We are not alone

Procurement and competition rules. Can the NHS be exempted?

Public procurement rules in the EU follow a weird path under ESA-2010 accounting rules. You can check it on p.22 of the Manual on Government Deficit and Debt. Implementation of ESA 2010. and the decision tree in p.25 showing a complex labyrinth.
This is the reason why in the UK (p.2 of the Kings Fund Report):

If Labour wins the general election, it has committed to repealing the procurement and competition provisions in the Health and Social Care Act 2012, including the  Procurement, Patient Choice and Competition Regulations made under Section 75 of the Act.

And even more than that:

In his speech at The King’s Fund on 27th January, Andy Burnham, Shadow Secretary of State for Health, committed to ‘claiming a full exemption for the NHS from EU procurement and competition law’

This is precisely the reason why we should do the same and put all the effort to succeed in our attempt. We have to ask for full exemption from rules created for a different purpose and adjust them appropriately to our health context. These are rules created for public accountants that constraint adequate decision making. Accounting is devoted to measurement of the costs and benefits of decisions. Rules for decision control are related to governance and audit procedures, not accounting. This is the main reason why we should ask for exemption, they were created from a wrong perspective.
We are not alone in this position, in the NHS they are concerned with the same problema.

Hommage a l'Arménie

Jordi Savall et Hesperion XX. L'Esprit de l'Arménie. Hier a Istanbul


Sans Émotion il n'y a pas de Mémoire, sans Mémoire il n'y a pas de Justice, sans Justice il n'y a pas de Civilisation, et sans Civilisation l'être humain n'a pas de futur.

L'Arménie est une des plus anciennes civilisations chrétiennes de l'orient, qui a survécu miraculeusement à une histoire convulsive et particulièrement tragique. Depuis sa fondation, elle se situe politiquement et géographiquement au milieu d'autres grandes cultures imprégnées par des croyances orientales et par la pensée musulmane et a vécu une histoire très douloureuse, ponctuée par des guerres et des massacres extrêmes, qui ont causé la disparition de plus de la moitié de sa population, l'exil de beaucoup d'autres et la perte de grandes parties de son territoire. Malgré cela elle a su conserver l'essence de ses particularités nationales tout au long des siècles, comme le prouve surtout la création de son propre alphabet (en 405 par le moine Mesrop Machtots) et comme le montre aussi son riche patrimoine architectural, éparpillé aujourd'hui, même en dehors de ses territoires actuels. Bien que ce patrimoine tangible en soit un des témoignages les plus frappants, elle a aussi gardé un riche patrimoine intangible, dans le domaine musical: un répertoire très riche et très différencié mais malheureusement assez peu connu (à part celui du duduk).

De toutes les cultures développées, la musique – représentée par certains instruments comme par les manières de chanter et de jouer qui peuvent la concrétiser –, devient le reflet spirituel le plus fidèle de l'âme et de l'Histoire des peuples. De tous les instruments utilisés dans ses anciennes traditions musicales, l'Arménie a accordé une préférence particulière à un instrument unique : le duduk, à tel point qu'on peut affirmer que cet instrument la définit d'une manière presque absolue. Dès l'écoute des premiers sons de ces instruments – habituellement ils se jouent en duo – la qualité (presque vocale) et la douceur de ses vibrations nous transportent dans un univers élégiaque et poétique hors norme, et nous entrainent dans une dimension intime et profonde. La musique devient ainsi un véritable baume, à la fois sensuel et spirituel, capable de toucher directement notre âme et, en la caressant, de la guérir de toutes les blessures et de tous les chagrins.

PS Le déni turc.

PS. Health care in Armenia

A successful implementation of a bad idea

Since 2012 it hasn't been posible to know the price of new drugs funded by NHS. The government considers that they are confidential. This is a clear example of what exactly means transparency and the application of the rule of law. Meanwhile a new strategy has been put into place. Without public prices, the government has decided to set budget ceilings for several innovative drugs: pertuzumab, ivakaftor, telaprevir/simeprevir, abiraterona, pirfenidona y ruxolitinib. And the last one is new drugs for hepatitis C, defined as "therapeutic group" not as a specific molecule. Following this strategy there is a proposal to extend such a model of budget ceilings by ATC, therapeutic classification.
This is really a bad idea that is already being implemented. As you know sometimes there are good ideas badly implemented, and therefore criticized. But in this case, it is a bad idea with a scrupulous implementation. Some officials consider that if they set a budget ceiling, all decisions will be taken  to fit in with it. Clinical decisions follow a different path, not the mechanical and administrative way officials are used to.
The measure represents a tough hit to economic evaluation, because in the next future the government will not be any longer interested in it. Why? Their only concern is about the budget ceiling, the value doesn't matter. A missed opportunity for the development of priority setting under a rational scheme. Health economists should react to such a big mistake.
The saddest  issue is that nobody knows what will happen when the budget ceiling is surpassed. This will be the job for the next government, nobody cares about it right now. Democracy and rule of law are only words subject to interpretation.

PS. All the details about hepatitis C controversy at Boletín AES.

PS. Understanding the foundations of confidential drug pricing, in Forbes.

PS. Explained at Health Affairs:

International Best Practices For Negotiating 'Reimbursement Contracts' With Price Rebates From Pharmaceutical Companies

By: Morgan, Steven; Daw, Jamie; Thomson, Paige

HEALTH AFFAIRS  Volume: 32   Issue: 4   Pages: 771-777   Published: APR 2013

 Abstract

Reimbursement contracts, in which health insurers receive rebates from drug manufacturers instead of paying the transparent list price, are becoming increasingly common worldwide. Through interviews with policy makers in nine high-income countries, we describe the use of these contracts around the globe and identify related policy challenges and best practices. Of the nine countries surveyed, the majority routinely use confidential reimbursement contracts. This alternative to drug coverage at list prices offers benefits but is not without challenges. Payers face increased administrative costs, difficulties enforcing contracts, and reduced information about prices paid by others. Among the best practices identified, policy makers recommend establishing clear and consistent processes for negotiating contracts with relatively simple rebate structures and transparency to the public about the existence, purpose, and type of reimbursement contracts in place. Policy makers should also work to address undesirable price disparities within their countries and internationally, which may occur as a result of this new pricing paradigm.

What clinicians do and why they do it

The Nature of Clinical Medicine. The return of the clinician

Nowadays, technology pervades media and our live. This is a good moment to rethink the basics, the foundations of medicine, its values and goals. Eric Cassell contributes decisively to this aim with his new book, a must read at least for physicians and all professionals related with medicine.
Health economists should be aware of better understanding  about the goals of medicine and purposes of physicians. They reflect the true "production function".
Here is a brief summary of the book and afterwards its goals and purposes:

Clinical medicine, as a thinking discipline, is concerned not only with what clinicians do, but why. When physicians act in medicine they have some purpose or goal in mind. What they actually do and how they go about it is in the service of their purposes and their goals. Such goals cover a wide range of topics centering on patients, the doctor-patient relationship, the acts of doctoring patients, and the goals involved in being a physician among other physicians working within the institutions of medicine.

The Nature of Clinical Medicine takes its direction from a catalog of goals of medicine that range from the expected diagnosis and treatment of diseases to wider concerns for patients, for physicians, and for medicine itself. The chapters are specific in teaching the kinds of knowledge that clinicians require in order to be able to achieve these goals. The central focus of the clinician and of this book is the patient. According to Eric Cassell, everything else, including the disease, is secondary.

Summary of the Goals of Medicine

A. Patient-centered goals

1. Save life.
2. Prolong life.
3. Cure disease.
4. Prevent suffering.
5. Relieve suffering.
6. Do no harm.
7. Protect the patient from danger.
8. Do not frighten the patient.
9. Relieve the patient’s fears.
10. Make the patient better in the patient’s terms.
11. Do nothing unnecessary (or more than necessary). B. Goals related to the physician–patient relationship
12. Develop and maintain a good relationship.
13. Be trustworthy.
14. Tell the truth.
15. Be reliable.
16. Be constant.
17. Be there when needed.
18. Make a difference.

C. Goals related directly to doctoring the patient

19. Make a diagnosis (where pertinent make a tissue diagnosis).
20. Decide what the problem is.
21. Obtain the necessary information.
22. Make sense of the case (in pathophysiological, anatomical, psychological, and social terms).
23. Decide the correct treatment and its timing.

D. Goals related to being a physician among other physicians

24. Seek and maintain comprehensive knowledge.
25. Maintain the standards of medicine.
26. See that things are done right.
27. Protect the patient from bad medicine and incompetent physicians.
28. Behave in a proper, doctorly manner.
29. Look good to other physicians and the patient and family.
30. Avoid error.
31. Avoid blame.
32. Maintain relationships with peers.
33. Stay alive in the institution (hospital or medical school) and community

The relationship between purposes or goals and values (p.166). Five kind of goals:

1. Specific obligations to other people or institutions—patients, other caregivers, or the hospital
2. Responses to rights that everybody has, for example, the right to refuse treatment, or to freedom from assault or coercion.
3. Purposes based in what might be called utility. Things pursued because of the benefit to the patient, or the avoidance of injury. Also purposes directed at general benefit, like the advance of medical knowledge.
4. Purposes related to what might be called self-development values. Here, there is intrinsic value in acquiring a particular piece of knowledge or skill because it is believed to be part of the general good if even one person has special knowledge. The goal of acquiring a particular knowledge or ability lies in this arena of values.
5. Purposes related to one’s own project in life, like becoming a good clinician apart from, for example, the acquisition of a specific skill  or the general advance of medical knowledge

Tapering mechanisms for hospital payment

Tapering payments in hospitals

In Germany, payment to hospitals is based on DRGs. This means that there are some estimateas of specific relative weights and an expected volume of cases. The base rate is the pivotal element of the system. Health insurers want to avoid any surprise on their budget ceilings. Therefore some criteria in paying hospitals is the key to accomplish the budget. And what they do is the following:

Any increase in activity volume (based on the case-mix) compared to year t-1 within the range of negotiated volumes for year t is reimbursed at rate tapered by 25% (rate in force in 2013 and 2014) 

The tapering criteria is also known in our country as marginal payments, the amount that it is paid beyond a certain ceiling of discharges or visits.
Tapering is always controversial, because it may be applied to volume or to the costs (through shrinking the base rate). In both situations it is difficult to have a clear verdict of wether there is too much suplier induced demand, or just an epidemic (?).
Therefore if appropriateness criteria are not in place, the result can be anything but the fair: penalising efficient hospitals or incentivising waste.
I have always been concerned about marginal payments. A recent OECD report on this topic describes current practices and puts some caution in its application. As far as this is the first report that informs us about these practices, I specially recommend it to those officials reponsible for the issue.

PS. OECD Graph of the month. Slowdown in health spending in Europe has affected all spending categories, particularly pharmaceuticals and prevention

Variations in Health Care in just one infographic

From King's Fund

PS. WHO on cesarean section rates.

Physician self-referral: a call for action

Physician Self-referral: Regulation by Exceptions

In 2002 a new agreement was published in internal medicine reviews on Medical Professionalism in the New Millennium: A Physician Charter. Some years ago I posted the same issue. Today, I would like to highlight three points again:

• Commitment to professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.

• Commitment to maintaining trust by managing conflicts of interest. Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals

• Commitment to maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.

 After reading JAMA article on physician self-referrals in US, definitely I have to say that this principles are far to be applied. The size of the resources coming from self-referrals is continously increasing despite the existing regulation for decades. The article puts a lot of expectations on changing the payment system, from fee-for-service towards value-based payments to curb the situation. I'm not so confident on this tool, because its implementation is far from optimal.
Anyway this is a difficult issue, and the same happens to dual practice in general. Some weeks ago a new resolution on how to handle conflicts of interest between public and private care was released. Two different concerns appear on my mind. The first is when any patient that decides to start a private treatment, then there is no option to go back to the public sector. He rejects explicitly public coverage. This statement may be appropriate for those patients on public waiting lists, but its application to other situations may be fuzzy. The second relates to information by the healthcare faciliy to patients about benefits and rights. I'm uncertain about how this can be applied without biases, without interference of physicians. My suggestion would be to use more transparent and centralised ways to inform patients through internet.
Unfortunately what I missed is precisely any regulation on physician self-referrals, the core of the problem. This affects publicly funded -in case of dual practice- and private care. Somebody should have a clear position on that. In my opinion, it should start by physicians associations. Self-regulation is a better starting point than any ban on this practice. As you may deduct easily, the general application of the former physician charter would solve this issue.

This is unsustainable

Demystifying Sustainability

My position is clear and I have said it several times before: the use of the term sustainability is misleading. From an economics point of view, the term should be "dynamic efficiency", keyed by Schumpeter long time ago. However an environmentalist term entered into our language and now we can't disentangle what it really means. That's why initially it is welcome a new book on this topic written by an environmentalist that beyond the concept it focuses on the solutions in these issues:

1 Worldview, ethics, values and ideologies
2 Redesigning ourselves to enable change
3 Population
4 Consumerism and the growth economy
5 Solving climate change
6 Appropriate technology: a renewable future
7 Reducing poverty and inequality
8 Education and communication
9 The politics of it all!

For each issue you'll find what you can do. Unfortunately, there are too many issues to be covered in only one book without any reference to incentives and dynamic efficiency or market design...

Finally it says

Can we demystify ‘sustainability’?
Yes we can, we can demystify ‘sustainability’. The key step is to accept reality, accept the gravity of our predicament, roll back denial, and rapidly put in place the solution frameworks covered above.

Sounds a little bit naïf again. Nature and social behaviour are more complex to be solved this way. A simple recipe is not enough. A better transdisciplinary understanding is needed. I'll continue to refrain from the use of term sustainability.

PS. What is really unsustainaible-irrrrrrresistible is precisely what happened yesterday in our Parliament on this topic.  An horrendous example of an outdated political style. Citizens are demanding to tackle real problems, not more political shows. The future of population health policy starts with consensus. Again, my position is clear. If you don't understand exactly what I mean, have a look at this excellent book by Neil Postman:

Public Health Priorities

Start Well, Live Better: A Manifesto for the Public’s Health. London: UK Faculty of Public Health, 2014

These are the 12 suggested priorities for public health in UK for the next 5 years:

Give every child a good start in life

• Give all babies the best possible start in life by implementing the recommendations of the 1001 Critical Days cross-party report
• Help children and young people develop essential life skills and make Personal, Social, Health and Economic, and Sex and Relationship Education a statutory duty in all schools

• Promote healthy, active lifestyles in children and young people by reinstating at least 2 h per week of physical activity in all schools

Introduce good laws to prevent bad health and save lives

• Protect our children by stopping the marketing of foods high in sugar, salt and fat before the 9 pm watershed on TV, and tighten the regulations for online marketing
• Introduce a 20% duty on sugar-sweetened beverages as an important measure to tackle obesity and dental
• caries—particularly in children
• Tackle alcohol-related harm by introducing a minimum unit price for alcohol of at least 50 p per unit of alcohol sold
• Save lives through the rapid implementation of standardised tobacco packaging
• Set 20 m.p.h. as the maximum speed limit in built-up areas to cut road deaths and injuries, and reduce inequalities

Help people live healthier lives

• Enable people to achieve a good quality of life, health and wellbeing—give everyone in paid employment and training a ‘living wage’
• Reaffirm commitment to universal healthcare system, free at the point of use, funded by general taxation

Take national action to tackle a global problem

• Invest in public transport and active transport to promote good health, and reduce our impact on climate change
• Implement a cross-national approach to meet climate change targets, including a rapid move to 100% renewables and a zero-carbon energy system

As you can see, many similar things with our PINSAP, the Health Policy Consensus and Health Plan. However, after yesterday news the pending issue of our public health is mainly alcohol abuse. We should focus on what works to reduce alcohol and addictive substance abuse. And first of all, we need to understand the foundations and best approaches to the problem. I would suggest you have a look at this book and specially this one:

PS. Binge drinking 'costing UK taxpayers £4.9bn'  Does anybody know how much does it cost here???

PS. In Spain, publicly funded health expenditure reached 64.150 million € in 2012,the amount for financial system bailout was 101.283 million € (p.24). Don't forget it: these are the priorities.

Healthcare satisfaction guaranteed

La veu de la ciutadania: Com la percepció de la ciutadania es vincula a la millora dels serveis sanitaris i el sistema de salut de Catalunya

In Exit, Voice, and Loyalty (1970), the book written by Albert O. Hirschman, you finally understand that the ultimatum that confronts consumers in the face of deteriorating quality of goods is either “exit” or “voice”. Exit is equivalent to the invisible hand of markets in Adam Smith. The greater the availability of exit, the less likely voice will be used. However, loyalty may modulate the final impact. Loyal members become especially devoted to the organization's success when their voice will be heard and that they can reform it.
Under mandatory publicly funded health insurance, the role of voice is specially relevant to fulfill citizens expectations. The efforts to measure patient satisfaction provide precise information on this issue. Now you can find an excellent report that summarises recent trends under a strict methodology.
The results (from p.65) are clear: currently the levels of satisfaction with public health services are higher than at the begining of the crisis. I have already posted about the same before, however what you'll find today as headlines in the newspapers is exactly the opposite. Journalism ethics is not currently in its best days. As citizens we deserve better consideration.
Fortunately, internet allows to bypass journalists ("exit" in Hirshman words), though it requires a dose of extra effort and only a minor part of the population is prone to assume it.
If healthcare satisfaction is rising, as it is, then no need for exit, citizens will remain loyal.

PS. In case of severe disease, voluntary health insured members would use private services in 32% of cases, while public sevices in 39% of cases. P.9 of the barometer.

PS. Journalism ethics: Seek Truth and Report It

Piketty's nuances

After selling 1.5 million books, now Piketty says:

The way in which I perceive the relationship between r>g and inequality is often not well captured in the discussion that has surrounded my book. For example, I do not view r>g as the only or even the primary tool for considering changes in income and wealth in the twentieth century, or for forecasting the path of inequality in the twenty-first century. Institutional changes and political shocks— which to a large extent can be viewed as endogenous to the inequality and development process itself—played a major role in the past, and it will probably be the same in the future.

His obsession with taxation remains:

In my book, I propose a simple rule of thumb to think about optimal wealth tax rates. Namely, one should adapt the tax ratesto the observed speed at which the different wealth groups are rising over time.

One of the main conclusions of my research is indeed that there is substantial uncertainty about how far income and wealth inequality might rise in the twenty-first century, and that we need more financial transparency and better information about income and wealth dynamics, so that we can adapt our policies and institutions to a changing environment. This might require better international fiscal coordination, which is difficult but by no means impossible.

Why is he focusing strictly on taxation, while admitting that institutional changes and political shocks play a major role?

So what?. Maybe the inequality explanation lies on housing wealth... and not on the return on capital. Anyway, the profitability from the book -for Piketty- is huge, and the solutions remain uncertain.

PS: WSJ, The economist,

PS. From the last Sistema Nacional de Salud report p.170:
"Extremadura con 9,5% de gasto sanitario público sobre el PIB, junto con Cantabria con 8,3% y Murcia con 7,9% fueron las comunidades autónomas que presentaron en el año 2012 el porcentaje más elevado. En el extremo opuesto se encontraba Madrid con el 4,1% de gasto sanitario público sobre el PIB y Cataluña con 4,9."
These are facts, not opinions. Now you can understand why we want to leave from this state soon,  double of public budget over GDP under the same taxation system!. Unacceptable. Good bye!

The tragedy of commonsense morality

Moral Tribes: Emotion, Reason, and the Gap Between Us and Them

The suggestion by Joshua Green in his book "Moral Tribes" is to put our gut reactions aside, and rely on our utilitarian moral compass for direction. There are two fundamental moral problems. Me versus Us is the basic problem of cooperation. Our brains solve this problem primarily with emotion and thanks to these automatic settings, we succeed in this controversy. However complex moral problems are about the latter, Us versus Them,-between tribes, not within tribes-.

The morality concept:

 Morality is a set of psychological adaptations that allow otherwise selfish individuals to reap the benefits of cooperation

The fact:

Two moral tragedies threaten human well-being. The original tragedy is the Tragedy of the Commons. This is a tragedy of selfishness, a failure of individuals to put Us ahead of Me. Morality is nature’s solution to this problem. The new tragedy, the modern tragedy, is the Tragedy of Commonsense Morality, the problem of life on the new pastures. Here morality is undoubtedly part of the solution, but it’s also part of the problem. In the modern tragedy, the very same moral thinking that enables cooperation within groups undermines cooperation between groups. Within each tribe, the herders of the new pastures are bound together by their moral ideals. But the tribes themselves are divided by their moral ideals. This is unfortunate, but it should come as no surprise, given the conclusion of the last section: Morality did not evolve to promote universal cooperation. On the contrary, it evolved as a device for successful intergroup competition. In other words, morality evolved to avert the Tragedy of the Commons, but it did not evolve to avert the Tragedy of Commonsense Morality.

This is a very interesting and intricate book that requires rereading. There are strong implications for health economics. His recommendations, to be discussed (some day), are the following ones:

The six rules for modern herders:

• 1. In the face of moral controversy, consult but do not trust, your instincts.
• 2. Rights are not for making arguments; they are for ending arguments
• 3. Focus on the facts and make others do the same
• 4. Beware of biased fairness
• 5. Use common currency
• 6. Give

PS. You may apply his arguments to the current political nightmare, and it fits perfectly.

The identified person bias

Identified versus Statistical Lives: An Interdisciplinary Perspective

The concept:

The identified person bias: A greater inclination to assist (and avoid harming) persons and groups identified as those at high risk of great harm than to assist (and avoid harming) persons and groups who will suffer (or already suffer) similar harm but are not identified (as yet).

 The issues:

1. When precisely does the identified person bias arise? And what exactly does it consist in? For example, is it simply a matter of a very human response to the vivid human faces of people with personal stories, in the hospital ward or on TV screens? Is it something that arises only when the risks are known, only under strict  uncertainty, or regardless of how much we can specify the risk? Does that bias arise only when few victims are involved?
2. What, if anything, might justify giving priority to identified persons at risk?
3. What would be the practical implications for law, public health, medicine, and the environment of accepting the priority given to identified persons, or of forsaking it—if we could successfully do so?

The book, a must read:

 

PS. Former post on the same topic.

PS.  Harvard events of interest.

Don't think of privatization

Let's do a little thought experiment today.

Close your eyes. Imagine a privatized healthcare consortium as vividly as you can. It is clear! Is it? There are private owners. Or seems to be some officials geting dividends?

Now, I want you to NOT think about privatization. Think of anything else but privatisation. Try it for a few minutes.

What are you thinking of? How many times did the privatization issue cross your mind? Quite a few times, right?

Now, close your eyes again and try to think about what you did for today? Who you met? Where you went? Anything interesting happened when you were traveling? What did you eat for breakfast/lunch? Try it for a few minutes.

How many times did you think of privatization? None? Maybe once or twice especially since I asked this question?

This is an exercise that shows that suppressing your thoughts in your mind doesn't really work. When we try not to think about something and try to suppress it, our minds keep going back to the same thoughts. This is a well known experiment from Wegner et al. (Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thoughts suppression. Journal of Personality and Social Psychology, 53, 5–13). As you know, I could also refer to Lakoff mental frames and its: Don't think of an elephant for different evolutive and modern cognitive perspective, but I've done it before.
If you combine deception -about the concept of privatization- and the difficulty of suppressing your thoughts, you'll get the current health policy mess. Distraction is a strategic move that has alleged political profits. For sure, the whole population only receive the losses from such strategy. We have been installed in this paradigm for many years: the privatization devil is here and there, although there is no shareholder getting any dividend. Fortunately, the world stands beyond spaguetti western films. Ownership has impact on efficiency but depends on the context, sometimes public incentives prevail over private ones, and sometimes is the opposite.
If all these sounds weird to you, have a look at our last Parliament resolution and you'll find the astonishing agreement of all parties against the current ruling party on one issue that doesn't exists: a public consortium privatised!!!. If it is public, as it is, can't be private if the owner is the government, as it is. Disappointing, shameful.
I'm really sad that in my country public representatives play with fire in such a way. I just want to say today, that I'm available for those deputies interested in a free private lecture on organizational economics, on what ownership is and what it means for efficiency. Just give me a call or send me an email.

A relaxing cup of café con leche

Genetic testing: a knotty problem

Food and Drug Administration. Optimizing FDA's regulatory oversight of next generation sequencing diagnostic tests — preliminary discussion paper

Cutting the Gordian Helix — Regulating Genomic Testing in the Era of Precision Medicine

"Scientific progress alone won't guarantee that the public reaps the full benefits of precision medicine, an achievement that will also require advancing the nation's regulatory frameworks"

This strong statement reflects a wider concern on the implementation of precision medicine or stratified medicine. I have commented before on this issue, the NEJM article of this week clarifies the last attempt by FDA to shed some light and a specific approach to disentangle the current challenges. FDA has submitted a document for comments just to start a new era of regulation in health, a "collaborative framework" for creating reliable databases of genes and genetic variants underlying disease, and provide a "safe harbor" for the interpretation of genomic tests.
This is exactly the right direction. As long as, information is a public good, genetic testing -clinical validity and utility- should be provided only by the regulator.  Professionals and citizens need to trust in precision medicine and avoid snake-oil sellers.
Having said that, today I'm more concerned than yesterday on how our government is delaying to start such effort. Today is one more day lost.

Dufy at Thyssen Museum right now

PS. Somebody should think twice about the style of health policy debates in public TV.

In favour of consumer protection

Can Consumers Make Affordable Care Affordable? The Value of Choice Architecture

Healthcare.gov 3.0 — Behavioral Economics and Insurance Exchanges

Recently Google has entered in the insurance comparisons market. Right now is available for car insurance and health insurance could be the next step. This business model changes the search costs and has strong impact over current sales channels. Understanding the salient features of health coverage for any citizen, should require that government regulates the right conditions for consumer protection. If insurancee companies pay the comparison site, as google says, is there any change on how information is shown according to the amount paid?. Have a look at the Peter Ubel et al. article at NEJM or at the PLOS one, and you'll be convinced that the potential for manipulation is huge.
Therefore, if this is so, there is a role for protecting consumers against well designed biases in comparison sites.

Practice makes perfect

Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain

My concern over variations in clinical practice relies on a specific issue. Once you've describe it, you need to understand its implications. Thus, somebody should assess whether variations cause poor health outcomes. Before starting such a task, somebody has to measure relative performance, and this is precisely what a recent article in EJPH does on CABG surgery in England and Spain. I would like to highlight this statement:

In this article, we use patient-level data within and between two countries to assess the added value of pooling administrative data across countries and to explore hypotheses that may explain differences such as those reported in cardiac care. These may be driven by a small number of hospitals with unacceptably high mortality rates (perhaps due to coding differences or under-performance). Otherwise, country differences in outcomes may be explained by the concentration of services into specialist centres with differences in clinical facilities and staff experience, as reflected by hospital volume of surgery. These hypotheses cannot be tested adequately using within-country data or national aggregates, but lessons may potentially be learned from hospital-level comparisons across countries using comprehensive administrative data.

If we focus on performance, national aggregates confound. And this is focus of the article:

Unadjusted mortality rate following CABG surgery demonstrates a considerable difference between hospitals (particularly in Spain) and between countries (average mortality is 2.3% in England, 5.0% in Spain)

After adjusnting and pooling data from both countries, then results look different:

First, the hospitals’ performance contrasts substantially with the traditional within-country findings. Nine Spanish hospitals are identified as ‘alarms’ in the pooled assessment compared with five in the country-specific assessment. Thirteen Spanish hospitals are additionally identified as ‘alerts’ that were within the normal range when considering Spain alone. Four English hospitals are now identified as alerts and none is assigned alarm status. Second, there is a clear separation in the number of expected deaths between English and Spanish hospitals, reflecting differences in volume across countries. The median hospital surgical volume in Spain is 154 patients a year, compared with 690 in England, and the highest volume hospital in Spain treated 337 patients in 1 year, whereas the lowest volume hospital in England treated 327. Third, despite the large overall between-country difference, the vast majority of hospitals in England and around a third of those in Spain lie within or below the 95% funnel and are largely comparable in terms of their SMR.

This is an excellent explanation of "practice makes perfect" argument. And, if this were the only factor, there is a compelling reason to concentrate CABG surgery in certain hospitals and close services in others. We know that some concrete hospitals may have high adjusted mortality rates and deserve a concrete action. Urgent decision is needed, just to reduce mortality ratio by half.

PS. The whole issue on variations in EJPH represents a milestone in health services research. Congratulations to the authors and the ECHO project.

PS. GCS blog on the same topic.

PS. New book available: The Triple Aim for the future of health care by Núria Mas and Wendy Wisbaum

An illusionary free lunch

Some months ago I started a series of posts under the title "Fasten seat belts". The topic is well known, how new skyrocketing drug prices are distorting budgets and access. Yesterday we got the final resolution. Fasten you seat belt, this is the moment of truth: The government has decided that hepatitis C patients under specific conditions will get treatment. And once he has decided coverage, he concludes that he will not pay the bill. Somebody else will have to do it, autonomous communities governments. Free lunchs exists in Sepharad!
This is a complete mess and it is only the begining, new drugs are knocking at the door. For catalans, this foreign decision represents 470 m €, an additional deficit for the 2015 budget of 5.7%!!! (if all expenditure were charged in one year). Does this make any sense?. Of course Basque country is not included in such arrangements...
There is an objective need to disconnect, the time is getting closer. Things couldn't have been done worse.

Beyond the genome

FORUM Epigenomics. Roadmap for regulation. Diseases mapped

My suggestion for today. Have a look at the papers in Nature on epigenome, and at the following figure:

The Roadmap Epigenomics Project has produced reference epigenomes that provide information on key functional elements controlling gene expression in 127 human tissues and cell types, and encompassing embryonic and adult tissues, from healthy individuals and those with disease. a, Many of the adult tissues investigated were broken down by cell type or region — blood into several types of immune cell, for instance, and the brain into regions including the hippocampus and dorsolateral prefrontal cortex. Tissue samples and cells were subjected to a range of epigenomic analyses, along with genome sequencing and genome-wide association studies (GWAS). b, Embryonic stem (ES) cells, which are taken from the embryo at the 'blastocyst' stage and can give rise to almost every cell type in the body, were used to analyse, for example, the differentiation of stem cells into different neuronal lineages. The ES-cell-derived cell lines underwent the same epigenomic analyses as the tissue samples.

The key article, here.Tissues and cell types profiled:

For decades, biomedical science has focused on ways of identifying the genes that contribute to a particular trait, or phenotype. Approaches such as genome-wide association studies (GWAS) identify locations in thhuman genome at which variations in DNA sequence are linked to specific phenotypes, but if the variant is located in a region of DNA that does not encode a protein, such studies rarely provide insights into the regulatory mechanisms underlying the association. In these cases, comprehensive epigenomic analyses can provide the missing link between genomic variation and cellular phenotype.

If this is so, why are governments reluctant to introduce a ban on genetic tests with spurious associations between genome and diseases?




PS. Manel Esteller in DM.

A closely guarded secret

Stealth Research. Is Biomedical Innovation Happening Outside the Peer-Reviewed Literature?

How can we identify a snake-oil seller?. Not so easy. Have a look  at JAMA, John Ioannidis article shows his concerns about Theranos, a company that is providing lab services with a new propietary technology that has no peer-review article in any scientific publication. Nobody can check tests sensibility and specifity, no external quality controls, and so on.
If this is the path for the future of health care provision, then I am really concerned because it will be a complete disaster. No consumer protection, no regulation, uncertain science and more uncertain outcomes. After all this years, is this what citizens deserve?.
Such style of "laissez-faire, laissez-passer" medicine could represent huge profits for some and a big loss for everyone.
Otherwise some alternative should be proposed to boost publication and transparency. The author's suggestion is the following one:

To solve this conundrum, it may be necessary to find ways to realign the reward system for innovation. One possibility is to make the scientific literature more receptive to innovators. This could include models in which reports of disruptive discoveries that are in dissonance with the mainstream can still be communicated as preprints without prior peer review, perhaps in the same way as the successful example of arXiv in the physical sciences, which has now reached 1 million e-print articles. That there has been no peer review of these initial reports should be transparent to researchers and the public.

Thus, some better regulatory process is needed so that innovative ideas for financially successful applications can be scrutinized by the wider scientific community as to their validity. A company should not be forced to disclose its science secrets in detail, especially while its efforts are still exploratory rial-and error and while creating basic elements for its products and services. However, if a product or service reaches the point at which it generates substantial revenue, the science behind it should then be communicated in detail to ensure adequate review.

Opening the door to recreational genetics testing

On February 19th, the US Food and Drug Administration (FDA) authorized 23andMe to market a direct-to-consumer (DTC) carrier test for Bloom syndrome. Such test was classified as a medical device, and exempting it from premarket review. This may pave the way for DTC genetic testing in the US market.
The decision to open door for one test may represent the biggest move towards a recreational genetic testing market. You know that from this blog I have backed a ban on developing such markets and the need for an effective regulatory review different from the flawed medical device system.
The european regulator is still on holiday, I said that some months ago and it is still "out".

PS. Variations in health care in GCS Blog.

Lakoff brilliant analysis

Handbook of Neurosociology

Today I would like to quote a clever analysis of US health reform. Just as an alert for any other country that wants to start a similar process.

Solving a Social Science Puzzle

In 2009, when President Barack Obama chose the policy provisions for his health care plan, polls showed that most provisions (e.g., no preconditions, choice of plans) were supported by 60–80% of Americans. Yet, when the whole plan was polled, fewer than 50% supported it. Why? Why the disparity between the parts and the whole, when the whole literally equals the sum of the parts?
The answer is straightforward from the perspective of real reason. When President Obama came out with the provisions of his health care plan in early 2009, the conservatives decided to attack it not on policy grounds but on moral grounds. They chose two areas of morality: Freedom (“government takeover”) and Life (“death panels”). And they repeated over and over that “Obamacare" (naming matters) was a government takeover that was a threat to individual freedom, with death panels that were a threat to life itself.
Note that the policy provisions were about the everyday details of dealing with one’s HMO. They were in the Practical Health Care Details frame. The conservative attack was in the Morality frame, activating freedom and life. The conservatives understood that all politics is moral, that political lead- ers all say they are doing what is right, not what is wrong.
The policy details and the moral attack were in different frames, located in different parts of the brain. From the perspective of real reason, the whole health care act was, for those with a conservative worldview, not equal to the sum of its policy parts. Conservatives and independents (actually biconceptuals, who are progressive in some respects and conservative in others) had their conservative moral worldview activated by the conservative moral attack. This separated the moral whole from the practical parts.
For progressives, their morality and the practical details fit together; for conservatives and biconceptuals (aka “independents”), they were different subject matters.
Such an explanation is natural when you think in terms of the brain and frame-circuitry. It is not possible when you think in terms of the logic of Enlightenment reason, where the whole is necessarily (logically) the sum of the policy parts

PS. You may find former posts about George Lakoff's work on cognitive science, here and there.
PS. This is the coda of the first chapter of the book. The whole chapter is a must read for those interested in "brain circuitry", language, metaphors and politics.

Thresholds' controversies

Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis

The threshold for cost-effectiveness is under controversy again. This is not new. FT explains a new York University paper that has created great concern. Is it NICE cost-effectiveness way of implementation really "cost-effective"?. From their point of view, thresholds are higher than they should be to guarantee access.
Thresholds are only one side of the coin. The other one is the introduction of equity criteria in cost-effectiveness analysis. Three years ago, I explained this topic in a post commenting on Tony Culyer''s article. He says that there are two "dragons" in dealing with cost-effective analysis: equity and our ignorance about how to introduce it. I then quoted this statement:

‘Arguably the biggest threat to our public health care system is not our ability to pay for the increasing cost of care, but rather a loss of public confidence.’’

An older post on Eddy's work explains similar concerns over thresholds and equity. We have to convene that there is not only one method to do it. However, some well known academics have published an interesting proposal: criteria for access to be considered jointly with cost-effectiveness.

The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).

Basically, these criteria are well known. The difficulty of its measurement has yet to be overcome.

PS. My former post on the same topic and authors in York. 

Medicine as a data science

THE PATIENT WILL SEE YOU NOW
The Future of Medicine Is in Your Hands

Maybe the title is the most confounding factor of the new great book written by Eric Topol.  Once you have finished reading it, you'll be convinced that he set the expectations to high, ordinary people should develop certain skills beyond their capabilities to apply such concept. I would say that a greater part of the medicine is in your hands, not medicine at all. The rationale behind the book is that medicine digitization allows patients to know more about their disease and how to "manage" it in certain cases. The most important thesis is that future medicine has to be considered a data science. And this is exactly the impact of the digitization of diagnostic and treatment: pervasive application of Bayes theorem in clinical practice, using big data and analytics.(Remember my archimedes posts, surprisingly Topol forgot it).
The book includes many topics that those that follow this blog it would sound familiar, i.e. ch. 4 about Angelina Jolie and BRCA genetic tests, a must read. And chapter 5 is a journey on the new omics of the medicine, a topic that I have also covered in the blog.
Nowadays, Eric Topol is the writer that is able to capture what's going on in medicine and its impact on society. That's why this book is a key reference of our time and I strongly recommend it.

PS. If you don't believe me, check Forbes, NYT, WP, WSJ.
PS. The book is also an invitation to change the current academic programmes for life sciences universities. Better now than later.

Less volume, more value

From 2009 to 2013, the number of primary care visits has fallen by 12.5%, from 51.1 million to 44.7 million, 6.4 million visits less. This is a lot!.
Sometime ago I posted on the same topic. The number of professionals has shrunk slightly, 2.5%. The result is that there is more time for the same patients because the population is closely the same. Therefore, we have to confirm that the impact of electronic prescription and other organizational strategies have a larger effect than anybody could guess, compared to the copayment mantra. However, a deeper analysis of the causal factors and its relationship with health outcomes is needed. We know that there is less volume and we have some clues about more value, though not enough for a sound conclusion.

Health policy extremism and radicalisation

Going to Extremes: How Like Minds Unite and Divide

After reading this accurate article by Guillem López-Casasnovas, I thought that it was worth to quote Sunstein book. His key messages are:

• When groups polarize and separate from mainstream society – either psychologically or physically – they can become extremist.
• People change their attitudes when they want a group to accept them.
• People will abdicate moral decisions to a recognized authority.
• Collective behavior, or “groupthink,” provides a means of identifying decision-making processes that lead to extremism and mistakes.
• Information moves and amplifies among groups via “social cascades.”
• Investment clubs making decisions by unanimous votes produce the worst investment returns.
• Group deliberation produces sounder decisions than individuals acting alone.
• Techniques to blunt extremism include traditionalism, consequentialism, and checks and balances.
• Informational cascades can affect markets and mass behavior.
• In a democracy, information, criticism and skepticism combine to improve an institution’s performance.

Take care, we are right now on a social and informational cascade. Have you noticed?

A bit worse before it gets better

Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease

A new mental frame was created some weeks ago when President Obama gave a speach on the creation of the initiative on Precision Medicine. To be honest, the term was in the title of a 2011 report by IOM.
In my opinion, it is a bundle: stratified medicine+big data+regulatory science+... This is the bundle of the new buzzword, and unless new details arise, nothing specially new.
Now the New Yorker speaks abouts the problems of precision medicine, and focuses on the risks. The final paragraph illustrates the issue:

For Solomon, genetics is simply a new tool with a learning curve, the same as any other. “When the electrocardiogram was first developed, about a hundred years ago, most physicians thought it was voodoo,” Solomon said. “Now, if you don’t understand it, then you shouldn’t be practicing medicine.” But Mary Norton sees that analogy as too simplistic. The pace of genetics research, the variability of test methods and results, and the aura of infallibility with which the tests are marketed, she told me, make this advance a more complicated one than the EKG. Norton believes that, as genetics becomes increasingly integrated into medical care, “over time everyone will come to have a better understanding of genetics.” But, as the demand for DNA testing increases, she says, “it will probably be a bit worse before it gets better.”

Could we avoid the initial bit worse of  "imprecision of stratified medicine"? . I'm full convinced that appropriate regulatory efforts could mitigate such impact. Unfortunately, governments are on vacation.

Dancing to public accountants' tune

I would have never imagined that the health policy could have been distorted and dictated to by public accountants. Yes, you have heard correctly. European Union and its statistical arm, Eurostat, has decided what is a public firm. And the decision is so anomalous that it deserves a short comment.
We all know and agree that public accountants need to define with accuracy the size of government deficit. They consider what is public administration according to several criteria (p.25), this is their responsibility. However, the collateral damage of doing it in a weird manner, puts a severe strain on the health system as we know it today.
Management autonomy has been introduced in the last decades within the publicly financed system under a myriad of different organizations. Today, the application of ESA 2010 -the accounting rules in place since last September 1st- represents that all of them have to follow the same path and autonomy will be jeopardized. We will be dancing to public acountants' tune.
Management autonomy helps to boost efficiency, even in public systems where incentives are low-powered. Hence, when somebody complains in the near future about inefficiency, we'll have to remember that european public accountants and its politicians have contributed to worsen health systems. Thank you so much, accountants.

PS. Please save this post for the future. It will have strong implications.

PS. This is the end.

The hype over genetic tests

Implementation of a companion diagnostic in the clinical laboratory:The BRAF example in melanoma

Analytical validity is one of the three steps for any assessment of genetic tests, combined with clinical validity and clinical utility. Understanding how this process affects specific tests is not that easy.Fortunately you can find a detailed explanation of one of them:the BRAF genotype analysis in tumor tissue samples for identification of melanoma patients that can benefit treatment with BRAF inhibitors.
Once you begin to read the article you'll understand the complexity of being precise in a test. This is the reason why if specificity and sensibility is uncertain, different methodologies are needed (check Figure 1).
But how to do it?. How to set up external controls of quality?. All these issues are covered in this article, that explains what's going on in practical terms. I'm concerned if due to such complexity, all "genetic test talent" is not concentrated in one site of the organization-hospital, and many departments and services -oncology or cardiology- are developing their own genetic tests. Somebody should block this option before it is too late.

The size of the health budget

In 2015 the per capita expenditure (1,120€) will be the same as in 2006, nine years earlier (p.46). The economy follows exactly the same pattern. GDP per capita in 2014 was less than in 2006. Therefore, those that are concerned about stagnation and cutbacks, should look at statistics. The health budget is set according to political criteria, and what this amount reflects is exactly the same social effort to cover health risks as before the crisis.
Unfortunately I haven't seen this argument in any debate, up to now. It's really annoying that ideology overpowers evidence.

PS. James Buchanan blog in BMJ

PS. Robbed by the Kremlin in the WSJ.

Mandatory complementary private insurance

Compulsory private complementary health insurance offered by employers in France: Implications and current debate

It looks strange at a first glance. Why a country with statutory Social Health Insurance (SHI) has to set up a mandate to employers to buy private health insurance for their employees?. In France by 2016 all employers will have to do it, and this complementary insurance covers basically copayments in the SHI system. It is really strange, because copayments are created to reduce moral hazard, hence if somebody insures copayments, then its impact on utilization is the same as if it were no copayments in the SHI but with a high and avoidable loading fee. And, as far as this insurance is mandatory and private, then it makes no sense at all.
Each country decides politically according to the context, nothing to add, though this is a very weird case. You'll find more details in this article.

Is this the end my friend? (2)

Once upon a time there was a country with seven Schools of Medicine for 7,5m inhabitants. The needs for future physicians were estimated 8 years ago and the time goes by but somebody seems he is not aware of that. Some months ago I said that the organization of health care system as we have known it, was at their final days, now I can confirm that medical profession structure is also in the same situation.
A big and unnoticed change has occurred. In 2006, only 1,8% of resident physicians were foreigners, in 2013 this figure has jumped to 32,3% (!). Does this makes any sense?.
How is it possible that our citizens can't study medicine and we are able to open the system to foreigners without the right level of qualifications?. Who is boosting this?. I explained it in this post some years ago, here and there.
The time to disconnect is coming. Enough is enough!

The Dunning Funnel criteria for the health basket

The basic benefit package: Composition and exceptions to the rules. A case study

In the Netherlands there are four criteria to assess any benefit to be included in the health basket:

1. Care should be essential: Does the illness, disability or the care needed justify a claim on solidarity within the existing cultural context?
2. Effectiveness: Does the intervention do what it is expected to do? In other words: it is proven to be effective and evidence based.
3. Cost-effectiveness: Is the ratio between the cost of the intervention and the outcome
acceptable?
4. Feasibility: Is it feasible to include the intervention in the basic package, now and in the future?

This is known as the funnel originated by a commission report chaired by Mr. Dunning in 1991. The application of such criteria has been evolving and a recent article says that some benefits have followed a yo-yo effect, being in and out of the package for unspecified reasons. I think that it is better to have some clear principles and justify its application, than not having any.
Here we have some principles, sometimes we change them, sometimes we assess them, sometimes not and nobody knows why.

PS. The Irish  have made a recent effort of definition in this report.

The challenge of setting fair priorities

Public views on principles for health care priority setting: Findings of a European cross-country study using Q methodology

The clash between equity and efficiency is featured nowadays with hepatitis C drugs. High prices mean that access requires some kind of prioritisation. An interesting article may help to understand it:

 Resources available to the health care sector are finite and typically insufficient to fulfil all the demands for health care in the population. Decisions must be made about which treatments to provide. Relatively little is known about the views of the general public regarding the principles that should guide such decisions

The tension between equity and efficiency in the health care sector is apparent in a range of routine decisions and practices. For instance, in the prioritisation of patients on a waiting list, the aim to maximise overall health benefits from treatment may be at conflict with that of obtaining an equitable distribution of health and health care.

 Now ask yourself about the following principles to allocate health resources:

(I) “Egalitarianism, entitlement and equality of access”;

II) “Severity and the magnitude of health gains”;

(III) “Fair innings, young people and maximising health benefits”; 

(IV) “The intrinsic value of life and healthy living”; 

(V) “Quality of life is more important than simply staying alive”.

 Are you able to set a ranking? Does a general ranking of priorities always apply to all cases?. Not so easy. This is exactly what they do in the article and the results are:

Given the plurality of views on the principles for health care priority setting, no single equity principle can be used to underpin health care priority setting. Hence, the process of decision making becomes more important, in which, arguably, these multiple perspectives in society should be somehow reflected.

Let's think about the somehow...

PS. Sofosbuvir vs. NICE . And the winner is?

The satisfaction paradox and the need for a dose of realism

A paradox is a "situation that is made up of two opposite things and that seems impossible but is actually true or possible". This is exactly what is happening to satisfaction with health services in times of economic recession. Everybody would think that less budget damages satisfaction perception. What's going on is exactly the opposite. Satisfaction with health services is increasing (from 79% of people satisfied with the public system in 2006 to 88% in 2013). And this is also happening in the UK, John Appleby et al. from King's Fund say:

Overall public satisfaction with the NHS increased to 65 per cent in 2014 – the second highest level since the British Social Attitudes survey began in 1983. Dissatisfaction with the service fell to an all-time low of 15 per cent.

One interpretation of the increase in overall satisfaction for the NHS is that it is likely to reflect a vote of support for the NHS as an institution in difficult times. A lack of objective improvement in NHS services and the fact that improvements in satisfaction appear to have been driven by an 11 percentage point increase in satisfaction among Labour supporters and those without recent contact with the service, may lend weight to this analysis. This may especially be the case given that some see the NHS as currently under threat, for example from privatisation, and some feel ministers and others have been too critical of the NHS and its staff.

Official measures of performance tell a different story: NHS funding has been under increasing pressure since 2010 and there have been well-publicised performance problems with high-profile targets such as the 4-hour A&E waiting time standard and the 18-week maximum wait from referral to treatment. At the same time, the media has featured negative stories about the financial position of NHS hospitals and the need for additional investment in the service.

This context suggests a possible alternative explanation for the increase in satisfaction in 2014. We know that what drives changes in satisfaction is not straightforward – and almost certainly is never simply satisfaction with the NHS per se, for all respondents to the survey. Political beliefs, attitudes towards the government of the day, media stories and expectations of the NHS will shape people’s satisfaction.

So, while satisfaction improved in 2014, this is not necessarily synonymous with an improvement in the actual performance of the NHS, nor does it simply reflect an actual improvement in satisfaction. Nevertheless, it is clear that public satisfaction with the NHS and support for it as an institution remains high.

I suggest you have a look at the report. Satisfaction is a different dimension from performance, good point. If overall performance is based on healthy life expectancy, then the conclusion for us would be the same. We have increased healthy life expectancy all these years.

Those that complain about austerity want to forget such results. Also journalists. They don't figure out that the issue is a balanced budget and cutbacks have not been applied on an ideological foundation as some pretend. Anybody can blame over budget cuts, but immediately they would have to understand what they would do at home if their income is 7 years less than  before (2013 GDP per capita is less than those in 2006!!!). For sure they would return to an expenditure level simliar to previously,  in one way or another. Can anyone defend that these are ideological budget cuts at home?.
You can't live permanently in increasing debt, I'm satiated of cheap populism. A dose of realism is required.

PS. As you may notice, realism begins after reading the data, but you have to read them.