Episode 62 – 3rd December 2010

[Direct MP3 Link] [Add to iTunes]

Enjoy the show? Please consider donating to help us keep the show going!

New Lifeforms (3:16) by Liz Lutgendorff
NICE Changes Are Good (8:14) by Simon Howard
Tuition Fees Are Good (16:32) by Fred Tilley
Aussie Monarchy (22:28) by Andrew Gould
Lying About Santa (28:02) by Rob Weeks
Strictly Come Bigoted (33:14) by Jennie Rigg

Would you lie to your kids about Santa Claus? Tell us in the comments!

13 thoughts on “Episode 62 – 3rd December 2010

  1. Simon Howard’s criticism of NICE seems to be “it isn’t perfect, so lets get rid of it”. There is little consideration of how unpleasant (not NICE?) the replacement is. You said it right; a nasty old postcode lottery.

    Perfectly good for those who live in a well off (and therefore generally healthy) areas will be fine under this system, but those who live in poor areas, where people are less healthy, you may well be out of luck.

    Especially if these areas have even worsening health because of the regulatory capture achieved by the fast-food industry that you were cheerleading the other week. The notion of food choices is largely the preserve of middle-class and higher people, and completely the preserve of adults.

    What you seem to be advocating, in both cases, is selfishness rather than individualism. You, I am guessing, have won the postcode lottery already, and thus you see nothing at all wrong with it.

  2. But the ‘Postcode Lottery’ is something of a myth.

    We already have a ‘Postcode Lottery’ in many senses. If you happen to live near a Centre of Excellence in coronary care and have a heart attack, you’ll get primary PCI, if not, you’ll get thrombolysis. Primary PCI is altogether better than thrombolysis.

    If you happen to live near a Centre of Excellence for Stroke, your outcome following a Stroke will almost certainly be much better than if you go to a DGH.

    Abolition of the postcode lottery doesn’t work, as we found back in 1998, when the aim was equality in health services. Within a limited budget, that means worsening the care at the best centres, not funding innovation, and ending up with a stagnant system.

    We need innovation for services to develop, and innovative services must be located somewhere, so there will always be a postcode lottery. The inverse care law means that the better centres will be where they’re least needed, unless we actively intervene to change that – and I have no objection to intervening to make that so, but that still doesn’t stop a Postcode Lottery existing.

    With regard to drugs, it’s actually a significant oversimplification to say that NICE decides on availability of drugs on the NHS – they merely decide what PCTs are required by law to fund. Anything above that is down to the individual PCT to decide upon. So actually, removing NICE’s power to order PCTs to make funds available for the supply of given drugs doesn’t change the situation wholesale, just gives PCTs (or GP Consortia in the new world) more options to respond to local need. Why have to set money aside for stroke thrombolysis if there is no unit in the region performing it? Why not free that money up for something else?

    NICE currently lays down clinical guidelines on best practice, and will continue to do so. Any commissioner ignoring best practice guidance will leave themselves open to litigation, and so that’s simply not likely to happen. The requirement to provide a basic service remains untouched. And the best bits of NICE remain – I’m fairly clearly not of the opinion that “it isn’t perfect, so lets get rid of it”, more “it isn’t perfect, let’s improve it”.

    As for the discussion on food choices, I would like to clarify that I wasn’t championing the fast food industry, merely pointing out that they have something valuable to add to the policy discussion, just as energy companies have plenty to add to the discussion on energy usage reduction, and airlines have to add to the discussion on climate change. We shouldn’t necessarily follow their lead, but to ignore them in policy-making is a ludicrous suggestion.

    And as for whether I’ve won the postcode lottery – I’m a Public Health doctor in Middlesbrough, one of the least healthy and most deprived cities in the country… I’ll let you decide!

  3. I tried to use the Santa Claus thing as an exercise in critical thinking for my (then) 8 year old daughter: discussing the logistics of the delivery-to-whole-world-and-getting-down-a-chimney thing and what might be a more likely explanation. I think she drew the right conclusion, but now appears to be playing her own variation of Pascal’s Wager: If she says she believes she will get the presents and, therefore, has nothing to lose from playing along with the grown-ups. If she says she doesn’t might there be an outside chance that the presents will not appear?

  4. Simon,

    You claim the postcode lottery for healthcare is a myth, then confirm it exists, and then defend entrenching it and making it worse.

    Also, those food companies have nothing to add except ‘eat more of our crappy food’, because if they recommended anything else their shareholders would be deeply unhappy with them.

    In both cases you seem to be ignoring the negative consequences.

  5. Hey Pete,

    You’re quite right. The first sentence should have read ‘But abolition of the ‘Postcode Lottery’ is something of a myth.”. Hopefully, that makes more sense!

    Let me give you some more examples as to why I think avoidance of the “Postcode Lottery” is not the correct thing to drive towards.

    I’ve been working recently on increasing the uptake of screening in Middlesbrough. To avoid the “Postcode Lottery” in a national screening programme, everyone is sent an identical invitation and associated information, whether you live in Tunbridge Wells or central Middlesbrough.

    People in Middlesbrough do not understand the information they are being sent: It’s too lengthy and too complex, since ever more detail has been included to set at rest the minds of the middle-classes. Yet the cause of Nationalisation of the Health Service means that it can’t be changed. A simplified letter for a less well educated population seems a great idea to me, but it would introduce a “Postcode Lottery” to the screening programmes, which are resolutely “National”. So I can’t do it. That is patently insane.

    Recently, the National Immunisation Programme had vaccinations at 12 and 13 months. That’s now changed, so that both sets of immunisations can be given together; but before it was changed, there was a great desire locally to modify the schedule and give these vaccinations together. We knew that the Middlesbrough popoulation are relatively less likely to attend vaccination appointments than the population of the rest of the country, so why not combine two visits into one? Yet it’s wasn’t possible, because that would de-natioanlise the immunisation programme. The needs of the local population were being overlooked because of a desire to avoid a “Postcode Lottery”.

    Another example: A local service for diabetics offers one-stop-shop appointments for retinal screening, foot checks, blood checks, and all the rest. That is now under review because it is not in line with national policy. We’re offering our local population something better than the service provided elsewhere, and something much more appropriate to a population which does not turn up for appointments. Apparently, that’s not on, because it creates a “Postcode Lottery”. Disaggregation of the appointments is currently being seriously considered so that we are brought into line with national practice. Again, local needs overlooked through a desire not to introduce a “Postcode Lottery”.

    There are countless examples like this. As someone with responsibility for the needs of a population, it seems absurd that services cannot be customised to local need, all because of a misguided desire to offer National services. Yet one size very clearly does not fit all.

    If being able to communicate with and engage my population means entrenching and worsening the “Postcode Lottery”, then yes – I’m all for it.

    And the enormously frustrating thing is that we have a “Postcode Lottery” in some areas, as discussed above. But trying to introduce new regional variation to services is damn near impossible.

    Clearly, quite clearly, there are negative aspects to this approach. It’s very politically easy to promise the same services to all people. It’s sometimes hard to defend why things are done in different ways in different places, and people can sometimes feel hard done by. Denying one person a drug or offering them a different service based on where they live is not easy. But that doesn’t mean it’s necessarily wrong.

    As for the issue with the junk food companies, you suggest that their shareholders will not allow them to push any line other than increased consumption of ‘bad food’.

    Yet you have to remember that they are being asked to advise on a process that could ultimately result in tighter regulation of them. In that situation, with their backs against the wall, they may have something to contribute. Alternatively, they may not.

    But if they do only wheel out lines in support of themselves, there is absolutely no compulsion for policymakers to roll over and agree – and nor would I expect them to do so. I certainly wouldn’t.

    To me, it seems silly not to talk to them because we think we already know what they will say. What’s wrong with asking them the question? If nothing else, a failure to meaningfully contribute to policy-making in this area will make it much easier to introduce punitive legislation.

  6. The idea of ‘different but equal’ treatment for different parts of the population, frankly, does not have a good history. The gutting of NICE, and the radical localization of the NHS in general, seems to be a deliberate attempt to create a two-tier system, and I don’t think that this can be justified by comparatively minor regional problems. Surely, being able to write letters aimed at the reading level of the local population doesn’t require the tearing down of the national structure from PCTs up?

    Understand this is stealth privatization. The proposed set up means the NHS can be sold off bit-by-bit, without a sufficient shock to cause mass opposition. Do you understand this, but not oppose it?

    The reason I bought your previous report into this is because you in both cases you seem to be substantially downplaying the corrosive effect that for-profit interests can bring into essential government services. As its quite obvious what McDonald’s position will be on junk food, bringing them into the discussion of the regulation of their own industry is corruption. Turning PCTs into something like GP-run businesses is little better.

    Are you trying to slip a bit of libertarianism into the Pod Delusion?

  7. @Toby

    Hi Tony – sounds like she’s learning nicely about something else then 😀 Something to reflect on later I suppose. I know for a while as a child I carried on ‘pretending’ to my parents that I believed, mainly because I got to go and “see” Father Christmas and get a present…. another lesson in ulterior motives…..

    The more I think about it, the more lessons I see everywhere….


  8. I completely agree that these problems don’t require wholesale reorganisation of the NHS, and I’m not altogether supportive of the Government’s proposals in “Liberating the NHS”. I think the disbandment of PCTs in particular has been poorly thought through, and I think there are better ways of involving GPs than putting GP Consortia essentially in charge of the NHS – especially given the conflicting financial priorities that introduces, as you point out. The Outcomes Framework (that I’ve been writing about all afternoon!) seems fundamentally flawed, too.

    But I do support a more local approach to healthcare, and I make no bones about that. I think different approaches are needed in different areas. It’s faintly ludicrous to say that the healthcare needs of the population in rural Yorkshire are the same as those living in inner London, when their health needs are so patently different. Standardising approaches to care across those populations is madness.

    Yet, sadly, I don’t think more localism will ever really come to fruition – it’s not politically convenient.

    The seed of the idea is great – allow regional variations, and compare cross-regionally through patient outcomes rather than processes. But I don’t think the Government has the balls to wear it. My hunch is that media stories of different treatments for different populations will not be supported, even if the regions have comparable outcomes.

    I don’t agree that NICE is being ‘gutted’ – I think it’s being refocused, and not in a bad way. Removing cost-effectiveness analysis removes a whole layer of politics, and should lead to guidance which is more clearly focussed on illustrating the clinically best pathways for patients, rather than a compromised version.

    As for the food thing: I don’t agree at all that talking to interested commercial parties about policy is corrupt. In fact, I couldn’t disagree more. I couldn’t conceive of coming up with a carbon reduction policy without talking to the manufacturers of planes, trains, and automobiles; I wouldn’t dream up policy governing TV advertising without talking to TV stations, programme makers, and advertisers; and it wouldn’t occur to me to try and write policy on healthy living without talking to food and drink manufacturers and retailers. But as you say, that may well be reflective of a difference in our politics!

    I don’t support bit-by-bit privatisation of the NHS, but it has been going on for years. Sexual Health services in my area are provided by a private company, several lab based services across the country are provided by private companies, and there are many more examples. I don’t support expansion of the involvement of the private sector, as I think it promotes short-termism – another reason why this reorganisation of the NHS (which suggests more private sector involvement) is flawed.

    In this report and the last, I don’t intend to come across as supportive of the Policy as a whole. I am supportive of involving stakeholders in decision-making, and of making health services more locally focused – and one of the ways into that is through re-focusing NICE, and allowing more local interpretation of it’s guidance.

  9. Despite our differences in both approach and conclusions (I wrote an earlier report on the NICE changes that disagreed with Simon) he has a very valid point about regional variations in interventions> in general. Public health programs, including “preventative” healthcare, screening and patient safety do appear to work best when tailored and targetted. I use the word “appear” because he is right too that the evidence base for non-drug interventions is quite hard to establish empirically.

    This doesn’t decrease the value of evidence – quite the contrary – and I get very annoyed by those who point to the lack of evidence in some areas of healthcare as an argument against evidence-basebd policy. The fact that tradition and annecdotal support is the basis for some healthare is not an arguent that this is a good thing to be extended, and I am disappointed by the sloppy argument-by-implication that Simon included in his report.

    I also think that as a GP he should be well aware that the people making financial decisions in “GP consortia” will not be practicing GPs. The government argument that they are transferring control from “bureacracy” to “people in touch with local communities” is cynical double-speak at best. The fact that the new system will only work properly if local people are properly evaluating evidence in a local context is not an argument that this will actually happen. Until PubMed and Google Scholar have a default filter for research that has been independently replicated and not contradicted by other results, GPs will be dependent on a fully-functioning NICE to evaluate evidence for them. This _includes_ cost-benefit tradeoff decisions.

    Incidentally, Simon’s argument about the inflation of the cost-effectiveness target only applies if old treatments are not re-evaluated as the new treatments are added. In general the cost of healthcare increases over time, but this is a political decision to increase the net amount of healthcare, not an effect of the cost-benefit tradeoff.

  10. Drew,

    On reflection, you’re right: My bit about the lack of evidence for many bits of medicine was pretty sloppy and probably ill-advised. I didn’t really intend for it to come across as an argument against Evidence Based Medicine (as it undoubtedly did, listening back), but rather meant to point out the gap between available evidence and practice.

    I didn’t intend to suggest that anecdote outweighs evidence. Clearly evidence is best.

    I disagree that local interpretation of evidence won’t happen – or, at least, more local interpretation of guidance. Whether or not this local interpretation will be high quality remains to be seen – I suspect not. I suspect we’ll see at least a couple of Consortia willing to fund homeopathy or some other quack treatment in spite of the evidence (this is a bad thing). Given half a chance (which they won’t be because it’ll be within the remit of PHE), larger numbers of Consortia would switch from funding Cervarix to Gardasil (this would probably be a good thing). And I think the ‘spirit’ rather than the ‘letter’ of guidance will be implemented.

    Admittedly, that’s not quite the same thing as local appraisal of the evidence, but my hope is that with good quality Public Health people advising Consortia, there will be folks who can actually interpret real evidence in the light of local situations.

    Who makes the financial decisions in GP Consortia remains to be seen, but I doubt it will be standardised across Consortia. I’ve had personal discussions with a Clinical Director of a local consortium (not on my patch) who intends to get very involved in the financial decisions. Clearly, the GPs will need an administration of some size to support this Commissioning role, but I wouldn’t bet on GPs failing to take a strong hand with regards to this aspect.

    As for your point about the inflation of the cost-effectiveness target – I don’t follow your logic completely. Surely whether or not you re-evaluate old treatments as new ones come on-stream (I was assuming that was given), with an ever increasing number of treatments of ever increasing cost for an ever increasing number of ailments surely the cost-effectiveness cut-off inflates? I agree that where we go from there in terms of expanding the healthcare budget or not is absolutely a political decision – but it’s a Catch-22. It’s not politically acceptable to stop providing treatments that have previously been provided, nor to stop providing new treatments, nor (in the financial climate) to significantly increase the spend on healthcare. The only politically expedient course is to change the way in which things are assessed, and (essentially) pass the buck.

    Also, just to clarify, I’m not a GP (although I’ve had a bit of experience in General Practice), I’m a Public Health doctor currently working in a PCT.

  11. Simon, I concede the inflation point. I was guilty of confusing ideal CBA with political reality. If the reforms were motivated and labelled with your arguments – extending a scientific approach to include regional variation – I would support them as a good thing. It is the open criticism of NICEs approach to marginally effective drugs that worries me.

  12. Really good podcast, have just discovered it and am working my way backwards through it.

    Loved listening to the tuition fees sector, don’t agree with your correspondent but it got me thinking! Surely students add to society and potentially help us all, so tax payers should fund students not just them fund themselves?

    Anyway, thanks again for getting my brain working on the walk to and from work, Neil

Comments are closed.