Why Healthcare Insurance to pay for NHS services is probably closer than you think!

Recently, this story featured quite prominently in the UK newsmedia. The response from NHS devotees on social media and blogs was muted. Its significance, in my humble opinion may have escaped obsessees of the UK or English NHS. This is why I think so.
I sit on the cardiac surgery CRG or Clinical reference group.
Please let me explain before you surf away or fall into a deep slumber!!

Mind what you wish for!

Cardiothoracic Surgery in the UK is, as far as the General Medical Council and the Colleges of Surgery are concerned, a single specialty.

UK Falls Behind in Genomic Medicine Race.

The great Norman Shumway, the true father of heart transplantation, had many witty sayings. One that particularly appealed to me was 'the future of transplantation is xenotransplantation and always will be' reflecting his belief that the interspecies immune hurdles would never be conquered in a clinically meaningful way. The reason this famous Shumwayism appealed to me was the fact that he often visited me in the lab when I was working in the lab at Stanford Universiity in the early 1990s on a xenotransplantation project!

The future of medicine IS genomic medicine - and will become the present long before xenotransplantation ever will. This paper published recently in the JAMA, describes the findings of 2 recent studies and speculates how genomic or more accurately exomic medicine may be used in every day practice in the near future.

Both of these studies come from the U.S. and this should surprise no-one. This contrasts with the protracted and top heavy way genomic medicine is still being organised within the NHS in England as described in this painfully long document published by NHS England - another example if ever we need one of how the UK is falling behind its competitors in the hi tech world of specialist services.

 

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Patient Centredness, Ethics and Why You can' have them.

Two articles in a recent issue of the British Medical Journal illustrate different ways hospitals and healthcare institutions can introduce interventions to improve patient outcomes. The need for a response to poor cardiac surgery outcomes in one hospital in the Netherlands proved to be the impetus to radically change the way the institute and its employees deals with patients is described in the first.

Events that should Never Occur

Patient safety and healthcare quality initiatives started in earnest in the USA in the late 1990s/early 2 noughties. Similar initiatives introduced in the NHS over the past 10 years have migrated from across the pond. One such initiative is the compulsory reporting of what is termed a 'never event'.

The peculiarly termed never event is exactly that - something that, in the eyes of someone somewhere should never ever happen. As with many healthcare safety initiatives, the concept of a never event has been borrowed from the aviation industry. Good examples of never events include a surgeon operating on a wrong limb and accidental retention of a gauze swab inside a body cavity after surgery.

Comparing the English list to the American list makes very interesting reading -The most obvious difference is that the American list is much longer and that many items on one list do not exist on the other. The other big difference is the consequence of a never event happening. In the US where there is a predominantly private competitive healthcare system, publication of a list of never events by a hospital will very likely lead to less business and therefore less income. In the UK, a carrot and stick approach is used to manage the occurrence of never events in hospitals. The response is designed to ensure that processes are put into place to ensure those never events do not occur again.

The number of possible events that should never happen in hospital are innumerable. Different wards and specialities will have their own particular never events. It is impossible that every event in every corner of the hospital could be included in an infinitely long list of never events. There is however, merit in the publication of a hospital's performance as regards the occurrence of generic never events. The number of never events occurring in a hospital reflects its general approach to patient safety. They have featured in the recent Keogh report on underperforming hopsitals. Publication of these lists is in my opinion a positive and important development. I just hope that access to the performance of all hospitals in England hospital will be easy and straightforward for patients and that eventually occurrence of never events will become vanishingly rare.

 

 

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NHS England and Mitraclip - Room for Improvement

MitraClip passes FDA hurdle | theheart.org
Mitraclip is a device that can be used to treat a leaking mitral valve, which is one of the valves in the heart..  The main advantage of this device is that it  can be inserted percutaneously without the need for open surgery. The gold standard treatment for mitral regurgitation is surgery. However not all patients are suitable or fit for open surgery. Mitral regurgitation is also an epiphenomenon of heart failure and when present is associated with repeated need for hospitalisation. This type of mitral regurgitation is very rarely dealt with surgically.  Use of the mitraclip therefore has the potential to decrease many admissions to hospital due to heart failure.  More than 4000 of these devices have been inserted into patients in Europe since 2008 when the CE mark was awarded. The American FDA, who traditionally are very conservative when it comes to approving devices has finally given a stamp of approval through one of its expert advisory panels. These panels consist of cardiologists and cardiac surgeons who are recognised experts in the field of mitral valve disease and related heart failure.  The proceedings of these panels are open and transparent. 
In the UK, there is no equivalent of the FDA. Devices are approved as being safe with a CE mark granted by the European Union. There is no requirement for them to be effective. As one can imagine, the bar for CE marking is set pretty low. Mitraclip has had a CE mark for several years.  The NHS commissioning board or as it is now known NHS England are responsible for commissioning of specialised procedures and devices.   In recent weeks it has published guidelines on the commissioning of specialised procedures. It has decided that the NHS will not routinely commission Mitraclip. It will however  'Commission through Evaluation". This process is described on NHS England's website  - ‘Commissioning through Evaluation’ enables treatments or procedures to be commissioned initially on a limited basis whilst further evaluation is carried out to determine whether a substantive commissioning policy should be developed for future use'.
I am not sure that this position NHS England have decided to adopt is logical. It certainly is vague. There is no doubt that the Mitraclip reduces mitral regurgitation in a safe fashion and there is no doubt that it does so in a less traumatic & less invasive fashion when compared to surgery. That surely is the only evidence one requires before commissioning. The decision as to whether the patient is treated percutaneously, surgically or medically should be taken by the patient's physician or Heart Team. It is this decision that will be determined by emerging evidence.