UKC

This morning a professor of neuroscience and practicing physician did a complete fact-based demolition job on the statistics indicating that hospital outcomes were worse at weekends than in the week, thus totally destroying Hunt's arguments for imposing the new contract. (The DoH argument was based on artefacts that arose from the coding used after the admission event by clerks, which were significantly less robust at weekends than during the week.)

He even said that patients received better care at weekends, because as a clinician he could concentrate on patients rather than other admin concerns, which I thought was pushing it a bit.

This should blow Hunt's arguments out of the water. So why is it not front page news on the Beeb website? 'Professor demonstrates that DoH statistics are fatally flawed' would be both relevant and catchy, wouldn't it?

In reply to Rob Exile Ward:

Because the BBC is so utterly terrified of the Cons they have lost any notion of objectivity.

But of course you knew that.

In reply to Rob Exile Ward:

The head of BBC news, James Harding, is mates with George Osborne and happens to be an ex-Murdoch editor. Less running scared, more like owned.

In reply to Rob Exile Ward:

Because the EU referendum is a bigger story than an industrial dispute that has been rumbling on for months?

or

Because we have all become somewhat sceptical about statisticians?

or

Because there are good arguments in favour of a 7 day NHS that aren't reliant on statistics?

In reply to beth:


That'll explain Whittingdale's obsession with its left-wing bias, presumably.

In reply to Rob Exile Ward:

But this was proved as bullshit months ago, no one cares, or should I say no one in the government seems to realise we know they are lying.

The fact the doctors aren't arguing about Saturday pay yet the government keeps telling them they are should sound the alarm bells.

As for this "Because there are good arguments in favour of a 7 day NHS that aren't reliant on statistics?"

We already have a 7 day NHS when my mam had a stroke on a Saturday, she didn't have to wait until Monday, they saved her life the same day.

It's no good having the doctors working weekends if the ancillary staff aren't working too. this whole arguments is a smokescreen for something else, probably privatisation.

In reply to Dave Garnett:

let not forget about this; Rona Fairhead, Chair of the BBC Trust, and board member of HSBC.

"Her appointment does not coincide with the normal process, and many questioned why a business tycoon was right for the job. What it did coincide with was a string of interconnected visits from the BBC, HSBC, the Houses of Parliament and the Financial Conduct Authority (FCA) to Wilson’s website where he details the scam and the FCA and Cameron’s involvement in covering it up."

In reply to Rob Exile Ward:

Is not the head of the board of governors of the BBC also a director of HSBC and close friend of David Cameron and George Osborne? Is it Fiona Fairhead?

I often find myself wondering if the BBC and our National newspapers are reporting about a different country to the one I live in?

Cheers

Toby

In reply to krikoman:

You beat me to it. That's the one.

Cheers

Toby

In reply to krikoman:




If we already have a 7 day NHS why is it common to have family members sent home to clear beds before the weekend.

In reply to Rob Exile Ward:



the 'more or less' programme on R4 blew the whole statistical lie out the windows months ago. The basis for why the argument is flawed doesn't need a statistical professor to work out why. Their data fields are not relevant to the argument.

What none of this does solves is why doctors are working such long hours. Increase taxes or have funded healthcare, recruit more doctors, lower their hours and wages to a more normal level. Job done.

In reply to timjones:

You can provide statistically robust, U.K. wide evidence of this ?

In reply to lummox:


If you've never experienced it happening to family or friends then you are a lot luckier than most people that I know. Is it only UK wide issues that should be addressed?

In reply to timjones:

Possibly because the (often non-medical) staff - such as social workers - needed to facilitate discharge are not around routinely at weekends. Unlike both junior and senior medical staff, albeit in lower numbers than during the week.

This is because there aren't enough doctors to provide full 24 hour coverage 7 days a week for *non-emergency* care. Reading the popular press it would be easy to assume that there was no care at the weekends, which is patently rubbish. JH somehow magically proposes to get junior doctors to work as per the week service at weekends without either making them work longer or have less available during the week, without adding any more doctors (in any meaningful sense).

Because weekend discharges are often inefficient it is helpful to clear as best as possible before the weekend. That doesn't mean the same thing as is being peddled by JH and his press.

Although perhaps the JDs just want to get everyone out before the weekend as they think they are more likely to die if kept in?

b

In reply to timjones:

So this is just a feeling you have from discussions with other people rather than anything backed up by statistical evidence ?

In reply to lummox:

It may be timjones' experience though and probably isn't unique. But medical staff are well aware of the need to get people out of hospital ASAP (never ending political drive to get mean length of stay down, risk of infections etc -many reasons for this including time pressures eroding into hand hygiene practice, inadequate cleaning of wards, etc) and getting folk out at the end of the week allows some surge capacity over the weekend (well, it used to - not any more, 'cos the beds are blocked 24 hours a day 7 days a week now...)


b

In reply to lummox:
Ever heard the phrase lies, damned lies and statistics?

It seems rather bizarre to demanding stats in a thread that set out to discredit stats

Forget talking to other people, it has happened to my family at least 3 times in the last 15 years, I know it has happened because I have been the one that has driven to the hospital to pick them up. On 2 of those occasions I drove them back in on the Monday morning.

It happens and it shouldn't happen. We have 7 day leisure facilities, 7 day retailing and 7 day pub opening. All the trivial stuff runs 7 days a week, the fact that we don't have a FULL 7 day health service exposes a fundamental flaw in the values of our society.

In reply to timjones:


It seems even more bizarre to think this thread is about discrediting stats. As opposed to actually using them rather than making shit up and claiming that they are stats.

The rest of your comments dont make much sense either. Do you really think leisure facilities, retailing and pubs all have the same staff policy for all seven days? How long do you think pubs would remain open if they ran the friday/saturday night staffing at 11am on a wednesday?

In reply to KevinD:



Surely the differential workloads in both pubs and hospitals are entirely down to our obsession with a 9 to 5, 5 day week?

Why are we happy to extend shop opening hours but not the standard working hours of our health service?

I tend to believe that healthcare is far more valuable than the ability to buy some hay for your hamster and a bag of Haribo on a Sunday afternoon.

In reply to timjones:

'Ever heard the phrase lies, damned lies and statistics?' Yes; it's pretty much the first phrase that a politician reaches for when he/she wants to implement a policy which flies in the face of available evidence.

It's wilfully ignorant though, and doesn't mean that the rest of us have to use the same stupid expression.

In reply to Dave Garnett:

Tell people enough times what you want them to believe is the truth, will eventually be the truth.
Marketing innit.

In reply to timjones:

You are comparing the functioning of a pet shop with a hugely complex enterprise like an A & E hospital. Totally bizarre.

You might as well say 'my local builder can build a house in 9 months, I'll have a word with him and he'll sort Hinckley Point out in a jiffy.'

In reply to Rob Exile Ward:



I'm not specifically talking about A&E, it seems bizarre to me that more routine surgery is not available at the weekend but feel free to enlighten me on why you think that as a nation we are incapable of running a 7 day NHS.

In reply to Rob Exile Ward:



Are you denying that statistics are tweaked and spun by both sides in any dispute?

In reply to timjones:


So you think without that the pubs would have a balanced workload throughout the week? I am really not sure if you are taking the piss there. As a casual example look at student towns. They still have clear peaks and troughs at the student locations since its a tad crap everyone choosing a random party time of their own.


The NHS is open more hours than shops are. Plus once again you can look at the resourcing of those shops. If you go to a supermarket late at night it will have less staff on (on the tills anyway as opposed to stacking shelves) than they do during the day. Indeed some will not have any tills open now but just have self service.
Self service isnt really a viable option for surgery.

In reply to timjones:

I am suggesting that people who have taken the Hippocratic oath wrestle with statistics to improve patient outcomes in a rigorous and intellectually demanding way every day of the week, to dismiss them as being tweaked to suit one case or another is ... wilfully ignorant.

The case against the same level of service 7 days a week? (Because of course there is a 7 day service, just elective and non-critical procedures aren't readily available at weekends) ... well, point to another profession of similar complexity - or another health service elsewhere in the world - that *does* provide an identical service 7 days a week.

In reply to ben b:



My experience with relatives is that the doctors are generally desperate to get patients out by Friday afternoon but the the necessary services -results of tests, occupational therapists, drugs dispensaries are often not sufficient to do it, and of course these are not available at the weekends (well, I assume the drugs are?)

So you can have a test done on Thursday afternoon which should enable discharge but, because of the inability to get or act on the result, discharge may not actually happen until Monday or even Tuesday. That's a lot of bed blocking.

In reply to timjones:





The real question is whether we NEED any of them. And of course, most of the 7 day services are such because it makes more money. A full 7 day NHS would cost money the country hasn't got, and why the junior doctors should suffer because some bellend politician made an ill-considered election pledge is beyond me.

In reply to timjones:


Of course we can run a 7 day nhs, where the same level of elective and routine activity takes place on Saturday abd Sunday as it does during the week.

All we need is 7/5*100= 140% of the numbers of doctors as we have now. And, since doctors are newsworthy but in reality on a small part of the delivery of healthcare in the 21st century, 40% more physios, OTs, radiographers, pharmacists, theatre nurses, porters, clinic nurses, etc etc...

And if the government actually want a 7 day nhs, they can cost that up and see if we are willing to pay for it.

But that's nothing like what they are actually doing. They won't even be specific about what they actually mean by '7 day nhs', but given it doesn't appear to involve any of the professions mentioned above, I don't think they're meaning the same as you.

Perhaps they'll tell us at some point? Then again, given they've had several months and haven't yet, Im not holding my breath.

Its as if they're being deliberately vague about it for some reason. ..

In reply to Rob Exile Ward:

http://www.independent.co.uk/life-style/health-and-families/health-news/sev...

The Department of Health refers to the weekend effect as "established consensus", which sounds like pure undiluted bollocks to me.

In reply to no_more_scotch_eggs:

If I was being cynical, I might suggest that "7 day NHS" is something that sounds great in a manifesto.

In reply to timjones:



But, and you seem to be missing the point here, the whole reason for implementing these changes is based on flawed data. Yet it keeps getting trotted out as if it's fact.

The doctors data doesn't really have to disprove what Hunt and his mates have said, if the original data was wrong then what's the point of the changes? It's no longer to fix the things that we're being told need fixing.

So we can assume that the whole fiasco is a lie, either that or they made a mistake and are too bloody minded to back down.

Even now this further meeting, supposedly to discuss weekend pay, while they doctors are telling us it's not about pay. So Hunt will come out and say, "well we tried, but they didn't want to listen" and we'll be back at square one.

I think people have seen through the bullshit on this though and at the moment the public are still behind the doctors because they can see how stupid it is to ask a finite number of people, to do more work without working more hours!!

In reply to no_more_scotch_eggs:

One thing nobody seems to be talking about is that you actually need more facilities as well. Currently, the down time in theatres and other elective services at the weekend allows for deep cleaning, restocking, repair, maintenence of equipment, upgrades and improvements. These are mostly carried out over night or at the weekend. 7 day working will increase the need for these activities to occur during 'working time', so extra capacity will be needed to allow a theatre, scanner or other treatment suite to be taken out of service for this work. This will cost (about 40%!) more in capital investment and therefore also in maintenence and staffing.

Anyway, how many patients will want to come in on a saturday or sunday to get their scan or surgery if it's not urgent? Maybe some business types and self employed, but probably not the majority...

Why not run these services all night too? "Physiotherapy sir? Yes, we've got an appointment for you at 3am on monday..."

In reply to Trevers:


I think there is an established consensus on it. Its just Hunt is ignoring it.

In reply to minimike:




Probably more than you think, if you need a scan or surgery you'd be a bit silly to say that you didn't want it on a Saturday or Sunday.

In reply to Trevers:


If it strikes a chord with the electorate it might just be worth implementing it?

In reply to timjones:

'Free beer' would also strike a chord with the electorate but that doesn't mean to say that a) it would be a good idea or b) it was affordable or c) the electorate would continue to think it was a good idea if the full pros and cons of the argument were presented truthfully. ('Yes you can all have free beer but you'll die young from liver disease and we'll have to close all infant schools to pay for it.')

In reply to timjones:


If it's to be implemented properly, the electorate needs to know how much it's going to cost and how it's going to be paid for. And they need to know that it'll involve paying for a lot more of the ancilliary staff and services which have been mentioned, and that paying for all that stuff might involve paying more tax. Since this government, and most of its predecessors are ideologically sworn against raising headline taxes such as income tax and corporation tax, this might be difficult.

In reply to Rob Exile Ward:
It might have just finished but Jeremy Hunt & Co have just been answering questions from the Health Select Committee - viewable on Parliament TV. My husband's been watching it as he's currently working with groups of GPs to implement 7 day working in places where there's neither the will nor the demand for it but a government order that it must happen, regardless.

Edit: still rumbling on - apparently Hunt's been talking about the US healthcare model he's ultimately hoping to emulate.

In reply to Tall Clare:

'the US healthcare model he's ultimately hoping to emulate. '

Would that be the one which compared to the NHS costs 25% - 50% more as a % of GDP, delivers worse outcomes, excludes a huge proportion of the population and is inevitably skewed in favour of drugs, surgical procedures and other easily measured interventions rather than prevention and management?

In reply to Rob Exile Ward:

Yes, that's the one.

In reply to Tall Clare:


oh noooo. The words of summoning have been said and the postie will turn up to valiantly defend the cause.

In reply to KevinD:


Perhaps she'd like to produce the evidence that this is the model he hopes to emulate?

In reply to timjones:

Because there aren't enough beds!!!

In reply to Postmanpat:

Jeremy Hunt gave it as an example, I can't remember which hospital (us) it was but it might come up on a search with the right combination of words.

I think the Doctors will cave and it will be the end of the NHS. There is no change from the government, they keep repeating the same things over and over with no sigh of changing course.

Ho hum.

Toby

In reply to Toby_W:


>
An example of what?

In reply to Postmanpat:

The model of health care he wanted the NHS to be more like, he gave an example (I think) of a particular US hospital and healthcare provider.

Cheers

Toby

In reply to Toby_W:

Can't say I saw Hunt's performance, got better things to do than raise my blood pressure but the usual example of a notionally exemplary US hospital he uses is Virginia Mason Bospital in Seattle.
So to illustrate why that is irrelevant bollocks with respect to the NHS:
https://res.cloudinary.com/the-news-hub/image/upload/q_60,f_auto/v144563655...

In reply to Rob Exile Ward:

Interestingly the coding paper discussed on the Today programme today wasn't the only new paper rubbishing the idea that the Weekend Effect is (a) avoidable and (b) caused by lack of staff at the weekends (both of which are figments of Hunt's imagination as even his favourite paper, Freemantle et al. states that such conclusions would be "rash and misleading").

The second paper, which the BBC has largely ignored, is probably more compelling than the coding argument (which focused on a limited geographical area and a single presentation/disease).

Meacock et al. (Link at bottom) analysed data from the entire country for all diseases, and showed that in terms of people presenting to A&E the risk of dying is the same during the week and at the weekend.

However a smaller proportion of people are admitted from A&E at the weekend and these patients are sicker than those admitted during the week (ie the sickness threshold that triggers admission is higher at the weekend). Therefore although those admitted at the weekend are more likely to die within 30 days (IE not at the weekend but any time in the next month), this is accounted for by the difference in the absolute numbers of those admitted and their relative sickness - so even if they had been admitted during the week they would have been equally likely to die.

The simplest way to think of it is a group of the least unwell patients who are admitted during the week are not admitted at the weekend, so there is a higher death RATE amongst those who are admitted at the weekend but the same NUMBER of people would die.


Meacock et al.: http://m.hsr.sagepub.com/content/early/2016/05/05/1355819616649630.abstract

In reply to Rob Exile Ward:

Interestingly the coding paper discussed on the Today programme today wasn't the only new paper rubbishing the idea that the Weekend Effect is (a) avoidable and (b) caused by lack of staff at the weekends (both of which are figments of Hunt's imagination as even his favourite paper, Freemantle et al. states that such conclusions would be "rash and misleading").

The second paper, which the BBC has largely ignored, is probably more compelling than the coding argument (which focused on a limited geographical area and a single presentation/disease).

Meacock et al. (Link at bottom) analysed data from the entire country for all diseases, and showed that in terms of people presenting to A&E the risk of dying is the same during the week and at the weekend.

However a smaller proportion of people are admitted from A&E at the weekend and these patients are sicker than those admitted during the week (ie the sickness threshold that triggers admission is higher at the weekend). Therefore although those admitted at the weekend are more likely to die within 30 days (IE not at the weekend but any time in the next month), this is accounted for by the difference in the absolute numbers of those admitted and their relative sickness - so even if they had been admitted during the week they would have been equally likely to die.

The simplest way to think of it is a group of the least unwell patients who are admitted during the week are not admitted at the weekend, so there is a higher death RATE amongst those who are admitted at the weekend but the same NUMBER of people would die.


Meacock et al.: http://m.hsr.sagepub.com/content/early/2016/05/05/1355819616649630.abstract

In reply to tony:

From Hunts perspective he's got to win this dispute. Next he'll go after the consultants and encourage them to shit on their junior colleagues. Then it'll be the turn of the vast majority of NHS workers (low paid women) and the Agenda for Change payscale. Local pay and the removal of unsocial hours enhancements is the big opportunity to cut costs. Then there's the NHS England's edict to cut the headcount. Nine Band 6s being downbanded in my department right now.

In reply to Toby_W:

A compromise will be reached - it usually happens. Both parties have too much to lose .there will be a diplomatic fudge couched in suitable Union / management speak. It's simple
. Public support for the dr's will diminish gradually if they do more sellout strikes. The govt wants to do a deal - it does not have a big majority.

In reply to munro90:

.

plus seattle and south tees have very similar demographics I'd imagine

In reply to Removed UserDeleted bagger:
Good job he's being held to account and thoroughly toasted by the opposition... oh, hang on a minute...

In reply to munro90:

Does not make clear from the abstract who these 'subset' of weekend admissions are or indeed are they are the 'patients who get admitted to hospital at the weekend'. In which case its not really I would want to use to support my case. The study is essentially saying less skilled staff (senior) around at the weekends in both community and hospital lead to increased deaths. Which is what you/I would expect. I haven't got time to read it at the moment. Be interesting to have a look and see how variable the data is across the selected hospitals. Anecdotally, big city hospital with highly motivated staff, better diagnostics less of a problem. Toad Spit Cumbria, you take your chances.

D

In reply to Dauphin:

The subset is 'patients who get admitted to hospital from A&E at the weekend'. The fact that a smaller proportion of weekend attendees are admitted suggests, but does not prove, a higher threshold for admission is being applied at the weekend. That is, you have to be sicker in order to get admitted at the weekend. The study's argument is then that if you identified the same subset within weekday patients (those that meet the higher threshold) the mortality rates would be the same. So the same number of people are dying but the rate is higher because you admitted a smaller proportion of the same total population in the first place.

The problem with all these studies is they inevitably make multiple assumptions. The reason to give this study fair consideration is that it is as near as possible a facsimile of the paper published by Hunt's mates (Freemantle et al.) but makes an additional important correction (the proportion of patients admitted). Now it may be wrong, the 2.5% of patients at the weekend who don't get admitted but would have during the week, may all go home and die; but there is no evidence for that.

And that is the key point that the medical profession has made all along, there is no evidence. There is no evidence that 'Weekend Effect' deaths are avoidable. Nor is there any evidence that increasing staffing of any type, especially junior doctors, would do anything about it even if the deaths are avoidable. We notionally practice evidence based medicine in the UK, but that concept appears to have passed Hunt by.

Finally, even if by some miracle of prescience or higher intuition, Hunt IS right about the Weekend Effect being real, avoidable and solvable with more Junior Doctors and other staff:
- why should those staff be expected to work more evenings and weekends (spending less time with their families etc.) for no more (indeed in many cases, less) pay?
- why not increase the budget to employ more staff to fill the existing and newly created rota gaps?
- Because if Hunt won't employ more staff, then he will have to redistribute staff from weekdays to weekends, which will reduce weekday staffing making weekdays more dangerous, no?
- Or if Hunt's not going to pay for more staff, and he is not going to reduce weekday staffing, does that mean the existing staff will have to work more hours all across the week?
Except I thought that was dangerous too... (cf. the airline industry's rest periods)

Essentially the entire premise is an un-evidenced illogical pile of bovine faeces.

In reply to munro90:
Would be fairly easy to run a study to demonstrate the effectiveness or not on patient mortality of having senior staff work weekends. Whether it would cost effective?

I agree with your final paragraphs.

D

In reply to Dauphin:
Have they not done this at places like Salford and Newcastle which are advocates?

Is this not one of the fubdamental problems with your approach as some in the nhs say that it works?

In reply to timjones:

Oh FFS do you know any hospitals that close at the weekend?

In reply to neilh:

Its not me who is against it.

D

In reply to Dauphin:

Apologies.

In reply to no_more_scotch_eggs:

Apologies for quoting in its entirety, but this:







.....is just such an excellent post.

In reply to Just Another Dave:

the problem is the UK public doesn't want to pay for it.

It is the same with education, pensions, infrastructure etc.. everyone expects the best in the world, GB were once world leaders and look at us now etc... but look at the up front UK tax rate, 20% on earnings over £11k (and rising), you ain't going to get 5* services unless they are paid for.

The problem is the UK economy is still a little delicate, putting 5% on tax would hammer disposable income and the economy would suffer instantly. But a slow creep of tax up, rather than down can be the only solution in the long term. Or the UK accepts 'average' healthcare, education.... It's a choice between having a TV in every room of your house, multiple cars, £600 or £700 mobile phones, multiple holidays and having better services, there is only one cake.

In reply to munro90:

I agree the whole justification is flawed, but some how doctors should all be working much less, recruitment can be the only solution in the longer term.


I think they were offered a cap on total hours which is less than the current one and a pay rise? A pay system that currently relies on extreme hours and over time rate clearly needs some revising.


I agree 1 or 2% on the base rate of tax, and do the job in the NHS properly at all levels. Doctors and consultants don't need more money, but those below them certainly do. Ambulance crews are probably the most under rated and paid, in terms of responsibility and decision making, whilst not being surrounded by a whole team of specialists.

In reply to summo:

The UK per capita expenditure on healthcare is pretty low by developed standards and out of that smaller amount we also pay off the very expensive PFI debacle. I'm amazed in a country that has and loves the NHS the population isnt politically demanding more tax spend goes that way. The US government pay more per capita on healthcare than the UK and this is in an insurance based system before a cent of insurance money is spent.

We also need to be honest that some healthcare is always going to be rationed. If you want the very best you need to be rich and American but they also have their poor who struggle: before Obama brought in his changes, half the population couldn't afford proper insurance.

In reply to summo:

Not that simple. A 1% rise in the basic tax rate would provide £4.2bn in extra revenue (source IFS), so 2% would be £8.2bn. That's about 7% of NHS spending (actually less, because the tax figs are for the UK, and the health figs for England)That would still leave the system about 15% underfunded compared to its continental peers.

In reply to timjones:


Genuine question - is their actually a real desire for this? As with the GP weekend trials, their wasn't the public appetite for weekend appointments as first thought, maybe this is the same for non emergency medical care?


We don't want to fund it. (By we, I mean the nation, I'd happily pay more tax if it was ringfenced for the NHS)

In reply to galpinos:

Elective surgery at the weekend also needs full (or near full) staffing from ODA's, theatre nurses, anaesthetists, orderlies and for significant surgery the backup of the acute pain team, the medical emergency team, the intensive care unit, the physios, the nutrition team, the dieticians,, the nurses, and the junior doctors looking after the post-op ward patients. To name but a few. Sure, very basic surgical procedures can be done 7 days a week but (as mentioned several times above) trying to get "normal" staffing levels at the weekends requires significant investment across multiple groups of professionals who aren't currently sat around doing nothing.

b

In reply to ben b:

Oh, I'm aware of that. That's what frustrates me. We don't know what is meant by the Government when they say "7 Day NHS", there is no current plan as to how it's going to be implemented, no indication of how it will be funded (though the hint form the starter for 10 with the junior doctors means stretching the existing staff even further) and no idea if anyone actually wants it.

My point to Tim, was that he appears to believe that, as a nation, we want to have non-emergency medial care, including non-emergency surgery, available at the weekends, regardless of the cost. I was questioning whether this is true and what this opinion is based on.

In reply to galpinos:

Mostly the JH plan appears to be variations on divide and conquer, plus spin it as hard as possible while keeping 90% of the press in your pocket.

And then presumably leave the House and take up a couple of fat directorships in private health firms.

Just my opinion, obviously.

b

In reply to Offwidth:


where is the money going, it's not on the lower ranks? Middle Management, PFIs and Agency fees? Perhaps other countries are more selective in terms of what drugs they issue, or their people pay a modest fee at the point of treatment too.

In reply to Postmanpat:


I would agree, it needs much more money. Many countries have a modest fee at point of use, more tax on alcohol and tobacco etc..

In reply to summo:

Personally I think major savings could be made from pharmaceutical budgets, but such an idea is apostasy to many (particularly on the right, but not wholly so). Whilst the NZ Pharmac model has issues particularly in terms of responsiveness it does save a heck of a lot of cash with outcomes being essentially identical.

Pharma has the US healthcare system over a barrel; the NHS less so - but competition doesn't really bring the prices down much (especially if there is only 1 player in town).

b

In reply to ben b:


I think the licencing system is partly the cause of the problem, where companies know they have a given number of years to make their money before it becomes open source. But, they need to fund new research where perhaps only 1 in 100 or even 1000 of potential drugs ever reach human use, they need to have some reward for often spending millions on something that in the end goes no where. Then there are share holder issues, how can a company which is effectively in the business of saving lives, put profit first. Perhaps development of life saving drugs should never be for profit.

In reply to summo:
>Then there are share holder issues, how can a company which is effectively in the business of saving lives, put profit first. Perhaps development of life saving drugs should never be for profit.
>>

And how else are you going to raise the money to finance R&D on the 999 drugs that never reach human use?

In reply to Postmanpat:



that is my point, it is a no win situation. Drugs cost a fortune for their first couple of decades of sale. A new life saving drug will be in demand for good reason and everyone barr the NHS budget benefits.

You lower drug cost and companies struggle to fund as many new potential lines of drugs. Which means they will only pursue the most likely avenues.

Solution; state run drugs companies as well as private ones? Pay more tax to fund more expensive drugs? Both I would say.

In reply to summo:


How are State run companies going to save money? Can you imagine trying to justify raising taxes in order to finance the development of drugs, 99% of which never see the light of day? Even big pharma buys in a lot of its R&D from smaller companies whose owners get very rich if their drugs work. Can you imagine the uproar over that?

In reply to Postmanpat:

A lot of their basic research is also done for free in Universities, Hospitals and/or charities.

In reply to Postmanpat:

i was just pondering how life saving new drugs can be sold nearer cost, with only enough money made from them for future R&D, not shareholder dividends etc.. The government had a fantastic research side arm in another sector, and it was sold off on the cheap in 2007. Qinetic, they were and are cutting edge, whilst being state owned. So it's not impossible.

In reply to Offwidth:


it is not for free, there are grants etc... although labour costs of the semi student working on it, as part of a doctorate are much less than a private sector full time employee.

In reply to summo:


Well, you could sell the actual drugs nearer cost, obviously, but without the finance to research lots of failed drugs then the successful ones will never happen. I cannot see how you will justify the tax payer financing lots of failures in the hope (which even big pharma has massive problems with) that a few successful drugs will emerge that can then be sold more cheaply.

In reply to Postmanpat:

Perhaps, you are right. But when the NHS says it can't afford drug X, despite NICE approval, what they are really saying is they can't afford the company profit margin and shareholder dividends of the big companies. For those people with a fatal illness and insufficient personal funds to go elsewhere, that's not going to be a nice feeling for them.

In reply to Postmanpat:
If the unsuccessful drugs were that much of a drain you wouldn't get the likes of GSK paying 5+% dividends at a time when interest rates are so low.

Big Pharma makes stacks of cash, you just don't like the idea of state owned business so stop it with the smoke and mirrors.

In reply to Graeme Alderson:



Since you seem to feel the right to spray around the abuse: you really haven't a clue have you ? They can pay the dividend because they are able to charge a high price for the successful drugs. Nobody is denying that pharmaceutical companies have been very profitable or claiming that they are paragons of virtue, but governments are squeezing them through drug pricing and tighter licensing requirements, and many are cutting back or outsourcing their R&D as a result.

5% is cost of money. The government has to pay for that as well but the whole point of Summo's idea is that they don't charge a high price, so the taxpayer would have to pay both the the cost and take the risk.

Smoke and mirrors my arse.

In reply to summo:

>
No they are not. They are saying they cannot afford the cost of the money needed to finance R&D over a wide range of failed drugs.

In reply to Postmanpat:



Are you implying they don't make a profit and the often huge price tag is purely for future r&d?

It's a little immoral, you invent a drug that can cure some disease, but you won't sell it cheap enough so all sufferers can be saved, as you want some profit and some money to potentially save other people in the future who aren't dying yet. Natural selection through wealth?

In reply to summo:



No, I'm saying that to raise the money to finance R&D they need to make a profit in order to pay for that money.
What is immoral about making money to potentially save more people?

In reply to summo:

Free to the 'big pharma' companies.... ie a good bit of their expensive research wasn't done by them. They also get very good tax breaks and a bizarre lack of competition in the US market. They dont need people feeling sorry for them, just the opposite: they need publc pressure for shaking them up.

In reply to Postmanpat:

http://truecostofhealthcare.net/the_pharmaceutical_industry/

In reply to Offwidth:


Which is what they have. Essentially, as your link shows, they are living on borrowed time and trying to find ways maintaining a new drug pipeline whilst their profitability is under pressure. Hence they outsource research, do deals with venture biotech etc etc because their internal research has spent vast amounts (about 70% of profits according to the link) with decreasing returns ( Tax breaks are entirely logical if the government wants to encourage R&D.) Taking the example of GSK, its proprietary drug revenues over the next five years, and this earnings, look like falling off a cliff.

Nevertheless there is no doubt that, as in most industries and especially in the US the corporate lobbyists have too much power but regulators around the world are getting more and more resistant to licensing drugs or paying up unless they are truly innovatory. Hence those innovatory drugs carry a premium. One of the advantages of having an NHS, as opposed to a bunch of insurance companies, is that it has leverage over pricing.

If we adopted the frankly daft idea of nationalising pharmaceutical development and production we are basically taking the somewhat mad bet that with a smaller budget and less diversity the State can somehow produce a pipeline of new innovative products that the best and best rewarded scientists in academia and business are struggling to develop.

In reply to Postmanpat:
I'm not entirely up to speed in this area but I have a few comments/questions about the NHS, NICE and Big Pharma.

1) My understanding is that NICE exists primarily to assess the cost effectiveness of treatments, so typically when a pressure group (or some US politician) yells that 'NICE is not allowing my mum the drugs she needs' it's because those drugs only deliver marginal or even non existent benefits. This seems wholly sensible to me but poorly reported. 2) An issue about the way that pharma companies work is that they are inevitably incentivised to research drugs that manage rather than cure conditions, thus generating recurring revenue. Not sure how to resolve this... 3) Another issue is that both pharma and the medical-industrial establishment inevitably big up the efficacy of their interventions; this is understandable but leads to unrealistic expectations, and fuels increased demand for interventions that are marginal at best. Which is why I am implacably opposed to the creeping privatisation of healthcare in the UK - it will (and does) inevitably generate demand rather than satisfying it.

In reply to Postmanpat:



R&D is a business cost, they make a huge profit after it is deducted, whilst people die because health services can't afford to treat everyone. That sounds immoral to me?

Why not make zero profit and reinvest all that money in research, or sell drugs for less and save more lives. Giving a shareholder a dividend, doesn't save anybodies life, now or in the future.

In reply to Rob Exile Ward:



Not entirely sure about <2> although there is some logic to it. <1> and > are largely true which is why it's important to give NICE or the equivalent plenty of power and to remove any incentive for medical practitioners to prescribe drugs unnecessarily.

In reply to summo:



Well, if you sell drugs for less you don't make a profit so you can't develop new drugs. If you don't pay either your lenders or your equity investors for their money (out of your profits) you won't have the capital to invest in R&D or anything else.

It seems immoral to structure the industry in order to to stop drugs being developed to save people in future in order to save a few now.

In reply to Postmanpat:


You do realise those scientists aint exactly that well rewarded. If you want the big bucks you become sales staff, patent lawyers or the tax accountants.
I am also not sure why you put the academics on the side of the business either.

In reply to KevinD:



Because a lot of academic work gets commercialised.

In reply to timjones:

Sadly not. My saturday elective endoscopy lists have run at approx 40% non attendance. This is after reminder letters, texts etc... It's nowhere near this during the week. Weekend GP service pilots are undersubscribed.

Elective weekend services are only worthwhile if there is public appetite and willingness to pay. It will come at a cost premium as you cannot expect weekday services to continue as is, and for us to take on more weekend work.

Apart from convenience (and very costly convenience) I cannot see a persuasive arguement for routine weekend elective work.

In reply to Postmanpat:


Which fails to answer the question. That their work gets commercialised is separate from who actually pays for their work initially. Which is often the state or charitable trusts since business wants quick returns and not something which may pay off in 20 years time. Although sadly the state funding is increasingly crippled by the belief it should give immediate commercial return.

In reply to Postmanpat:


AFTER paying those loans, R&D, marketing etc... Phizer in 2014 only scrapped a $22billion profit, poor things.

The figures for the biggest 10 are here, revenue, R&D, marketing and profit etc.. all broken down, so you can see how they are struggling. http://www.bbc.com/news/business-28212223

In reply to summo:



We have already etablished that the industry is very profitable.

In reply to Postmanpat:


exactly, so make a little less profit for share holders, cheaper drugs for all. There would be no impact on R&D, as it's a cost before profit and dividends.

In reply to KevinD:

>
Irrelevant to the point being made.

In reply to summo:

There is no pay rise. This is clear obfuscation on the part of the DH. 13.5% increase in basic coupled with the removal of banding which for me is 40% of my basic.

The maths isn't that challenging - it is a paycut. Pay protection will cover most (not all, despite the public assertions it will cover all) currently in higher JD posts but those coming after will be on less for more.

The NHS employers own info graphics show current and new pay as equal if you include 'additional rostered hours' in the new deal. That is a pay cut!

The main argument however is about staff retention, safety, discrimination etc.

In reply to summo:


So we gone from, "why don't we nationalise the industry" to "why don't we make it zero profit" to "we could reduce profits a bit". On the latter, we probably could, but as I pointed out before, that is in the process of happening anyway.

You are not addressing the point: that capital has to be available to develop drugs, and that is what dividends are for.

In reply to Postmanpat:


you seem to be missing the point, phizer for example made $22b after money was put into R&D, marketing etc.. they make a massive profit after ALL costs. So the capital would still be available, the loser would be the shareholders receiving less, but more people get the new drugs. I fail to see why you are against this.

I'm general against re-privatisation, but I see no reason why the government could not set up a bigger special lab to tackle key diseases. There are already many specialist labs that are government owned, pirbright, porton down, roslin.. plus many others under the medical research council, it's not a big leap to look deeper into future medication.

In reply to summo:


1) They make a massive profit because they get premium prices for their self developed drugs. If they did not get those prices, as you are recommending, they would not get that profit so could not pay for R&D on new drugs.

2) Much of that profit is paid to shareholders in the form of dividends. This is the cost of capital to grow the business, which requires spending on R&D. Given that for many of the majors revenues are stagnating and profits are expected to fall these dividends will become unsustainable so shareholders will sell (ie. no longer wish to provide capital to the industry) and companies will merge.


Well, they are welcome to, but the current experience of big pharma is that they might spend a lot of money and come up with f**k all. Why should Joe Taxpayer bear that risk rather than Joe voluntary shareholder?

PS. the Pfizer number is a one off because of an asset sale. The industry average is much lower, although still high.

I'm not pretending big pharma is an ikon of moral probity or on its last legs: just that the idea that a nationalised drug industry or zero profit drug industry is a viable alternative is mistaken.

In reply to Postmanpat:


I'm a little confused and am skim reading but the profit is after expenditure on R&D is it not?

In reply to galpinos:


After.

In reply to Postmanpat:
>> Well, they are welcome to, but the current experience of big pharma is that they might spend a lot of money and come up with f**k all. Why should Joe Taxpayer bear that risk rather than Joe voluntary shareholder?

because if Joe Taxpayer doesn't, before long he's going to find that routine minor operations are going to become a lottery over whether they lead to lethal sepsis or not. antibiotics are a prime example of where the current model doesn't work well. massive investment for something that will have to be prescribed very sparingly. hence very few new antimicrobials coming down the pipeline and a real worry that those 'post antibiotic age' headlines may become a reality.

this is one area where the consequences are too serious to be left to a badly performing market; governments are responsible for the safety of their populations and this falls into that category. state funding of research into novel antimicrobials is going to be necessary.


and entire industry no; but where the market fails, an in my example above, yes

cheers
gregor

In reply to no_more_scotch_eggs:

>


>
I agree, although some sort of sharing of risk and reward might be the most effective option.