Sean Boyle

No evidence that patient choice in the NHS saves lives

The Health and Social Care Bill 2011 has been framed to abolish direct parliamentary control and public accountability for the National Health Service (NHS) in England. In the face of enormous public opposition to the Bill, the UK Government stood down the legislative process between April and June, 2011. Prime Minister David Cameron used the temporary pause to advance the case for the Bill and argued “Put simply: competition is one way we can make things work better for patients. This isn’t ideological theory. A study published by the London School of Economics found hospitals in areas with more choice had lower death rates.” The study to which Cameron referred was a working paper by Zack Cooper and colleagues. However, contrary to Cooper and colleagues’ claims, their study did not show a causal inverse relation between patient choice and death rates. A statistical association is not the same as causation. As set out by Bradford Hill in his seminal paper, certain factors must be considered when determining whether a statistical association is likely to be causal: ”experiment” or study design, plausibility of intervention and outcomes, strength, consistency, specifi city, coherence, temporality, and quality of data. Cooper and colleagues’ study does not meet scientifi c standards. In the absence of evidence proving that competition improves health, Cooper and colleagues’ work should not be cited as scientifi c evidence in support of choice, competition, or the current market-oriented Health and Social Care Bill 2011. A revised version of the study, published in The Economic Journal, clarifi ed points of detail, but Cooper large comparative studies, one reporting data from two academic institutions and one from a multicentre community-based cohort, both noted—after many adjustments for case-mix and disease risk—substantially improved outcomes after surgery compared with radiation. The community-based analysis also recorded, as did Warde and colleagues, better out comes after either surgery or radiation than after androgen deprivation monotherapy. In both studies, diff erences between treatments were small for men with low-risk disease, and increased progressively as risk rose. Warde and colleagues have provided the strongest evidence to date that androgen deprivation therapy alone for men with high-risk prostate cancer is not adequate. These patients require an aggressive, multimodal approach incorporating prostate-directed local therapy. However, the crucial question—whether the optimum initial strategy should include radiation combined with androgen deprivation therapy, or surgery followed by selective radiation on the basis of pathological fi ndings and early biochemical outcomes— is still open. The defi nitive answer will only come through trials of men with high-risk disease randomly assigned to receive surgery or radiation as an initial treatment.

Blair's billions: where will he find the money for the NHS?

This paper was first posted on www.bmj.com on 13 March 2000 Government ministers have often committed to increased levels of NHS expenditure—but conditional on real growth in the economy as a whole. The prime ministers new spending pledge—to raise total (public and private) healthcare spending to match the European Union (EU) average as a proportion of gross domestic product by 2006—is largely independent of the performance of the economy.1 No matter how well the economy does, health spending must grow much faster to meet the pledged target. Since this pledge, many have queried the arithmetic rigour of Tony Blairs calculations and the financial feasibility of hitting the target he has set, 2–4 It now seems that the governments interpretation of the EU average (8.0%) is wrong and that a more accurate figure is 9.0%. If this new figure is accepted, what are the options open to thegovernment in order to fulfil Blairs pledge? #### Summary points The prime minister has pledged to raise total UK healthcare spending by 2006 to match the European Union (EU) average as a proportion of gross domestic product (9.0% in 1997, not 8% as indicated by the prime minister) All other things being equal, NHS spending would need to increase in real terms by 9.7% a year over five years (by £29.2bn in total) to reach the 9% target There are three ways to increase healthcare expenditure: increased government spending, shifts in public spending towards the NHS, and increased private healthcare spending Increasing taxes (such as 10p on the basic income tax rate or increasing VAT to 27%) or borrowing could fund the necessary increased spend but would be politically and economically unacceptable and could substantially increase government spending as a proportion of gross domestic product (from 39.7% to over 56%) At one extreme, money …

Remuneration of medical specialists. Drivers of the differences between six European countries

Between countries there are large differences in the remuneration of medical specialists. We compared the remuneration levels in 2010 in six countries: Belgium, Denmark, England, France, Germany and the Netherlands. We used OECD figures for the remuneration levels, but corrected them extensively for differences in measurement between countries. English doctors earned most in 2010, French doctors earned least. For the six countries under study the number of doctors per capita is most consistent with the differences in income. Surprisingly, the payment scheme (salaried or fee-for-service) does not seem to account for differences between countries, although within countries fee-for-service specialists earn more than their salaried counterparts. Differences in the role of the GP, differences in workload, composition of the workforce and education could not account for differences in remuneration between these six countries. As our conclusions are based on only six countries more research involving a larger number of countries is needed to confirm these findings.