism to program therapeutic practices as a prophylaxis from chaos and catastrophe. In parallel, a Panethnic unhypocritical economic synergy and harmonization in a democratic climate is basic. I apologize for my eccentric monologue. I emphasize my euharistia to you, Kyrie to the eugenic and generous American Ethnos and to the organizes and protagonists of his Amphictyony and the gastronomic symposia.

2008-03-13T13:39:00.002Z

12th March: Ljubljana

Slovenia will have a general election in September. Health care is rising rapidly on the political agenda, largely because of the high share (about a third) of health expenditure now being paid directly. The Slovenian health financing system has a large co-payment element, which many people cover through complementary insurance but others pay out of pocket (See HiT profile).

I was invited to talk about the roles of planning and markets in health care, with particular reference to the UK. My host was the Friedrich Ebert Stiftung, a German foundation that supports dialogue on public policy issues.

The starting point was that markets have clearly delivered many benefits. No-one now would want to go back to the centrally planned system for distributing food in the Soviet Union. The question is whether the conditions for markets to operate apply in health care? Another issue to consider is the differing goals of the various actors. Governments seek to improve the health of their populations, to respond to their legitimate needs, and to do so fairly (or at least they should – this is the WHO definition). Private companies are legally obliged to maximise the returns to their shareholders. These goals may overlap, but it is unlikely that they will overlap completely.

Health care is not a commodity like baked beans, apples, or widgets. It has certain features that make it special. Many people who need care don’t realise it. Even if they know they need something, they may not know what. They are easy prey for unscrupulous providers. This is what we call information asymmetry. It is not only people who are ill who have an interest in being treated. The rest of us also have an interest. This is obvious where they are suffering from infectious diseases, which may infect us, or mental health problems that may lead them to harm us. But simple concern for others also leads us to want to see their suffering relieved – what we call externalities.

Then there is the changing nature of disease. Markets are fine where the transactions are simple, as was once the case in medicine, where an individual patient would go for a single visit to a doctor, who would make a diagnosis (often wrong) and prescribe treatment (often ineffective). The patient either got better or died. The situation now is quite different. A typical older patient may have arthritis, Parkinsons Disease, heart failure, bronchitis, diabetes, and depression. They go to their family doctor. They are then referred to a series of medical specialists, nurses, other health professionals, all working together in a network, collaborating with each other. They receive multiple powerful and effective medicines, all of which are affected by their organ function and by the other drugs they are taking (which will never have been evaluated in combination). They remain under continuing review for the remainder of their now active and fully engaged life. This is seriously complex and someone has to manage it. Unsurprisingly, private providers will run a mile from patients like this. Instead they concentrate on straightforward non-urgent surgery, where the costs are largely predictable, and if they do venture into chronic disease management, they select those people who only have one disease and are otherwise healthy. The public sector picks up the rest – what we call cream-skimming.

But does this matter, as long as everyone can get treatment somewhere? It can do. Think of situation where a family is injured in a high speed car crash. They arrive at an emergency department. There is no paediatric service – it has been moved into the community. Their eye injuries cannot be treated as the ophthalmologists have been relocated to an independent treatment centre to concentrate on waiting lists for cataracts. The complex hip fracture cannot be treated, because the orthopaedic surgeons have been relocated to an independent treatment centre to concentrate on waiting lists for knee replacements. There is no microbiologist to speak to about the wound infection because the service has been privatised and moved 200 km away.
However, perhaps the greatest challenge relates to preparing for the future. As Donald Rumsfeld famously said “there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know. And … it is the latter category that tend to be the difficult ones.” So when we are thinking about the competing strengths of public and private provision, a key issue must be which allows more flexibility to adapt to future challenges. Then there are the things that we can predict, such as the need to train the next generation of health professionals and the need to engage in research and development to generate new knowledge. Again, we need to ask which is better at investing in these future needs.

Taken with the conventional questions such as value for money, this then gives us a framework for looking at two of the developments that have taken place in the UK, the Private Financing Initiative (PFI) (as a means of funding new hospitals) and Independent Sector Treatment Centres.

It is now apparent to all but the most ideologically driven commentators that the UK PFI scheme has been a failure. Allyson Pollock has provided most of the evidence in a series of papers, in the process exposing herself to vicious personal attacks from the supporters of PFI (or in some cases from backbench Members of Parliament who probably never understood the issues but were doing what they thought might be appreciated as they sought to advance their careers). She has shown how the procurement process is expensive, complicated, and prolonged. One result is that several projects have been abandoned at an advanced stage, wasting millions of pounds. Several of the hospitals that have been completed have suffered major quality problems. However, for us the real problem is the inflexibility (see our paper in the Bulletin of the WHO). Because the contracts are negotiated in so much detail, it is virtually impossible to change the specifications, even though we know that the nature of health care is changing rapidly. One example is the ratio of operating theatres to beds. With short acting anaesthetics and minimally invasive surgery we need more of the former and less of the latter. Yet some recently completed hospitals (including one close to where I work) are already obsolete in his respect by the time they open. The accompanying picture illustrates the problem. Given the declining need for beds, a newly built hospital now may have too few (an example is the now notorious Norfolk and Norwich hospital PFI scheme). However, in 30 years time it will have too many. The situation is worse for schools. There are now quite a few examples of schools built under the PFI scheme that are now surplus because of falling birth rates (see article in the Guardian). Yet the local governments still have to pay for them to be maintained for the next 30 years, at a cost of millions of pounds each.

The Independent Sector Treatment Centres raise different issues. Here the evidence is rather less, largely because they have consistently failed to supply the data that were required from them. Consequently, a cartoon accompanying one of Allyson Pollock’s paper in a recent issue of the BMJ compared them to a black hole, with money and patients being swept into them but no idea what happened afterwards. One problem is cream-skimming. They only take the straightforward cases, leaving the NHS to look after the rest. Yet bizarrely, give the lower costs that result, the government pays them 11% more per case! (and this is on top of various other subsidies plus a guarantee to buy back the premises at the end of the contract). It then doesn’t even check whether they have performed all the procedures they have been paid for – a reasonable estimate is that they have performed about 70% of the contracted work but of course they received 100% of the payment.

Now I am not saying that markets have no place in health care. Of course they do. All that we have to do is ask whether, in a particular set of circumstances, the prerequisites for a market exist and then whether it will actually deliver what it promises. Fortunately, I don’t have to answer that question for the Slovenian population!

Footnote 1: Credit where credit is due. On Tuesday evening I passed through Terminal 2 at Heathrow. This is normally a deeply unpleasant experience, reminiscent of Douglas Adams’ comment about being drunk, as experienced by a glass of water. Amazingly, I got through security in only a few minutes because there was a security supervisor who was actually managing the process. No-one should underestimate the importance of this development. Could it be that the executives of the British Airports Authority have finally realised that they are meant to be managing an airport, rather than a shopping mall? Somehow I doubt it. Terminal 5 opens in a few weeks and we already know there will only be enough seats for about two jumbo jets’ worth of passengers, presumably with the intention of forcing people wanting a seat to buy food and drink from the many commercial outlets. No. I suspect that this was just an individual who takes pride in his job. I fear he won’t last long.

Footnote 2: I returned through Terminal 2 at Frankfurt. A 20 minute queue to get through security, having been screened only 90 minutes earlier at Ljubljana. It’s close, but in the competition to become the most incompetent airport operator, Frankfurt seems to be drawing ahead.

2008-03-08T21:55:00.004Z

6th March: Brussels

In June, WHO is organising a ministerial conference on health systems in Tallinn, Estonia. The theme is “Health Systems, Health and Wealth”. The concept underpinning the conference is that all three are mutually linked. Health systems can contribute to better health and to economic growth. Better health reduces the burden on health systems while supporting wealth (economic growth). Wealthier populations are healthier and can afford better health systems. The challenge is to create virtuous circles in which each reinforces the other.

The European Observatory is producing the background material for the conference. This includes a set of policy briefs and two books, one on health system performance, edited by Peter Smith and Elias Mossialos, and one on Health Systems, Health and Wealth, edited by Josep Figueras, Nata Menabde and myself. We were in Brussels for a workshop with the authors of our book.
Many of the elements are already there. Marc Suhrcke, Lorenzo Rocco and I have now published extensively on the contribution that good health makes to economic growth through greater productivity and higher labour force participation. Ellen Nolte and I have shown, in our work on avoidable mortality, how health systems contribute substantially to better health (unless, as in the case of the US system, they are highly dysfunctional – see blog entry of 8th January 2008). The challenge is to bring it all together.

There are, however, some gaps. Although collectively those of us in the room have a great deal of direct experience of health policy in Europe, it is really difficult to find anyone who has made a comparative study of how health policies are made (or not made). One of my favourite quotations is Bismarck’s saying that “two things should never be made in public, laws and sausages”. It may be that the experience of observing policy being made is so awful that few people want to watch it twice! Whatever the reason, there is a desperate need for politician scientists with a comparative perspective who would like to study European health policy (aspiring PhD students please get in touch).

The book will not, however, just be a rehash of what is already there. One of the most interesting areas is the relationship between the health system and the macroeconomic environment. We are often told about the need to ensure a profitable pharmaceutical industry because of its contribution to the economy. But given finite resources, is this really the best use of money? On the available evidence, the jury is still out. On the other hand, there is growing evidence of other ways in which health systems contribute to the economy. Peter Smith cited evidence from China where, especially in rural areas, the health system has largely collapsed. As a consequence, families are hoarding money as a form of insurance against ill health. This is sucking huge sums out of the economy, with serious macro-economic consequences - a warning, for those who seek to shrink the scope of publicly funded systems.

2008-03-08T21:00:00.003Z

25th February, Sydney
To Sydney for the annual summit of the Oxford Health Alliance. The Alliance brings together participants from industry, academia, NGOs, and governments to tackle the epidemic of chronic disease. They come from many backgrounds, not just public health but the law, the media, the built environment among others. The message is simple – 3four50:

3 risk factors – smoking, poor diet, lack of physical activity, lead to

4 diseases – heart disease, type 2 diabetes, lung disease, and many cancers, accounting for

50% of deaths in the world.

We were allocated to groups, at tables, and asked to discuss the issues raised in a series of plenary presentations (speeches, panel discussions and video clips). OXHA has always had a strong emphasis on understanding (and changing for the better) the environments that people live in and how they impact on their health. This year we focused on cities where more than half of the world’s population now lives. A key theme, developed in particular by

Tony McMichael, was the issue of sustainability. Too often policies create sick people and sick environments. Greater car use leads to obesity, heart disease and diabetes and pollutes the immediate environment while contributing to global warming.

Of course, even in an audience that is committed to tackling chronic diseases, there is scope for disagreement. One area of contention was about how much evidence is enough. Should we delay calling for action until we have all the evidence? Or should we adopt the precautionary principle, even though we may occasionally be wrong? Those favouring the former highlighted the danger of unintended consequences, while the latter reminded us that that it was many years after the original epidemiological studies before we understood, at the biological level, of how tobacco causes lung cancer but it would have been a disaster if we had waited until we had it before acting to reduce smoking.

My role was two-fold. The first was to speak on a panel on getting evidence into policy, something I have spoken about many times. It was an exceptional panel and I was accompanied by Larry Gostin, Fiona Adshead, and Simon Chapman. You can hear commentary on the session by Richard Smith on the conference web-site (click on the Day 2 pm tag). I was arguing that we need to understand where politicians come from, recognising their personal agendas and trying to find win-win solutions. Yet that does not mean that we should not challenge how the political process works. In recent years there has been an enormous amount of soul searching by researchers about issues such as interpretation of evidence and research fraud. This is entirely justified. Yet the sins of a few researchers pale into insignificance in comparison with much everyday politics.

Unfortunately, few health-related decisions are subject to the scrutiny that we need to understand how they came about. Instead, we need to look for insights from other areas of policy. Our sources are some recent books, such as Anthony Seldon’s biography of Tony Blair. Bob Woodward’s State of Denial, and Carl Unger’s The fall of the house of Bush. These well-referenced books remind us of the importance of personal relationships. Unger shows how many of George W Bush’s policies were driven by his determination to go down in history as a greater president than his father. Woodward describes how the decision to go to war in Iraq took place in a US cabinet where, when Donald Rumsfeld was speaking, Colin Powell ignored him and vice versa, while George W Bush seemed incapable of understanding what either was saying. In the UK, Seldon describes graphically how policy making was dominated by the visceral and mutual hatred of each other by supporters of Tony Blair and Gordon Brown, to the extent that some of their senior advisors would not even sit in the same room. The relation was summed up best by Gordon Brown’s now famous remark to Tony Blair that "There is nothing you could ever say to me that I could ever believe."

It is, however, when we get into the detail of the decision-making process that we can really understand how some politicians understand the concept of evidence. The best described example is, of course, the case for invading Iraq. Here our sources are Woodward and Unger. It is now apparent that the “uranium from Niger” story was manufactured by the Italian security services to ingratiate them with the Americans. The flaws in the story, such as the fact that the French authorities were in complete control of the Niger mining operation and the story required that 500 tons of uranium ore be transferred between ships on the high sea (if not impossible certainly extremely difficult) was conveniently overlooked by the US and UK security services. The mobile chemical weapon factories, later found to be trucks for filling weather balloons with helium, were known to be harmless from the beginning. Interestingly, we now know, from an analysis by Ronan Bennett, that it was not French obstruction that prevented a UN resolution in favour of an invasion of Iraq but rather the role of the Mexican Ambassador to the UN, Adolfo Aguilar Zínser, then on the Security Council, who was the only one not to be taken in by the “intelligence” and to ask serious questions. One was whether there was any correlation between how well hidden weapons were and the speed with which they could be deployed. The admission that this was true suggested some contradiction between the two arguments being made that a) the weapons were so well hidden that they could not be found yet b) they could be made ready within 45 minutes! He was not persuaded, and as a result, neither were the ambassadors of the other undecided countries. At this stage, French support would have been irrelevant. So how was this peer-reviewer rewarded for his diligence in exposing this appalling example of research fraud? The US authorities put pressure on the Mexican government and he was recalled. While of course we need to continue the struggle against fraudulent researchers, we should not let politicians get away with the same crimes.

I did, however, have a second role. OXHA has been at the forefront of exploiting the opportunities offered by the media, thanks to the expertise of an extremely innovative production company, Joose TV. The summits are web cast live and, if you have followed the links above, accompanied by webcast commentaries. In an innovation this year I did a series of interviews with some of the participants: Larry Gostin, Srinath Reddy, Judith Mackay (Bloomberrg Tobacco Initiative), Abdullah Daar (leader of the Grand Challenges project), Claire Lyons (Pepsico Foundation), Viliani Tangi (Health Minister of Tonga), and Christine Hancock (OXHA). You can view them on the 3four50 site.

2008-03-08T17:17:00.008Z

18th February: Izhevsk, Russia
Not an auspicious start. Shortly after we arrived at Moscow airport it was announced that our Izhavia flight was delayed two hours, then another two hours, and then a few more. Izhavia only has a few planes and several of them were out of order. Our Yak 42 that should have left at 7pm finally took off, in heavy snow, at 3 am. The joys of travel…
We have been working with colleagues in Izhevsk, an industrial city near the Urals, for about 5 years. It was there that we undertook the research showing the major role played by surrogate alcohols (aftershaves, fire lighting liquid and the like) in the Russian mortality crisis. In our earlier work we reported that these substances were drunk regularly by about 8% of working age men and their consumption was very strongly associated with premature death, even after taking account of consumption of other forms of alcohol. There are, of course, a few sceptics who are unconvinced of their importance but the evidence is now overwhelming.
The obvious next step is to do something about this problem. In fact, the Russian government did introduce a package of measures in 2006 that reduced supply of these substances, mainly by making it more difficult to get licences to sell them and the monitoring equipment needed to assess tax on them. Since then, life expectancy has increased markedly although it is still too early to say if it is a direct result of the new legislation or not.
Our current research involves following up those men who were the controls in our earlier study, to see how they have fared since we last spoke to them. We are also inviting them to come for health checks, where we can advise them about problems such as high blood pressure – a major problem in Russia. Those who are drinking heavily are being invited to participate in a randomised controlled trial of motivational interviewing, a brief intervention that has been effective in changing behaviour elsewhere.
By coming back to the same place for several years it is possible to see how things are changing. When we first came to Izhevsk we stayed in a trade union hotel for health workers that had changed little since Soviet days. Like other buildings of the period, no two steps on the stairs were the same height, something that we tend to take for granted in the west. Now we stay in a lovely little hotel that could easily have been transported from Vermont, with its beautiful wood panelling, comfortable bedrooms, incredibly helpful staff, and even WiFi. But it is not the only thing that is changing in the city. This time we got stuck in a traffic jam, something that was previously unimaginable. We heard that there are now quite a few Porsche cars in Izhevsk and there are now some very up-market cafes serving food from around the world. Yet many people still live in the wooden barracks built before WW2. This is definitely a society in transition.
On the way back, I took a brief trip into Moscow to catch up with colleagues at the Open Health Institute. With funding from the Bloomberg tobacco initiative, they have created the Russian Antitobacco Advocacy Coalition (Ataca), something I described a few weeks ago on this blog, following my last trip here. Ataca has already made enormous progress. The Russian government is well on the way to ratifying the Framework Convention on Tobacco Control and a much strengthened law on tobacco advertising has just been passed. There is a long way to go but it is great to see so much happening so quickly.

2008-02-17T17:33:00.002Z

Still on Ljubljiana - you can also listen to several of us discussing our book on cancer in Europe in a podcast.

2008-02-10T20:36:00.000Z

Ljubljana - 7th February. Slovenia is the first of the countries that joined the EU in 2004 to hold the rotating Presidency of the EU. Each country uses the Presidency to promote an issue that it sees as important, in the hope that it will be able to influence policy across the EU, either through the legislative process (a long term goal) or by recommendations from the Council of Ministers (easier). The Slovenian government chose cancer as its priority and, as with many of the previous Presidencies, we have been helping to bring together the relevant evidence.
Over the past year, with my colleagues Michel Coleman and Delia Alexe, at LSHTM, and Tit Albreht, from the Institute of Public Health in Ljubljana, we have been editing a book on cancer in Europe. Of course there is an enormous number of books on various aspects of cancer already available but this differs in several ways. First, it covers the entire range of issues related to cancer, from research and drug discovery through screening and cancer plans, to psychological aspects of cancer and palliative care. We were extremely fortunate to get contributions from many of the leading authorities on these topics, including researchers, practitioners, and representatives of patients. Unbelievably, we pulled the whole thing off in just over a year!
The book provided the basis for a major conference on cancer in Europe. We had actually launched the book to the media two days earlier, getting some coverage on the BBC and elsewhere, but what had been overlooked when putting the timetable together was that this coincided with Super Tuesday in the US presidential race. Clearly, we have some way to go to become experts in spin! (sorry, media relations).
The conference was held in the Brdo conference centre, newly built for Slovenia’s presidency. Slovenia is a stunning country and the conference centre is ain a great location, with a backdrop of snow-covered mountains.
It was my task to sum up the meeting. This is always difficult as much of what needs to be said already has been. I did, however, draw out some lessons. We first need to decide, in each country, whether we really do want to do something. You could argue that the existing systems sort of work. Most people get treated, and for some cancers outcomes are not too bad. However, the evidence we had heard over the past two days was that this was not good enough. There are still large variations in incidence and survival from cancer across Europe. In many countries, care is highly fragmented and patients face long delayed in accessing effective treatment. Only a few countries, such as the UK, have really embraced palliative care on any scale, and even there it could be strengthened. So something really must be done. But what?
Whatever is done, there is a need for co-ordination and, ideally, integration. Rifat Atun, from Imperial College, provided an overview of cancer plans in Europe, noting how many countries have yet to put anything in place while others are still quite limited. Inevitably, given that many of the authors of the plans were in the audience, his sparked considerable debate, as people claimed that there was more written between the lines! Yet that surely misses the point. There is little point in having a plan if you need inside information to understand it.
We talk of a war against cancer but we forget that, in any war, if the forces at your disposal are fragmented then at best you lose the war and at worst you shoot yourself. “Friendly fire” is a perennial risk when some of your allies have complex and potent equipment that they don’t fully understand how to use. Yet, in some countries, politicians seem determined to make things worse, fragmenting systems further in their continuing ideological pursuit of “patient choice”.
It is far too easy to overlook the role of the patient. We were extremely fortunate that Lynn Faulds Wood, president of the European Cancer Patients Coalition, and herself a survivor of colo-rectal cancer, agreed both to contribute to our book and speak at the conference. She reminded us that a diagnosis of cancer is the beginning of a long and complex journey. Our role, as researchers and practitioners, is to ensure that the patient has a map, signposts, pathways along which to travel and places to rest.
There is still a great deal to be done in cancer prevention. The past few years have seen enormous progress against tobacco, with increasing numbers of countries banning smoking in public places. Yet many of these bans still have exceptions that will have to be tightened in the future and some countries have yet to do anything. Worryingly, the tobacco companies are working hard to subvert the bans. Their worry is that, given most smokers do want to quit, they will use the opportunities offered by the bans to wean themselves off their addiction to nicotine. The industry needs to find ways of ensuring that people remain addicted. It is doing this in several ways. First, it is campaigning to legalise sales of snus, a form of oral tobacco, across Europe. It is currently sold only in Sweden and Norway. As we show in a recent paper, the industry’s claims for its effectiveness as an aid to quitting are without foundation. Second, it is producing mini-cigarettes, so that smokers can pop out for a few minutes and get a quick nicotine fix without having to smoke a whole cigarette. At the same time, other companies are producing electronic devices that extract the nicotine from tobacco without producing smoke (something the tobacco industry is less keen on because it clearly highlights the role of nicotine as an addictive drug). During the conference a Dutch court ruled that the last of these products, the electronic device, could lawfully be regulated as a drug. This is an extremely important decision as it now opens the way for regulating all nicotine products sold in Europe just like any other pharmaceutical product.
Screening is a key element in secondary prevention. Witold Zatonski, from Warsaw, compared the highly effective, population-based, and carefully managed Finnish cervical cancer screening programme with the much less effective, opportunistic, and essentially unmanaged German model. Finland has brought deaths from cervical cancer down to a very low level while in Germany the death rate remains about twice as high as in Finland. Yet while a typical Finnish woman will have 7 cervical smears in her lifetime, a typical German woman will have 50. Yes, five zero! The explanation? Hardly a surprise – German doctors are paid for each smear taken, while the insurance funds do almost nothing to promote evidence-based care. Clearly, many countries still have a long way to go.
Cancer control is critically dependent on information. Cancer registers have contributed enormously to our knowledge of what works and what doesn’t. Yet too many EU Member States have failed to put in place effective registration systems. What is worse, a few that once had excellent registers are damaging them irreparably> one of the worst examples is Estonia, where the Parliament enacted legislation based on an early version of the EU Directive on Data Protection, before it had incorporated protection for research and health monitoring. With my colleague Mati Rahu, we will be describing the worrying consequences of the Estonian legislation in a paper to be published soon in the International Journal of Epidemiology.
What is most remarkable is that governments that seem keen to use concerns about data protection to impede the war against cancer while they are equally prepared to abandon any pretence at safeguarding privacy in the “war against terror”. Every time we travel to the USA, our governments send over 50 items of information to the US authorities and while this doesn’t include religion it does include whether we have ordered a halal or a kosher meal! Our movements are tracked constantly from our mobile phone records and, in case this is not enough, the UK has more closed circuit televisions than the rest of the EU combined, with one for every 14 citizens at the last count. Many are now linked to facial recognition software. The UK also allows almost all public authorities to bug phones and, as we have seen recently, the police seen to have no reservations about bugging the conversations of members of parliament. In these circumstances, it is difficult to avoid the conclusion that our political leaders might usefully consider their priorities.
The successes so far in the war against cancer have arisen primarily from research. Innovative treatments have made cancer at some sites, such as the testes, as well as some childhood leukaemias, curable in almost all cases. Yet there is still a great deal to be done, especially in areas such as health services research and the psychological aspects of cancer. Too many countries have failed to invest in the research that is needed to determine what models of care are most appropriate for their circumstances, or to put in place the infrastructure that allow as many of their citizens as possible to contribute to new forms of treatment by participating in clinical trials. As Richard Sullivan, from LSE, reminded us, “Research is a necessity, not a luxury”.

2008-02-08T14:18:00.000Z

31st January - Moscow. I was joined by my colleague Anna Gilmore for the first international advisory board meeting of the new Russian Anti-Tobacco Advocacy Campaign. This initiative, funded by the Bloomberg Initiative, brings together a broad ranging coalition of non-governmental organisations to tackle the scourge of smoking related diseases in Russia. It is no secret that the international tobacco companies have invested vast resources in penetrating the Russian market, something that we have documented in papers previously. More recently, in another paper, we showed how the prevalence of smoking among Russian women, once low, has doubled in 15 years. Smoking already exacts an enormous toll of premature death in Russia and the recent trends among women mean that this will increase further in the future.
One of the orginal goals of the coalition was to get Russia to ratify the Framework Convention on Tobacco Control. That, at least, now seems to be happening, with the Cabinet sending the relevant legislation to the State Duma, where the majority leader has indicated that it will be supported (see story in Moscow News). Yet that is only the start.
The challenges are enormous but we were greatly reassured by the results of a new poll, conducted in a representative sample across Russia, showing a very high level of support for effective restrictions on smoking and, in particular, easy access to cheap cigarettes. The overwhelming majority believed that not enough was being done. So, there is much to do but considerable grounds for optimism.

2008-02-08T09:27:00.001Z

8th January 2008 The new year started controversially. With my colleague Ellen Nolte we have been working for some time on the concept of avoidable mortality – identifying deaths that should not occur if health systems are working well. We all know that the US health care system is not working, but how bad is it? In a paper published in Health Affairs, we calculated the death rate from these causes in 19 high income countries, looking at how they had changed between the late 1990s and the early years of the 21st century. Most countries did well, with falls in death rates of about 17%. There was, however, one not entirely unexpected exception – the USA. It had improved hardly at all, going from near the bottom of the list to the very bottom. Many of the reasons are obvious:
a) the lack of universal coverage,. There is now a wealth of evidence that people who are without coverage delay seeking timely care and as a result are sicker when they do make it, often quite inappropriately to Emergency Rooms. There is also a lot of evidence that people with insurance face sever barriers to care because of the many obstacles put in their way by their payers.
b) a fragmented system, with high tech specialist care prioritised over family medicine. Barbara Starfield from Hopkins has been showing the problems this creates for the US for years
c) cost of drugs - the Commonwealth Fund has shown how US citizens are much less likely than those in other countries to fill prescriptions. One factor is the complexity of some pharmaceutical benefit plans such as Medicare. Another is the very much higher cost of drugs in the US than elsewhere because the US government is unwilling to impose price controls like almost everyone else does.
d) the sheer cost of getting care because of the inefficiency of the system. Multiple payers, high profits by payers and providers, the cost of malpractice insurance etc. all combine to make care far more expensive than in Europe, meaning that in a system where there are no guarantees of coverage, people cannot afford care.
Unsurprisingly, our findings revealed markedly differing views (with intensive discussions on the bulletin boards). Many people felt that our findings confirmed their own experiences. Given their comments, Michael Moore could make a sequence of sequels to his film Sicko. However, others totally rejected our views, questioning our motives (more anti-Americanism from those awful Europeans…).
The experience of reading the blogs and online comments was fascinating but extremely depressing, as we read once again of the many stories of individuals who have been unable to get timely and effective care but also we saw the total inability of a significant number of people who are totally unable to see that, for many people, the American dream is really a nightmare.

2008-02-07T23:38:00.000Z

It’s back. After a ridiculously long break I’ve finally managed to regain the enthusiasm to relaunch my blog. It’s not that I haven’t been doing anything the past three months. Quite the contrary, as the brief round up below will show. The real problem is that I’ve been doing too much – with trips every week between October and Christmas, two doctoral students finishing their theses, lots of papers to write, and a ludicrously large number of books to finish. I normally write these entries on planes coming back from wherever I have been – for the past few months that time was used entirely for writing other things. What follows is a brief summary of events since mid-October.

15th October – Copenhagen. We had the second team meeting of our project on preventing obesity in Europe – EURO-PREVOB. This brings together partners from across Europe, including not just EU countries but also Turkey and Bosnia. The goal is to understand better how policies being pursued in Europe either help or hinder the fight against obesity. We all know that the decisions that people make when they choose how much and what they eat and how much they exercise are highly constrained. Governments can make a real difference, through policies in areas such as urban planning, agriculture, education, and transport. The challenge is how to assess these policies as a prelude to changing them. This is not easy. A report that would be published a few days later, by the UK Government’s Foresight Programme sets out the tasks ahead. This contains a diagrammatic representation of the pathways that lead to diet and physical activity. Readers may see some similarity with a plate of spaghetti! It has been criticised, for example by Andrew Jack (the FT journalist) writing in the Lancet as being over complicated. Politicians want simple solutions he writes. Yet the reality is complicated and maybe we need to tell them this before they launch yet another simplistic (and usually unworkable) policy based on an idea they had in the shower this morning.

26th October- Valencia. I was giving a plenary speech at the annual conference of the Association of Schools of Public Health in the European Region (ASPHER). In my speech I was asking the question “What are governments for?”. It is something I have talked about before, and have written about it in a piece for the Australian Medical Journal linked to the forthcoming Oxford Health Alliance meeting in Sydney. Essentially, I look at the differing perspectives on what governments should do. There is a minimalist view, set out in the pages of the Economist and the Wall Street Journal, that they should simply defend the borders of the state (from invasion and migrants) and promote the prosperity of its people (well some of them – I suspect no-one really believes any more in the trickle down effect of wealth distribution). In all other things they argue that the government should “get off the backs of the people”, cutting red tape and minimising legislation. Yet there are always some exceptions. They do want legislation that protects their property, be it intellectual (as in the cases of the entertainment and pharmaceutical industries), capital (as when companies invest in unstable countries abroad), and their safety (calling upon the armed forces to rescue them when they find themselves caught up in a coup). They want the state to cut taxes, especially on the rich, but what taxes are collected they want to see spent on subsidies for the basic research that gives them their intellectual property, or the infrastructure that enables them to operate. This leads to a paradox. Governments do intervene to save lives. After the events of September 11th “the world changed” . I don’t need to remind anyone of how the US government spun into action, leading to outcomes as diverse as the Patriot Act and the invasion of Iraq, a country that had nothing to do with what happened that day in September. Yet the response to another human disaster, Hurricane Katrina, was lamentable and successive governments have failed consistently to do anything about gun control, even though effective action might save the equivalent of 13 September 11th every single year. Our role in public health is to flag up the contradictions and hold politicians to account for their inconsistency.

2nd November – Rotterdam. The first project meeting for our new study, DYNAMO-HIA, to develop a dynamic model that can inform health impact assessment in the EU. Led by Johan Mackenbach, the task is to create a model that will allow us to predict the likely health effects of policies to ban smoking in public places, to increase the cost of alcohol or limit sales outlet, or to change diet. We are only at the beginning but it is already clear that the final result will be of great value to policy makers.

3rd November – Washington. This was my first time at the American Public Health Association. It exemplifies the super-size conference, with several thousand delegates, and is so large that only a few cities can host it. I was speaking at a session entitled “International challenges for Public Health, Policy and Politics”. The choice of sessions was enormous. Unsurprisingly, the overwhelming majority dealt with domestic US issues. The US health system certainly has no shortage of problems. Some of the most interesting ones I got to looked at the prospect for reform of the US health system. There are now several attempts by individual states to introduce universal coverage, typically involving mandates for employers to provide coverage, with other provisions for the self-employed and unemployed. However, when one hears the details, it is clear that they will, at best, be only a very partial solution. These sessions were profoundly depressing because it really does seem that the reform mountain is too steep. There are too many powerful vested interests, both providers and payers, who have an interest in keeping the system the way it is.

14th November – Seoul. After a few days back in London it was off to the Far East. First stop was in Seoul, to speak at a conference celebrating 30 years of the Korean national insurance system. Note to self – next time make sure I check what hotel you are in and buy a quad band phone so that, if I forget, you can phone someone! I was with my fellow research directors from the Observatory, Elias Mossialos, Reinhard Busse, and Richard Saltman. The Korean health insurance system is a real success story. I knew something about it, having previously examined a PhD on the policy processes involved in its creation and expansion, but learned a lot more.

17th November – Taipei. Back to Taipei for my annual visit to the Global Health Leaders Conference. Each year the Taiwanese bring together a fascinating mix of speakers to look at a small number of key issues. I was speaking in the stream on health care quality, presenting the findings of our recent study on quality assurance strategies across the EU. Our book, which contains detailed descriptions of the very mixed activities in all 27 Member States, will be published in mid 2008.

22nd November – Munich. Participating in a meeting of the IMAGE project (Implementation of a European Guideline and Training Standards for Diabetes Prevention). The project pulls together experts on diabetes (and a few others such as me) from across Europe to develop European practice-oriented guidelines for primary prevention of type 2 diabetes, supported by a curriculum for training people who can engage in prevention, as well as development of European standards to monitor the incidence and prevalence of type 2 diabetes and its known risk factors. A great deal has already been done but much more remains to be done.

29th November – Helsinki. The director of the Finnish Public Health Institute (KTL), Pekka Puska, had invited a group of us (3 Finnish academics and 3 foreigners – myself, Michael Marmot, and Daan Kromhout) to conduct an independent evaluation of the Institute’s work in Chronic Disease Prevention and Health Promotion. KTL is a remarkable institution – a superb example of what a national public health institution should be. KTL’s research output is well known to be world class but, as importantly, it maintains an invaluable research infrastructure in Finland, in the form of cohorts, registers, and biobanks. This, along with its extremely capable workforce, has allowed Finland to punch well above its weight in public health research.

6th December – New York. I was in town for a meeting of the Open Society Institute’s Global Health Advisory Committee. This committee brings together senior people with backgrounds in law and health, but all with a commitment t human rights. The debates are always fascinating, often juxtaposing the individual ethical perspective of the lawyers with the collective perspective of the public health professionals. The task is to balance autonomy with the collective good. Many things to discuss but the most interesting, if depressing, was on the situation in Burma, where the authorities had recently suppressed the protest movement led by the monks, with appalling violence. We were privileged to hear first hand from people with first hand knowledge of the situation and to have a preview of a major report on the situation there.

10th December – Brussels. Steering committee of the European Observatory. In between all the travel I have been editing a series of books, one of which, on cancer in Europe, had just gone to production. This was a time to reflect on what we had achieved and plan for the next cycle – hopefully a little quieter than the last one!

18th December – Rome. The final trip of the year. A EU ministerial meeting on Health in All Policies organised by the Italian government. My task was to participate in a discussion on the relationship between health and economic growth, drawing on our earlier work for the European Commission.

So that brings me to the end of 2007 – a completely crazy year. The next entry will be in 2008, and I’m already behind with that, but it will have to wait for my next flight (tomorrow).

2007-10-18T20:06:00.000Z

Helsinki, 11-13th October
… for the Annual Conference of the European Public Health Association. An especially busy few days, with a plenary speech to give, as well as three shorter presentations and a workshop to organise.
The presentations were on topics I have spoken about many times before – the mortality crisis in the former Soviet Union, the health of the Roma people, and the relationship between health and economic development.
The workshop was something I had agreed to organise in my role as a member of WHO’s European Advisory Committee on Health Research. In November 2008 health ministers from around the world will converge on Bamako, in Mali, to discuss the state of health research world wide. The 2008 Global Ministerial Forum on Research for Health is a follow up to the 2004 conference held in Mexico. We wanted to make sure that, in this global discussion, Europe was not overlooked, both in terms of its interests and its potential contribution to the global health research agenda.
To my surprise, even though it meant missing out on lunch, about 50 people turned up and engaged in a lively and highly productive discussion. The key messages, which will appear later in a paper, were as follows.
First, we need to make sure that governments live up to the commitments they made in Mexico. There, they agreed:
* to commit to fund the necessary health research to ensure vibrant health systems and reduce inequity and social injustice,
* to establish and implement national health research policies,
* to promote activities to strengthen national health research systems, including the creation of informed decision makers, priority setting, research management, monitoring performance, adopting standards and regulations for high quality research and its ethical oversight, and ensuring community, nongovernmental organization, and patient participation in research governance, and
* to establish sustainable programmes to support evidence-based public health and health care delivery systems, and evidence-based health related policies.
It will be important to document what Europe’s governments have actually done in the intervening four years. The overwhelming consensus of those present was “not much”. Indeed, there was a widespread feeling that no new developments could be attributed directly to the Mexico meeting.
Second, while accepting the importance of issues such as HIV, tuberculosis, malaria, and tobacco control, it was felt that these will be identified by every region in the world. Were there any specific issues that Europe would like to see in a global health research agenda? Three issues emerged: aging, migration, and alcohol.
Third, what can Europe contribute to the rest of the world? Here we identified expertise on the epidemiology and health system response to complex non-communicable diseases. These are rapidly growing in importance everywhere but often receive far too little attention.
The title I was given for my plenary was “The future of public health in a unified Europe”. I took the liberty of adding a question mark. Europe (or at least some parts of it) is now clearly united. Ten former communist countries, divided from the rest of Europe for 45 years by the Iron Curtain, are now part of the European Union. Yet it takes more to unite a continent than to pull down a wall.
Europe’s population is changing. Most obviously, it is aging and, as a consequence, needs more young people to maintain its workforce. With birth rates at a record low, this can only occur through migration. For the past half century, western Europe has been based on a particular social model, with consensus on the need for the rich to support the poor, the young to support the old, and the well to support the ill. This is very different in the USA. One obvious reason is that rich white people have often been reluctant to pay for poor black people, something that was all too apparent in the images of the aftermath of Hurricane Katrina in New Orleans. As Europe becomes more ethnically diverse, will it place strains on our commitment to solidarity? The newspapers I read on the flight to Helsinki certainly did nothing to allay my concers (see picture).
Then, how will our children respond to the much greater numbers of older people, especially when they realise that we have been borrowing from them for decades, through unfunded pension schemes and ill-thought out public private partnerships, such as the build today, pay (many times over) tomorrow UK Private Finance Initiative. In my talk, which will also be published in due course, I argued that we need to think about these issues now, because the alternative of a fractured, unforgiving society, where everyone must fend for themselves, is not a world that any of us want to live in.

2007-10-18T17:59:00.000Z

Washington, 7-8 October
I was in Washington for the annual meeting of the Institute of Medicine, to which I was (somewhat surprisingly to say the least) elected last year, along with my colleague Anne Mills (as there are only 84 foreign (non-US) members, we felt it was quite a nice surprise – and possibly a unique one- to have two elected from the same institution in a single year).
It was a rather imposing occasion, held at the National Academy of Sciences building just beside the State Department. The theme of the day was “Evidence-based medicine and the changing nature of health care.” It was at the same time interesting and depressing. Interesting, in that there were, as one would expect, some superb presentations. Depressing, in that so little seems to have changed in the US health system – at least in tackling some of the fundamental issues around quality of care - in the past two decades.
For me, the highlight was a paper by Elliott Fisher, from Dartmouth Medical School. You can listen to it online and download the presentation on the IoM site. The key message was that there are still enormous geographical differences in per capita Medicare expenditure. What was most interesting was the comparison between high and low cost areas. Rates of clearly effective interventions (e.g. reperfusion within 12 hours and aspirin on admission with a myocardial infarct or pneumococcal immunisation) and of interventions where patients can decide whether they want treatment, after balancing risks and benefits (e.g. hip replacement and CABG) were essentially the same in both areas. What differed was the process of care, with those in the high cost areas having more inpatient days, more visits to specialists, and more investigations. Importantly, there were few differences in outcome and, in all cases, where they existed, outcomes were better in the low cost areas. What explained the difference? One major factor was the ratio of specialists to primary care providers, a finding that was unsurprising in the light of Barbara Starfield’s excellent work over many years. Over-specialisation has profound implications for the US health system. Any solution will be difficult, but I was taken by Elliott’s observation that if 30% of the medical workforce in the US was to move to Africa it would improve the health of the populations in both continents!
While I was there I was greatly privileged to meet this year’s recipient of the Gates Award for Global Health, Mechai Viravaidya, the founder of the Thai Population and Community Development Association. The PCDA started out as an organisation providing family planning services to rural communities throughout Thailand that were not covered by government programmes. It worked through a network of village-based volunteers, with a strong emphasis on enabling women to take control of their own lives. When Thailand was confronted with the AIDS epidemic, it shifted gear. Mechai and his colleagues were the driving force behind a remarkable HIV prevention programme that is credited with much of the responsibility for an over seven-fold reduction in new infections between 1991 and 2003. Subsequently, it has expanded even further, into primary health care, water supply and sanitation, income-generation, environmental conservation, support for small-scale rural enterprises, and gender equality.
Listening to Mechai’s acceptance speech was one of those amazing occasions that will stay with me for ever. He took us on a remarkable journey, describing how the organisation had responded to emerging challenges. This is someone for whom there are no problems, only solutions. You felt that if anyone could sell snow to Eskimos, he could! He described how he had used humour to break down prejudices about sex, and in particular how he had tackled an unwillingness to use condoms. Indeed, in Thailand he is now often referred to as Mr Condom! He handed out T-shirts showing multiple sexual activities, each stating whether a condom was needed or not. He told us how his team worked to support young girls in rural areas who were being lured into the sex industry. And he told us how they had supported small scale enterprises so that villages could become economically self-sufficient, with benefits for health and education.
This was a truly humbling occasion – a quite remarkable man and a very well deserved recipient of this prestigious award.

2007-09-27T19:45:00.000Z

Six years ago, Elias Mossialos, Rita Baeten and I were asked by the Belgian government to prepare a book on the consequences of European law for health services, as part of their preparations for their EU presidency. At that time many governments remained in a state of denial on this issue. They had signed the Maastricht Treaty, which made clear that health services were a matter for member states and not the EU. Yet they forgot that all those things that a health care system needs to function, from drugs to medical technology to health professionals, were subject to EU law. For example, for over 30 years, health professionals had enjoyed the right to move freely within the EU. Patients could also receive treatment abroad, should they become unexpectedly ill, safe in the knowledge that their health care payer at home would cover the bill. It was also possible for patients to go abroad to get treatment for an existing disease but their insurer had to give permission in advance, or so it was thought. Anyway, these things were at the margin. Very few health professionals did move from one country to another, save for a few traditional flows, many of which long predated the EU, such as Irish doctors moving to England. The number of people falling ill abroad was small and anyway most claimed on their travel insurance. It was hardly surprising that no-one seemed too fussed.
Of course, in 1998 it all changed. Two citizens of Luxembourg travelled abroad, in one case to obtain spectacles from Belgium, in the other to get orthodontic treatment for his daughter in Germany. When they returned, they presented their bills to their insurer, who refused to pay. A long time later, it was forced to by the European Court of Justice.
These rulings sent shockwaves through the corridors of health ministries. Spectacles and dental treatment were not a problem, but where was this leading to? Yet in many capitals, the shockwaves rapidly subsided. Ministries reassured themselves that the Court’s rulings did not apply to national health services, or to hospitals, or indeed beyond the precise circumstances of the cases. In contrast, a growing number of people, often with remarkably unusual conditions, spread out across Europe seeking to test the limits of the new legal situation. Progressively, the right to obtain care abroad was expanded, and it became clear that many of the safeguards that governments thought they had in place were not as safe as they thought.
At the same time, a few governments were waking up to the implications of what had, until then, been a rather obscure legal instrument, the Working Time Directive. This limited the hours that people could work each week, but it was widely believed that it did not apply to medical staff who were on call but not actually working. Once again, they were wrong. The consequences are profound and even now poorly understood by many people responsible for the delivery of health care. Small hospitals, with a few medical staff on a rotation, became unviable. The established system of medical training needed radical revision.
Back then, we actually exceeded our brief for the Belgian government, producing one authored and one edited book. We now realise just how important the two books were. While I am still not convinced that many people, except for the small group of Euro-policy wonks, actually read them from cover to cover, the fact that it was possible to write two entire books on a subject that many people had previously regarded as a non-issue did seem to make an impression.
Yet six years is a long time (in fact the books appeared in 2002) and a trickle of health-related cases before the European Court has turned into, if not a torrent, at least a respectable stream. Consequently, again with support from the Belgian government, a new book is on the way. This time it is edited by Elias and Rita, along with Tamara Hervey and Govin Permanend. My role is limited to co-authoring two chapters (although today I seem to have acquired a third!).
Today we (the editors, authors, and a few policy experts whose job is to make sure we are grounded in reality) were in Brussels to discuss our draft chapters. Readers will be familiar with the concept of authors’ workshops, which we use with all the Euroepan Observatory books.
So what has changed in six years? The law of course. The European Court has ruled on a substantial number of cases hat have variously clarified or obscured the situation. However, it is beyond doubt that the legal situation is now very different.
Awareness of its importance has also changed. Now, no-one who is at all informed maintains that EU law is irrelevant to health care (but see later). In the intervening years, governments have established a high level reflection group to explore the nature of its implications. An attempt to treat health care like any other service, in a general directive on services, was roundly defeated. Yet while there is now an acceptance that health care is special, it has been extremely difficult to square the circle of delivering socially inclusive, evidence-based care, in an internal market.
Another change is the number of academics working in this field. Six years ago, there were only a handful. Now there are well-established teams of legal researchers specialising in EU health law in a number of universities, mostly in Belgium and The Netherlands, but also in, for example, Sheffield, directed by Tamara Hervey.
Yet some thinks have not changed. Surprisingly frequently, questions were raised about the conformity with EU law of developments in one country, England. There, a bewildering array of quasi-market mechanisms have been established, often shrouded in substantial legal uncertainty. From the time they were introduced, ministers have maintained that contracts between NHS purchasers and providers are contracts, but not ones that are legally enforceable. Outside the parallel universe in which many of their advisors inhabit, this is not a concept that is widely recognised. Furthermore, as new structures, such as Foundation Trusts, are created, the legal situation becomes ever less clear. Now this situation offers endless scope for debate on issues such as what is an undertaking or what is a service of general interest. And of course, nothing is more engaging for lawyers than endless debate (academic lawyers excepted of course!). Consequently, one question that came up several times was why none of the private health care providers active in England had challenged decisions under EU law. The only plausible solution was that, despite all its flaws, the pickings were so rich that no-one wanted to rock the boat. Whether this will continue if the flow of money slows remains to be seen.

2007-09-23T18:57:00.000Z

In the nineteenth century the world was transformed by the industrial revolution. In the twentieth century it was the turn of the information revolution. The scale and pace of change is truly amazing. In the 1940s, Thomas Watson, the head of IBM, is reported to have forecast that the total world demand for computers would be at most five machines! Today, the vast majority of families in high income countries are connected to the internet.
These technological advances are being used for many purposes. Some are clearly beneficial. It is a great advantage to be able to check one’s bank balance or book an airline ticket whenever you want to. Yet some are more problematic. This week it was revealed that the US Department of Homeland Security has been accumulating comprehensive details of all travel undertaken by American citizens (and presumably others as well). The European Commission is planning a similar system. The United Kingdom, a country where urban areas are already almost entirely covered by surveillance cameras, is proposing to introduce a biometric identity card that will track every encounter that an individual has with an official agency, in the same way that loyalty cards allow supermarkets to monitor individual’s shopping habits. Data protection laws seem simply to be ignored.
Yet, while every move that we make in high income countries is being recorded by someone, in poor countries people are still born, live their often short lives, and die without anyone ever recording anything about them. Worldwide, only about 70 countries have any reasonable data on deaths of its adult citizens.

This will probably come as a surprise to many people, familiar with graphs and tables that purport to show life expectancy in countries such as Liberia or Sierra Leone. In fact, these data are simply guesses, albeit guesses that are informed by some scraps of evidence (or what some people would call “estimates”).
What has happened is that standard life tables have been created, showing what is thought to be the probability of death at different ages in countries exhibiting certain characteristics. Then, data on deaths in infancy and childhood are identified, typically from surveys, and are fed into the life tables to give an overall life expectancy. Obviously, this is critically dependent on us having a good understanding of the relationship between deaths in childhood and deaths in adulthood, which we now realise we don’t have. In other words, we really have no idea about what is happening to adult mortality in much of the world.
This week I was invited to Seattle to join a small group of people to discuss what might be done. The meeting was organised by Chris Murray, who has recently moved from Harvard to the University of Washington, where he has established the Institute for Health Metrics and Evaluation. We had convened within the framework of Grand Challenge 13, funded by the Bill and Melinda Gates Foundation. The challenge is to devise new ways of accurately measuring population health.
We spent the first day looking at the problem of simply capturing data on how many people have died. As Alan Lopez reminded us at the end of our discussions, the gaps in our knowledge are a “scandal of ignorance”. There is little doubt about where we need to be. All countries should have effective systems of vital registration. Yet for many this is still at best a distant prospect, especially those where establishing even the most basic governance functions seems as far away as ever. There are, however, possible intermediate steps, such as sample surveillance, where data are collected from a sample of locations, in the hope that they will be reasonably representative of the overall population. This is what is done in India and China. Then there are the indirect methods, based on data from surveys. Yet none of these are perfect and we still face many unanswered questions about the validity of the methods we are using. A problem in many parts of the world is that many people do not know what age they are. This can lead to what is called heaping, where reported ages are concentrated in numbers ending in 5 or 10. However I was fascinated to learn, although I suppose I should have realised, that in societies where astrological correlates of birth dates are important, people are much better informed. Ken Hill told me that the distribution of ages in the 1953 Chinese census is perfect.
Day two looked at the even more difficult problem of collecting data on cause of death. Here, a degree of realism is needed in what can be achieved. Even in countries with the best possible systems, there will always be considerable uncertainty about the main cause of death in older people who have multiple disorders. Yet it is clear that even here we can do better, in particular by understanding the principles that are used in different countries in assigning a single cause of death where several co-exist.
Where vital registration systems don’t exist, an alternative is to use a “verbal autopsy”, where surviving relatives are asked a series of structured questions about the deceased. Yet here too there are many methodological issues unresolved about how best to allocate a cause of death. Computerised systems are consistent but not always correct. Physicians inspecting the data are less consistent, but may be more often correct. One interesting possibility proposed by Chris Murray was the use of a computerised model that would take the reported signs and symptoms and, based on a validated data set from the same (or a similar) location, allocate a probability to different causes of death. If combined with clinical judgement (i.e. the physician is presented with the probabilities of different causes and, using any additional information available, decides on the most likely cause) this could be a valuable way forward. Clearly the increasing availability of hand held computers offers considerable potential. This would also overcome the problem seen in many existing sentinel surveillance sites of piles of paper forms lying uncoded long after the events they describe took place.
There are other opportunities too. It was pointed out that we are coming up to the next round of censuses in many countries, typically conducted every ten years. It would be possible to include a question asking whether anyone had died in a household in the past year or so and, where this had happened, to follow it up with survey teams applying a shortened verbal autopsy instrument.
Of course, none of this will happen unless the world community begins to take adult mortality seriously, something that it has so far singularly failed to do. What efforts exist have focused on child and maternal mortality. It was even suggested that these efforts have diverted attention away from adult mortality. The problem, as is so often the case, is that we are in a vicious cycle. The priority for international development is the need to reduce child and maternal mortality rates, because these are often the only figures we have on population health in many parts of the world. Yet because these are the priority, no-one (except the Gates Foundation) is willing to invest in the collection of data on anything else.
But maybe there are solutions to the problem of resources. As I came back through Heathrow the iris scanning machine, designed to let frequent travellers pass through immigration a little quicker, was yet again out of order (as it had been last week too). As I noted above, the British government is about to spend billions of pounds (the exact amounts are shrouded in spin and obfuscation, as usual) on a system of biometric identity cards that is doomed to failure (the full account of the failings are in an excellent account by a team at the London School of Economics). If only a fraction of the resources being devoted by the British and American governments could be diverted from the almost entirely pointless and futile attempts to track every move made by their citizens, then maybe we might at least be able to move away from a position where our fellow human beings can live and die without anyone ever recording it. What is more, the much simpler technology required is at least likely to work.

2007-09-23T16:04:00.001Z

Over the past few years I’ve been working with Marc Suhrcke, from the WHO office in Venice and Lorenzo Rocco from the University of Padua to understand better the relationship between health and wealth. The Commission on Macroeconomics and Health showed how important health was for economic development in poor countries. We have subsequently shown conclusively how this is also true elsewhere. Specifically, in the European Union, South East Europe, and Eastern Europe and Central Asia, those in poor health are less likely to be working, and when they do they work shorter hours and they are less productive.
There are, however, many middle income countries where, although we may reasonably assume that this is so, we have no direct evidence. And we also know that policy-makers like to see local evidence before acting.
For this reason we were asked by colleagues at the World Bank whether we could apply our work to the countries of the Middle East and North Africa. This is a region where, so far, there has been remarkably little health research. The opportunity for us to present some preliminary work was at a meeting of the newly created Middle East and North Africa Health Policy Forum, a grouping of academics and policy makers from across the region. I was joined by my colleague Josep Figueras, who was talking about our experience in the European Observatory in translating evidence into policy.
The meeting was held in Cairo on 8-10th September so it was logical that we should start by looking at some Egyptian data. In fact, there are quite a few household surveys from countries in this region that are suitable for the sorts of analyses we have been doing. There is clearly enormous scope to make use of them.
The first task was to get some basic understanding of the health situation in the region, and in Egypt in particular, given that this is not somewhere I am especially familiar with. The available evidence reveals that Egypt has actually been very successful in improving health. Under-five-mortality has fallen by more than half in two decades and data from the most recent Demographic and Health Survey suggest it has fallen to 46 per 1,000. Male life expectancy has increased from 52.7 years in 1976 to 67.9 in 2003, while the corresponding figures for females are from 57.7 to 72.3. Looking to the future, Egypt has much in its favour. A falling birth rate means that there will be a substantially greater share of the population in the workforce. Fewer children also means that there will be more resources available for their education, a clear priority for future investment. Yet there are challenges. Using a model we have applied elsewhere we were able to show that if adult mortality could be reduced by 3% per year then, by 2030, Egypt’s GDP would be about $8,500 per capita, compared to $6,900 if it stayed as it is now, all else being equal. Unfortunately, even keeping it as it is now may be difficult. We looked at data on body mass among young children. Although there is still some evidence of malnutrition, what is really striking is the very high level of obesity, with almost 14% of under threes overweight in 2000, compared to less than 3% in many otherwise comparable countries.
The health situation in this region is clearly very different from that in eastern Europe, where I do most of my work. However the problems are equally challenging.

2007-09-22T14:04:00.001Z

This blog has been rather neglected over the summer. Colleagues sometimes ask me how I find the time to write it. Sometimes I wonder myself! Usually it is on planes back from wherever I’ve been but the past six weeks have been so hectic trying to clear the backlog of unfinished papers and books. I even discovered a new condition – shoulder injury from over use of the mouse pad on a laptop!
I did, however, take one short break from writing in August to teach on our new summer school. For many years the Observatory ran a very successful summer school in Dubrovnik, Croatia. It was, however, a huge amount of work to organise it and as the tourists returned to Croatia after stability returned to the region, it became impossibly difficult to sort out the flights and accommodation.
There was, however, an enormous demand to recommence the summer school and this year we decided to do so, moving across the Adriatic to Venice. Our colleagues in the Veneto region had identified a superb study centre, San Servolo, a short journey on the water bus from Saint Marc’s Square.
About 40 participants from across Europe, and even a few from beyond, came together to examine one of the most pressing issues facing health systems today - the people who work in them. The problem is simple. We never seem to have the right people in the right place at the right time. The solutions are much more elusive.
The first difficulty is knowing who is in the health workforce. Statistics are plagued by problems of comparability, especially where health systems are fragmented. There are always interface problems, especially where health and social care intersect. And the words don’t even mean the same things. Unfortunately, a nurse trained in one country may have a very different set of skills from one trained in another.
A second is how to keep pace with the changing nature of health care. Patterns of disease are changing. Complex chronic diseases are now by far the leading contributors to the overall burden of disease in industrialised countries. We need people with new skills and perspectives, who can work in multi-disciplinary teams and who can work in partnership with patients. In some countries we need to accept that doctors are not always the best people to manage chronic diseases. There is now compelling evidence that nurse-run clinics for conditions such as diabetes and asthma get better results.
A third is the increased movement of people across the globe. This is an especially acute problem in the European Union’s new member states, where wages are much lower than in the west.
There are no easy solutions. However, it is good to be able to take some time out, in a place that is so conducive to thought and contemplation, to learn from each other.
The next task is to decide what the subject will be next year!

2007-07-08T19:06:00.000Z

It is estimated that 230 million people worldwide have diabetes. Some cope well with this disease, managing to live a relatively normal life. Many don’t. In large parts of the world the onset of insulin dependent diabetes is a death sentence. John Yudkin and David Beran, at the International Insulin Foundation, have done a tremendous job in raising awareness of the many people in developing countries for whom a diagnosis of insulin-dependent is a sentence of death. For these people, mostly young children, the situation is unchanged from what it was before Banting, Best and their colleagues discovered insulin in 1921. Steadily, over a period of about 18 months, they waste away and eventually die. Yet even in wealthy countries many people with diabetes face almost insurmountable problems. Death rates from diabetes among young people in the USA, with its fragmented health system and its failure to provide more than the most basic care to 40 million people, are many times higher than in the much better integrated European countries. And things do not always get better. We have previously shown how death rates from diabetes have increased in most former Soviet countries (with detailed studies in Ukraine and Kyrgyzstan) as once functioning (albeit at a basic level) systems fell apart.
For these reasons we have increasingly seen diabetes as a lens through which we can observe the functioning of health systems. In essence, if health systems are working well, then people with diabetes survive; if the systems fail, then they die.
This was the subject of a talk I gave in Oxford on the 28th June. I was speaking at one of the now famous seminars organised annually at Exeter College by David Matthews. I began by looking at the enormous variations in outcomes of diabetes among industrialised countries, drawing on our earlier work relating mortality to the incidence of diabetes, before describing the reality for people with diabetes a variety of dysfunctional health systems in the former Soviet Union. The problem we face is that you need to get a lot of things right if people with diabetes are to receive effective care. You need trained staff who actually understand diabetes, reliable supplies of drugs (and not only insulin) as well as all the equipment to administer insulin and to monitor control, systems of referral when complications arise, and social support so that people with diabetes are not thrown on the scrap heap. All of this is discussed in detail in a new analysis of the management of chronic diseases led by Soji Adeyi at the World Bank, to which we were privileged to contribute.
However, as I mentioned above, things are not so good even where resources are plentiful. As the picture shows, death rates vary enormously within the United States. Unsurprisingly, the situation is much worse for African Americans, although the racial gap in outcomes varies considerably among states, with some surprising results. It is relatively narrow in states such as Maryland and Mississippi but wide in Tennessee and Louisiana.
Of course, I was talking to an audience of experts in diabetes. Do these findings have a wider relevance? Yes, they do. I also showed the close correlation, among US states, between deaths from diabetes and those from overall deaths that could be avoided if there was timely and effective care, a concept that my colleague Ellen Nolte and I have been revisiting over recent years (see our book for more details). However, looking beyond this, it must surely now be apparent to those trying to scale up treatment of HIV/AIDS that they face exactly the same challenges as those trying to put in place effective care for diabetes. The two disorders are both complex chronic disorders. They both need certain basic drugs – insulin/ anti-retrovirals. But they both need a lot more, in terms of an integrated system to deliver care. Furthermore, both diseases exemplify the way in which the traditional divide between communicable and non-communicable diseases is breaking down. People with diabetes develop long term infectious complications, such as a higher risk of tuberculosis or infected foot ulcers. People with AIDS are increasingly developing vascular diseases because of the atherogenic effects of anti-retrovirals. So yes, diabetes is a lens through which we can view, and understand, the health system.
The good thing about speaking at seminars such as this is the opportunity it gives to hear other people. The other speakers were, without exception, superb and I now know a lot more about the mode of action, and thus the effects, both positive and negative, of the new oral hypoglycaemic drugs. I also know probably more than I need to about erectile dysfunction, thanks to some graphic slides by Jonathan Levy! However two rather different presentations stood out from the rest. The first was by Helen Lloyd, a former BBC producer and now oral historian. In a Wellcome Trust funded project with David Matthews, she had interviewed 50 people diagnosed with diabetes between 1927 and 1997. Their stories can be read, and heard in their own words, on a superb project web site. Those diagnosed before the creation of the NHS faced incredible obstacles, with their families scraping together the money for insulin. So many of the stories from the 1920s-1940s echoed those I had heard in the former Soviet Union. Several people described how, as children, they had been excluded from education. Even in the 1980s, people in the UK with diabetes were being discriminated against, excluded from many jobs that they could perfectly easily have done, recalling contemporary practice in the former Soviet Union where children with diabetes are educated separately and, as soon as they reach adulthood, are labelled as disabled and excluded from the workforce. Anyone interested in the human aspects of health systems really should visit this web site. The project is now in a second phase, interviewing those who cared for people with diabetes. We had a preview; the interview that struck me most was with Harry Keen, who described the realisation that insulin was not a panacea and long term treatment was associated with increased risks of cardiovascular and other diseases, an observation with much contemporary relevance given my earlier comments about the cardiovascular consequences of AIDS.
The other noteworthy presentation was by Sir Michael Hirst, former Chair of Diabetes UK and now vice-president of the International Diabetes Foundation. He described the struggle to get a United Nations Declaration on diabetes. Now of course a declaration about a disease is just that, no more and no less. Yet for those struggling to tackle this disease, these things are important and highly symbolic, not least because of the way in which diabetes and many other chronic diseases are often effectively ignored.
It is a story that I hope he will publish sometime. The heroes are the governments of Portugal and Ukraine. The villain was the British government. It is a story of intrigue, duplicity, and deceit. Fortunately, following the recent cabinet reshuffle, some of those involved are now on the back benches. However, it did have a happy ending as the other EU governments, mystified by the hostile position of the British, one by one moved from not understanding what it was all about to active support for the Declaration. This is a story that should be heard by anyone trying to get health on the international agenda in the face of apathy or worse (especially when it is from one’s own government) outright hostility.

2007-06-23T14:28:00.000Z

The European Summit has reached a conclusion. We will have a Treaty, but not a Constitution. The European Union has become a “legal person”, even if it is still constrained by the governments of its member states. It will have a president who remains in post for two and a half years, instead of rotating every six months. And ten years from now it will have a sensible voting system for the Council of Ministers.
Yet there are many measures that have fallen by the wayside. Some are purely symbolic, such as the official recognition of the EU flag and anthem. Others are more serious, such as the watering down of the French proposal to strengthen the social dimension of the EU.
This was, as no-one can fail to notice, Tony Blair’s final European Summit. He came to power promising to place Britain at the heart of Europe. Has he succeeded? You can judge from my open letter to him:

Dear Mr Blair,
Now that you are moving on to the American lecture circuit, where your talents will doubtless be better appreciated, I want to thank you for the way you have taken forward our relationship with our European neighbours. Thank you for:

Your opt out from the Schengen agreement, so that I can have all that extra time to think great thoughts as I queue to get through passport controls. Oh, and also because this has ensured continuing employment for those British immigration officers working at the Eurostar terminals in Brussels and Paris – you know, the ones who check your passport five metres after they have already been checked by the French and Belgian officials.
Your opt out from the single currency, so that I can continue to contribute large sums of money to the terribly hard up banks each time I change money.
Your opt out from European Union provisions on criminal justice, even though you agreed an extradition treaty with the USA that allows British citizens to be extradited without the US authorities even presenting a prima facie case against them (of course the reverse does not apply – it would be inconceivable for the USA to extradite one of their citizens here, and certainly not those who have unlawfully killed British soldiers in Iraq with so-called “friendly fire”)
Your refusal to sign up to the Fundamental Charter of Rights, lest we should get ideas above our station and ask for basic rights such as freedom of speech (you never know, we may want to protest about something in Parliament Square without fear of arrest under your terrorism legislation).
Your continued opposition to anything that would strengthen the European Union in the area of foreign affairs, lest it should ever challenge our British status as an arm of American foreign policy.

I hate to think where we would now be if you had decided that you really didn’t want to be part of Europe!