How to 'save our NHS' - look to what works better elsewhere...

Via the Adam Smith Institute, I came across the Euro-Canada Health Consumer Index 2010 report (PDF), which ranks a number of European healthcare systems in terms of their 'consumer friendliness':

"The healthcare systems of Europe can be classified into two distinct models: the Bismarck model and the Beveridge model. Bismarck systems have been described as a “social insurance” model. In these systems, there are multiple different insurance organizations that exist and compete with one another. These insurers are organizationally independent of the healthcare providers in the country. Under the Beveridge model, the financing and provision of healthcare are handled with-in one organizational system. Financing bodies and providers are either wholly or partially contained within a single organization. Britain’s National Health Service, the Nordic countries’ medical systems and Canada’s Medicare system are all examples of the Beveridge model.

Throughout the history of the ECHCI, healthcare systems based on the Bismarck model have been shown to outperform the Beveridge systems. The larger Beveridge systems—Canada, Italy and Great Britain—have consistently been ranked near or below the middle of the indexes. These results strongly suggest that the separation of insurers from providers and the provision of consumer choice are important principles for the development of high-performing healthcare systems—especially in medium- and large-sized countries."

The top-line results of the 2010 index were as follows (p14):

Despite all of the additional billions of pounds that has been sunk into the NHS over the past decade, in terms of the customer perspective the UK resides only 17th in the list of nations compared; indeed of the 'big' EU countries only Spain falls below us.

Is it worth pointing out that Netherlands (#1), Germany (#2), France (#4), Switzerland (#5); Austria (#6); Luxembourg (#8) and Belgium (#10) - i.e. 7 out of the top 10 - all have 'Bismarck'-type healthcare systems?

While I agree with those people who are loudly proclaiming that we need to 'save our NHS', based on the results above I would strongly suggest that they may well be looking in completely the wrong place for the solution...

We're all doomed!!

I came across two articles over the weekend that resonated with me, both putting forward the case that - despite what the mainstream media, public policy 'experts' and the political class would have you believe - we are not doomed. Indeed, there is a lot to be positive about.

The first article is a plea from a German physicist in response to the hysterical reporting of the Fukashima incident:

"The media suggests a nuclear catastrophe, a mega-meltdown, and that the apocalypse has already begun. It is almost as if the 10,000 deaths in Japan were actually victims of nuclear energy, and not the earthquake or the tsunami. Here again one has to remind us that Fukushima was first hit by an unimaginable 9.0 earthquake and then by a massive 10-meter wave of water just an hour later ... Yet, after an entire week, the apocalypse still has not come to pass. Only relatively small amounts of radioactive materials have leaked out and have had only a local impact. If one considers the pure facts exclusively, i.e. only the things we really know, then it exposes the unfounded interpretations of scientific illiterates in the media. One can only arrive to one conclusion: This sorrowful state will remain so."

The second article takes in a wider perspective, and ties into something I hope to write about shortly - namely how the mainstream media continues to pump out scare story after scare story (and how in general we keep on being taken in):

"Why do we insist on ruining the life that we have – which for those of us who are children of the 40s and 50s, is probably the best anyone has ever known, by living in fear of the life we might not have come tomorrow morning….?

Enjoy today! Go on, fry a salmonella egg with some dioxidic Danish bacon, slip it between two trans fatty acid spread slices of cancer creating white bread, sup a mug of cancer causing hot tea, and reflect on the fact that you are still alive, you can still whinge about how bad life is – or you could reflect on your good fortune to have been of a generation and a country that has enjoyed a more privileged life than 99.9% of the world."

Quite!

Paradigm shift in Pharma - a mythical creature...?

A few days ago I spotted (and tweeted about) an article published in the New York Times:

"This year alone, because of patent expirations, the drug industry will lose control over more than 10 megamedicines whose combined annual sales have neared $50 billion.

This is a sobering reversal for an industry that just a few years ago was the world’s most profitable business sector but is now under pressure to reinvent itself and shed its dependence on blockbuster drugs."

This is, in of itself, not news - this 'patent expiry cliff' has been expected for some time now. What was interesting for me was a discussion that I got into with @DanBax76 on Twitter. In response to my comment to the piece, namely that a paradigm shift in the Pharma industry is due, Dan's response was that such a change is already underway.

The question is: what constitutes a paradigm shift in the context of the Pharma industry? To be sure, major changes are underway - clearly the era of the blockbuster brand is coming to an end. From the NYT article cited above:

"“We have to fix our innovative core,” Pfizer’s new president, Ian C. Read, said in an interview recently. To do that, the company is refocusing on smaller niches in cancer, inflammation, neuroscience and branded generics — and slashing as much as 30 percent of its own research and development spending in the next two years as its scientists work on only the most potentially profitable prospects."

Does cherry-picking only the most profitable therapeutic areas and drugs constitute a paradigm shift in the industry?

An article on the same topic in Motley Fool sees the industry shifting wholesale from pharmaceuticals to biologics, and a re-focus on emerging markets:

"So is this an industry doomed to a slow, lingering death? Well, actually, no. There is a future for the pharmaceutical sector. But it will be a future quite different from its past.

The future lies in biologics. Whereas most drugs of today are chemical medicines, biologics are biological medicines such as, for example, antibody treatments, vaccines, and stem cells.

These drugs are expensive to produce but they are highly effective and are often used to treat diseases with no cheaper alternative. They tend to be sold at a very high price, and thus at a considerable margin."

Does switching from pharmaceutical products to biologics, which attract much higher margins and - quite helpfully - are not straight-forward to copy by competitors once your patent expires (note the lack of any change in the underlying business model here) constitute a paradigm shift in the industry?

Perhaps the rapid and quite exciting changes that we are seeing in terms of how social media is redefining the healthcare landscape constitute a paradigm shift? Well, maybe, but I am not convinced that things will change that much while we still have a monolithic, state-run healthcare system like we have in the UK; by its very nature the system prevents patients from exercising the personal choice in how they want to be treated that will result from the increased education and awareness that social media is fostering among patients.

In my opinion, none of the above constitutes a paradigm shift in Pharma, or the healthcare industry in general for that matter. Obviously, this is the place where I would jump up and say "I have the answer!!", which would be a big lie. That said, there are some people out there who have questioned the status quo. For starters, what would happen if we got rid of patent law?

"What about pharmaceuticals? Some people argue that we need pharmaceutical patents because drugs require expensive R&D to develop, but then can be cheaply reverse engineered. So, the thinking goes, if we don't give drug makers patent protection, they won't bother to produce drugs in the first place.

Numerous facts undermine this argument. Boldrin and Levine have found that the pharmaceutical industry historically grew "faster in those countries where patents were fewer and weaker." Italy, for one, provided no patent protection for pharmaceuticals before 1978, but had a thriving pharmaceutical industry.

Another fact the conventional view overlooks is that patentable drugs are not the only medical innovations possible. Boldrin and Levine looked to a poll of the British Medical Journal's readers on the top medical milestones in history, and found that almost none had anything to do with patents. Penicillin, x-rays, tissue culture, anesthetic, chlorpromazine, public sanitation, germ theory, evidence-based medicine, vaccines, the birth-control pill, computers, oral rehydration theory, DNA structure, monoclonal antibody technology, and the discovery of the health risks of smoking — of these top 15 entries, only two had anything to do with patents. Similarly, nothing on the US Centers for Disease Control's list of the top ten public-health achievements of the 20th century had any connection to patents.

Patent law does create one incentive for researchers: to pursue more of the kind of research that will lead to patentable drugs, and less of the kind of research that might lead to other types of breakthroughs that cannot be patented — even though, as we've just seen, the latter kind may be some of the most important. If patent law were abolished, we would probably see fewer artificial chemical drugs and more discoveries related to remedies from natural substances such as vitamins, minerals, and plants. Given the harmful side effects of many prescription drugs, it is not at all obvious that this would be a bad thing.

Boldrin and Levine also show that patents are not essential to success in the pharmaceutical industry by pointing to the analogous paint and dye industries (which also depended on chemical formulas) in the 19th century. Germany offered no patent protection for paints and dyes at all until 1877, and even then only for the process involved in producing them, not for the products themselves. Nonetheless, German companies' market share rose from next to nothing in 1862 to 50 percent in 1873 and 80 percent in 1913. Britain and France, on the other hand, had patent protection for both products and processes all along and saw their market shares fall from about 50 percent and 40 percent, respectively, in 1862 to between 13 and 17 percent in 1873."

Much more topical bearing in mind what is going on in the US with Obamacare at the moment, and the raging controversy in the UK over the proposed reforms of the NHS, is the proposal to actually create a proper free healthcare market (i.e. with no Government regulation, with the customer as 'king').

A third idea would be reform - if not abolishment - of the FDA/EMA, in favor of complete transparency of clinical data and online peer-to-peer review [UPDATE: Much better link included here]?

All quite challenging ideas, I'm sure you'll agree, but perhaps necessary to include in the ongoing debate about where our industry goes from here. The status quo perhaps does not cut it any more...

SuperClinics too popular. NHS response? Shut them down!

There is a story in this evening's London Standard that I had to read twice to check that I had understood it the first time.

Superclinics introduced by the previous government could be phased out because they are proving too expensive for health authorities.

The GP-led health centres are said to be running up bills of up to £300,000 a year each.

This would seem fair enough as it stands - in the current economic climate it would be mad to permit such overspends to continue. However, there's a twist! 

A spokesman said: "As is the case with many other GP-led health centres in other PCTs, the huge popularity of the centre with local people plus the utilisation of the facility by high numbers of non-registered patients, who were all exercising patient choice, far exceeded the predictions made by the commissioners."

Okay, so what actually happened is that the 'commissioners' completely underestimated the popularity of these superclinics. What's been so popular about these superclinics? Seven days a week, 8am-8pm opening? Walk-in clinics with no need for a prior appointment? No need to pre-register? Sounds horrendous - can't see any of that taking off...

And so, we come to the denouement of the piece, which is quite breath-taking:

Duncan Stroud, Associate Director of Communications and Engagement at the trust, said: "The majority of patients who have been using the centres could quite easily have used another service.

"They were mainly patients who hadn't registered with a GP or hadn't made an appointment. They basically created a demand which wasn't there before."

So, in essence, people wanting GP services in London should take what their Lords & Masters give them, and should in no way expect the NHS to actually change to fit their needs. There are lots of existing services - use them and be grateful!

This demonstrates yet again that the NHS is simply not 'fit for purpose' and desperately needs major reform. I won't, however, hold my breath...

First step for Pharma to regain trust - quit being defensive!

Having worked in the pharmaceutical industry for a while now as a communications consultant, I have seen - like many others - how often the major players seem to get themselves into trouble with the general public. Sometimes this happens through no fault of their own, other times due to things they have done which literally cause my head to bang quite painfully on my desk in exasperation.

The cartoon above is probably quite a good illustration of how the industry is perceived by large swathes of the general public; quite frankly with good reason. Hardly a day goes by without some fresh scandal or negative piece of media coverage that reinforces that perception, and serves to undermine the immense good that the industry has and continues to do for the world population in general.

I have been following the #hcsmeu group on Twitter for a while now, and three contributors have recently posted on this topic:

@PedroLuisGS: To gain trust, pharma companies should change their business concept: drugs are not an endpoint but a path to regain wellness

@andrewspong: Pharma's rep[utation] is in tatters. After all the conv[ersation]s about trust, how about championing the patient's needs to ameliorate the former?

@navatanee: The image of pharma is as bad as the one of tobacco or financial industry. No innovation, just marketing. TRUST??

These tweets all make excellent points. In any holistic healthcare system, a prescription medication given to treat a particular illness is not the final step in the management algorithm, and current 'push' marketing strategies employed by pharmaceutical companies can very easily serve to erode public trust. Championing patient needs is clearly a great idea, but based on the current view of Pharma, if they were to start doing this would anyone really not question their motives? As much as I agree with all three comments, I think they all miss the point:

For me, there is one simple step Pharma could take immediately that would go a long way to start rebuilding the 'trust' that has been lost, and simultaneously help it to avoid the holes it regularly falls into from a communications standpoint:

Stop being so defensive about what you are! Pharma is a BUSINESS that exists SOLELY to MAKE MONEY for its SHAREHOLDERS. Stop tying yourselves into knots trying to hide that fact, and try instead to find ways to make your business model a win-win scenario for all concerned.

Okay, so this may come across as a bit heartless, but that doesn't change the fact that it is true. Governments can't (and probably would not) invest the billions of dollars it takes to develop a single new drug to market (it they could, malaria/TB would have been cured long ago), so it falls to Pharma and its shareholders to risk their own money in the hope of a decent return. If they did not do this, then there would be no drugs. So why all of the guilt?

For me, the real failure of communication from Pharma has been to come clean and talk about their business model with the public. Start a proper, grown-up conversation with doctors and patients about how the whole healthcare system can be improved.

More, better drugs = better outcomes for patients = more profit for Pharma = more, better drugs, and so on...

Open and transparent conversation (i.e. via social media, rather than one-way advertising) between Pharma, doctors and patients = better selection of/adherence to/trust in treatment = better outcomes = well, you get the picture...

In this new, internet-enabled age, everyone has the power to effect change in how things are done. We can all make a real difference, as long as we cast off the dogma that has held us back in the past.

Mad Scientist Syndrome - a significant and increasing burden on society

Science - in of itself - is pretty straight forward. You know the drill: review all of the knowledge on your chosen topic currently available; form a hypothesis which if verified by experimentation will extend that knowledge; perform said experimentation; discard hypothesis if results are not in agreement, otherwise publish hypothesis in Nature; repeat.

Obviously, medicine is in a number of ways a lot 'messier' than science, but exactly the same principles should apply. Epidemiology has no such excuse, since real people here are just numbers in a spreadsheet to be summed and averaged at will of the investigator. So, why do we continue to go through scare after hysterical scare about health matters - surely we should all be tired of it by now?

Cited on Dick Puddlecote's blog, I came across an excellent article by Simon Jenkins in the Guardian with a title which perfectly summarizes the problem: Swine flu was as elusive as WMD. The real threat is mad scientist syndrome.

"The BBC was intoning nightly statistics on what "could" happen as "the deadly virus" took hold. The chief medical officer, Sir Liam Donaldson, bandied about any figure that came into his head, settling on "65,000 could die", peaking at 350 corpses a day.

Donaldson knew exactly what would happen. The media went berserk. The World Health Organisation declared a "six-level alert" so as to "prepare the world for an imminent attack". The happy-go-lucky virologist, John Oxford, said half the population could be infected, and that his lowest estimate was 6,000 dead.

The "Andromeda strain" was stalking the earth, and its first victims were clearly scientists. Drugs were frantically stockpiled and key workers identified as vital to be saved for humanity's future. Cobra alerted the army. Morgues were told to stand ready. The Green party blamed intensive pig farming. The Guardian listed "the top 10 plague books".

If anyone dared question this drivel, they were dismissed by Donaldson as "extremists". When people started reporting swine flu to be even milder than ordinary flu, he accused them of complacency and told them to "wait for next winter". He was already buying 32m masks and spending more than £1bn on Tamiflu and vaccines. Surgeries refused entry to those with flu symptoms, referring them to a government "hotline" where prescription drugs were ordered to be made available without examination or doctor's note. Who knows how many died of undiagnosed illness as a result? Lines were instantly jammed. It was pure, systematic government-induced panic – in which I accept that the media played its joyful part."

Jenkins go on to make the point that we have been here before: remember SARS? What about BSE/CJD? To this list I would add AGW, although the list could go on and on. Every time it's the same: media quotes 'scientists' claiming that there is yet another major catastrophe just around the corner which, surprise surprise, means that we all have (a) give up more personal freedoms to the state, (b) pay more taxes, (c) stop enjoying something which we enjoy doing/taking that has been perfectly legal up till now, (d) live in a state of near-permanent anxiety or (e) any combination of the above.

Jenkins rounds off his article with the sad consequence of the ongoing farce of 'crying wolf' from our politicians and leading scientists/doctors:

"This is why people are ever more sceptical of scientists. Why should they believe what "experts" say when they can be so wrong and with such impunity? Weapons of mass destruction, lethal viruses, nuclear radiation, global warming … why should we believe a word of it? And it is a short step from don't believe to don't care."

 It's not meant to be like this...

Why can't drug policy be evidence-based?

Two recent articles on the vexed topic of illegal drugs caught my eye this week. The first was an interview in the Metro with Prof David Nutt, until recently the UK Government’s chief drugs adviser, who was fired after making 'outspoken' comments on how the country's current drugs policy is not fit for purpose.

Being a scientist by training, and working in the pharmaceutical industry where everything my clients and I do must be evidence-based and referenced, the glaring inconsistencies in the UK's drug laws have always perplexed me (writing as someone whose dabbling in mind-altering substances is strictly restricted to ethanol and the occasional bowl of Tira Misu) - smoking and alcohol are somehow okay (or at least legal) while drugs like cannabis and ecstacy are not. Even within the classification system there appears to be little evidence-based decision-making going on, with drugs being moved between bands on a seemingly regular basis with no clear justification.

Prof Nutt makes some pretty good points - to me at least - in his interview, for example:

"Alcohol is a drug that is most worrying to most parents and it is the drug that is most likely to damage young teenagers. One a day dies of alcohol poisoning and one or two a day die in a road traffic or other accident relating to alcohol – that’s why it is the most dangerous drug. We should be focusing our efforts on that, not pretending that other drugs are worse ... I am continuing to make a case that drug laws, to be fair and just, should properly reflect the harm to the person using and to society, and if they don’t do that then injustice will occur. More innocent non-drug-using people die from road traffic accidents and other damage from alcohol than any other drug."

Personally, I believe that adults should be free to do what they like with their own bodies, as long as they are fully aware of the potential consequences beforehand (for example, possible mental illness) and are willing to take responsibility for whatever may happen, and also as long as no-one else is harmed directly or indirectly as a result.

This leads to the second article, posted by Melanie Phillips on her blog at the Spectator. Phillips takes a very hard line on Prof Nutt's views and on those who consider that liberalization of the drug laws may be an avenue worth going down. Clearly, drugs policy is not my area, but one specific section sprang out:

"Nutt’s offence in crossing the line into opposition to government policy was merely the overt political expression of a position on drug law so irresponsible and potentially harmful, through its downplaying of the risks of drugs such as cannabis and ecstasy, that it should have barred him from public office long previously."

I freely admit that I have not performed a full literature review and analysis of the safety and toxicity of drugs like cannabis or ecstacy; however, what I have seen to date suggests to me that - while obviously not being risk-free - the potential dangers of either of these drugs are probably comparable in severity to drinking way too much on a night out or smoking 20 a day long-term.

As always, politics and people who are either simply ignorant or have vested interests always rear their ugly heads in any discussion on this topic. As a scientist by training, is it really too much to ask for some evidence-based decision-making??

Perhaps, as always, there is a conspiracy at work? ;-)

UPDATE: Have just found the Support Professor David Nutt: We want an evidence based drugs policy group on Facebook.