Daily Hospital News: June 2011

Thursday, June 30, 2011

NHS reforms could reduce patients' trust in doctors, BMA warns

Association fears that GPs may be suspected of withholding treatments and referrals in order to increase their pay

The leader of Britain's doctors has warned that coalition plans to reward GPs for enforcing budgetary controls could fundamentally damage trust with their patients.

Dr Hamish Meldrum, the chairman of the British Medical Association, said the suggestion under revamped plans from the health secretary, Andrew Lansley, might lead to allegations that doctors were withholding patient treatments and referrals to increase their pay.

The warning, made on the eve of the BMA's annual meeting in Cardiff, will be seen as another direct challenge to the government's plans for the NHS. David Cameron has already been accused by Labour of being forced into a dramatic U-turn after ditching his original reform plans for the NHS in England.

Meldrum said the BMA has "great reservations" about government plans to reward GPs for the high-quality commissioning of services.

"If patients even suspected that their GPs might be rewarded for how well they do, and particularly how well they do financially in terms of commissioning – giving way to suggestions such as 'You may not be referring me, you may not be investigating me, you may not be prescribing for me because that actually means money in your pocket' – well, that would seriously damage the trust.

"While we have always argued that doctors must be a part of the decision-making process, it has to be in partnership with patients and done in a way that doesn't undermine that trust," he said.

He said that the relationship between patients and their GPs would be a theme throughout the BMA's delicate negotiations with the government over the future role that its members would play in a changed NHS.

" At times of crisis, trust is more important than ever. There is a danger that this may be put at risk by some of the government's plans.

"The public is not prepared to gamble with the future of the NHS, and doctors are not prepared to see this trust abused by government policies that could undermine the value of doctor-patient relationships," he said.

An Ipsos Mori survey released by the association to coincide with the conference claims to show that doctors are the most trusted profession, with 88% of the public generally believing they tell the truth. The figure compares with 81% of teachers, 68% of clergy, 29% of bankers and 19% of journalists. Government ministers, on 17%, and politicians, on 14%, occupied the bottom two places. More than 1,000 members of the public were asked to say whether thy trusted people who worked in 21 different professions.

The association is in the middle of examining detailed government amendments to the original bill, and is expected to suggest further improvements, for example, in the make-up of clinical commissioning groups.

Meldrum cautioned the government on allowing cuts to be implemented without proper consultation of doctors and other professional staff.

"The government has correctly said that it is not going to cut the budget, but it's not going to grow as it has done in previous years. We are going to have to use the money more wisely. I have not seen yet how those savings are going to be made.

"We will certainly react strongly to some of the knee-jerk, slash-and-burn responses in some areas where they don't seem to be having those discussions. There needs to be a much more mature dialogue that takes place," he said.

This week's conference is expected to be a heated affair, as doctors debate the future of the NHS while struggling to comprehend government amendments announced last week.

On Monday, they will debate spending cuts within the NHS. The health and social care bill will be debated on Tuesday.

Rajeev Syal

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Who listens to Britain's cleaners? | Ellie Mae O'Hagan

Politicians are deaf to those at the bottom of a recession-hit market and managers cut their jobs. So it's down to the union

Last week I caught up with an acquaintance from my past: Paddy, who acted as my Unite union rep when I worked as a cleaner at Ysbyty Gwynedd hospital in north Wales. At the time I was employed by Initial, a private company whose management was so woeful that the hospital reverted to employing cleaners in-house shortly after I left. Better employee rights would ensue, the cleaners had thought – rights that would reduce industrial disputes, leading to higher wages and better standards.

According to Paddy, my former colleagues' optimism was misplaced. A couple of months ago Betsi Cadwaladr University Health Board, which runs Ysbyty Gwynedd, decided to make 19 cleaners redundant across its three hospitals. The board argues the cleaners were no longer needed.

Unite thinks otherwise, pointing to the fact that the board's poor management has led to spiralling debt; debt for which the cleaners were not responsible but for which they now must pay with their jobs. Lack of staff led to deteriorating standards, says Unite, and the union has now persuaded the board to reinstate the cleaners temporarily, to see if they really are surplus to requirements. Unsurprisingly most of the rehired cleaners are now working fulltime hours again.

The dispute struck me as a grim microcosm of the circumstances we find our country in, where those at the bottom are beginning to suffer the consequences of mistakes made at the top.

Public opinion is slowly conceding the unfairness of this situation as stories of obscene bonuses and soaring executive pay roll on. Our collective British sense of fair play is beginning to flinch in response to an austerity that is anything but transparent and equitable – yet we've stopped short of a discourse on what the cuts reveal about the way our society treats the people at the bottom of the chain.

Hospital cleaning is one of the most important jobs in the workforce – to the extent that the NEF estimates that cleaners generate £10 in social value for every £1 they are paid. Yet it is not cleaners who are offered handsome bonuses and enviable job security, but City bankers who, by the same token, destroy £7 of social value for every £1 of their income. A society with such topsy-turvy values might seem perverse but it is a natural consequence of capitalism: in a system where money talks, low earners are not only left penniless but voiceless.

Our politicians vie for the affections of the "squeezed middle" while those at the bottom are quietly airbrushed out of the picture. So it seems paradoxically reasonable that the leader of the opposition should promote a living wage while extolling the virtues of social mobility. Ed Miliband may pay lip service to the value of jobs like cleaning, but ultimately he sees it as something one should escape from, not aspire to – a job to be done not by him, not by his children, but by others his rhetoric has so far left unacknowledged. From my own experiences at Ysbyty Gwynedd, this lack of acknowledgement is all too familiar: I remember the managers who avoided eye contact, the sense that I couldn't be trusted, the company's lackey with his suit and ample payslip who listlessly assured us that he "understood our concerns".

It is to be expected that a group that society views as "other" will be subject to inhuman treatment. Our politicians showed contempt of their own this week by refusing to ratify an otherwise unanimous UN convention to improve international rights for domestic workers. A spokesperson from Anti-Slavery International said the decision meant the UK was "letting down other countries, it's letting down those most vulnerable to forced labour and abuse … the UK is not only not pulling its weight but is actually trying to pull others back".

Maybe our government thinks it's OK to deny working rights to other functional beings. They probably won't complain, and if they do, nobody will listen. They are, after all, just cleaners.

A country sinking into recession cannot rely on its social strata remaining fixed. Rising unemployment means that those in the squeezed middle might find that they are – like Ysbyty Gwynedd's cleaners – falling through the cracks. At the dark heart of capitalism lies an acceptance that certain people's lives will always be worse than our own. As the comforts most of us take for granted begin to be eroded, it is an acceptance that badly needs to be challenged.

Ellie Mae O'Hagan

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Doctors could take industrial action over 'assault' on their pensions

BMA chief says his members 'will consider every legitimate action' to defend doctors' pensions from overhaul
• Follow developments and have your say at our live strikes blog

Doctors could take industrial action over the government's "unwarranted and unfair assault" on their pensions, the profession's leader has warned ministers.

Dr Hamish Meldrum, chairman of the British Medical Association, delivered a sharply worded rejection of the coalition's pensions plans in his keynote address to the doctors' union's annual conference on Monday.

"Let me make it absolutely clear: we will consider every possible, every legitimate action that can be taken to defend doctors' pensions," he said in a speech to 500 doctors' representatives in Cardiff.

"I have this message for ministers. Whilst we will be reasonable, whilst we will not rush to precipitate action, whilst we will not put patients' lives at risk, do not in any way or for one single moment mistake this responsible attitude as a reason to underestimate our strength of feeling and our determination to seek fairness for those we represent.

"The profession will act responsibly, but we will not accept an unwarranted and unfair assault on our pensions."

Meldrum's remarks, which were greeted with loud applause, underline the strength of feeling among doctors over changes which he said should not be "just a poorly concealed tax on public sector workers".

A doctors' strike is highly unlikely. But there are other forms of industrial action they could take in order to apply pressure, although doctors have not done so since a work-to-rule over contracts in 1975.

The BMA leader was speaking ahead of a pensions debate by delegates on Thursday, where there will be discussions of what steps to take if ministers ignore their concerns.

There are calls for the union "to ballot the BMA membership regarding all forms of industrial action" if there is no rethink.

Dozens of conference motions on the issue show that doctors feel strongly about the possibility of paying more in contributions and losing their final salary scheme.

Meldrum called the government's pensions plans "another major threat hanging over the profession".

He also criticised Danny Alexander, the chief secretary to the Treasury, for, he said, making the job of negotiating a settlement "impossible, if all we hear are public ultimatums and ridiculous threats such as those we heard just a few days ago".

Alexander's signal that ministers planned to press ahead with their overhaul of public pensions drew criticism from Lord Hutton, the Labour peer who drew them up.

Meldrum said that big changes to the NHS pension scheme were unnecessary as it was updated as recently as 2008.

"Fact: even before the imposed change from RPI to CPI and the threat of the imposed Treasury levy, the NHS superannuation scheme was in surplus, and by 2015 the scheme will have contributed over £10bn to the Treasury," he said.

The post-2008 scheme already has tiered contributions to guarantee fairness for lower-paid workers, while all members of the scheme are paying more into it, with the highest-paid contributing 8.5% of their salary, he added.

Dr Andrew Dearden, chairman of the BMA's pensions committee, has warned that if ministers press ahead with their plans more doctors could opt for early retirement in order to benefit from the more advantageous current system.

A doubling of the usual rate of retirements could lead to contributions going down at the same time as costs rise, he said.

Meldrum also warned that, despite the recent changes made to the health and social care bill, the BMA would scrutinise the government's 180 amendments to ensure that "what's been promised is being delivered [and] that this isn't just a case of turning a pig's breakfast into a dog's dinner".

He also urged NHS bosses not to "slash and burn" as they try to operate within the tightest financial climate in the service's 63-year history.

And, while stressing that doctors are not against competition, he reiterated the BMA's opposition to attempts to introduce a free market into the NHS.

Denis Campbell

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Social care is on the critical list. But Dilnot won't cure it | Polly Toynbee

A nation that spends less than 0.5% on old age can hardly expect anything other than a decrepit system. We can do better

Another week, another care home shocker. The family of a resident in Ash Court Care Centre in London hid a camera in a clock and allegedly caught a care worker repeatedly slapping, hitting and shouting abuse at their demented mother, with other staff joining in.

The victim was an 80-year-old former dinner lady, seen on camera crying as she was hit in the face. The family suspected something was wrong when she wept whenever they visited, but she was past explaining. Police arrested a male care worker and suspended four women at the home, run by Forest Healthcare, which owns what its website cosily calls "a family of homes" all over the country. The scandal of these end-of-life warehouses will worsen, subsisting on lower fees, banished to the margins of political concern, the cash-starved regulator cutting inspections by 70%.

Money may not guarantee kind care, but the extreme lack of it makes unkindness, neglect and sometimes cruelty almost inevitable. Labour's record was poor: from 2004 total spending on older people's social care rose by just 0.1% in real terms, despite growing numbers of the very old. In the same years, spending on the NHS rose by an unprecedented £25bn. AgeUK and other charities estimate that home and residential care is £3bn short of the total needed to bring it up to official minimum standards. The political imperative is always to fund the NHS, not social care – a good reason why some suggest forcing the funding together under one budget.

Cameron and Osborne claim their cuts only trim away fat from Labour's spending years. But by no stretch of even their thin grasp on reality could they claim social care was anything but a pitifully skeletal service already. Yet in the last year councils have cut care by a devastating 8.4%, while inflation runs at 4.5%. Social care has moved from the serious to the critical list. How lucky for government that behind the secret walls of care homes, or hidden in people's homes, neglect and cruelty stay unseen as underpaid, untrained agency staff have too little time for washing and feeding, with none at all for "care".

Next week Andrew Dilnot publishes his report on social care. But its headline purpose touches none of the above. Its remit is to solve a problem that you might not think the most pressing of all in these straitened times – to relieve homeowners of the burden of paying so much for their nursing home care.

The coalition agreement promised a commission to "consider a range of ideas, including both a voluntary insurance system to protect the assets of those who go into residential care and a partnership scheme as proposed by Derek Wanless". (The King's Fund/Wanless report proposed a system of joint state and personal). In social care the most pressing political problem has often been dealing with the rage middle-aged children feel at finding their inheritance eaten away when an elderly parent has to go into care: any savings above £23,500 and the value of a property vanishes into nursing home fees. This means-testing falls hardest on those with a few savings and modest homes who lose every penny they planned to leave their heirs. It touches the richest less while penalising the thrift of small savers.

Dilnot's reasonable proposal is to cap what anyone pays at about £50,000, with the state paying anything extra – allowing people to keep the remainder of their wealth. The hope is that on retirement people will voluntarily take out insurance to cover that £50,000, if they want to safeguard it. The state will have to pick up a bill of less than £2bn that is currently recouped through means-testing.

Oddly, yesterday's media protested with "middle classes to pay more" stories, the exact opposite of what is proposed. Middle classes will pay less, the state will pay more, and it's voluntary: only one in six go into care homes, so you can stay uninsured and take your chances. Dilnot sees it as restoring welfare state fairness, since fate and Alzheimer's disease come down so heavily on some families and not on others. This builds a care payment system with public consent that will last, whatever the level of social care funding in future.

Naturally all the care charities, including AgeUK, are enthusiastic. What's not to like in cutting bills for some? Just as naturally, the Treasury is rattling its sabre at any suggestion of paying out more: if it happens at all there will be a white paper and eventually legislation, but with no chance of implementing it until well after the next election.

Osborne is said to be concerned that this smacks of Labour's pre-election plan for a National Care Service: Andy Burnham proposed it be paid for with a compulsory contribution of £20,000 on retirement by everyone with a property, either paid upfront or attached to the value of homes after death. It could only be kept as low as £20,000 if everyone had to pay into a pooled system. Although it, too, preserved inheritances, the Tories hammered it as Labour's "death tax". Mendacious but effective, the slogan worked: few voters understand the care payment system until they need it – then they are shocked to find it's not part of the free welfare state they imagined. Even this system still won't pay full costs, or for care at home.

This is a hot marginal constituency issue as 60,000 families a year are forced to sell parents' homes to pay for care. But it is a sideshow compared with the real crisis. Expect Dilnot to use strong words about the state of decay in care services – but that's beyond his remit. So is the bigger picture, where wealth is sucked up from younger generations to older ones. It may be in his remit to point out that we spend just 0.5% of GDP on social care for an ageing population. The richest generation is my own – the 55- to 64-year-olds – which has enjoyed four housing booms that poured wealth into our pockets for doing nothing at all – and now Dilnot removes the risk of losing much of it when we reach decrepitude.

So if the Dilnot plan is adopted, it should be balanced by other taxes. A mansion capital gains tax on the sale of homes sold over £1m (or less) would raise a hefty contribution to pay back some of the ill-gotten gains of my generation. Why do the over-60s pay no national insurance, however much they earn? Abolishing that would bring in £3bn, and that is enough to repair the shaming state of care.

Polly Toynbee

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NHS patients' complaints procedure must be reviewed 'immediately'

With over 1m complaints a year about the NHS, a cross-party report has recommended stronger safeguards for patients

The government should immediately review the way NHS trusts handle patients' complaints, according to a report by MPs.

The current structure is not working and more needs to be done to encourage a "more open culture" when it comes to dealing with complaints and admitting mistakes, it says.

The report, from the cross-party Commons health committee, says the government has sufficient data to conduct a review and "should do so without delay".

Ministers should seriously consider whether two systems should be created, one dealing with complaints about "customer care" and a second examining more serious complaints about clinical issues.

The role of the health service ombudsman should also be expanded to allow more claims to be examined as part of an appeals process when patients are unhappy.

At present, patients complain first to the NHS trust in charge of their treatment. If they are unsatisfied with the trust's response, they can ask the ombudsman to review their case. But MPs said the ombudsman's remit is much narrower than patients think it is.

A complaint is only accepted for formal investigation or intervention if the person has suffered injustice or hardship as a result of poor service or maladministration, and only if there is the prospect of "a worthwhile outcome".

Only about 3% of the complaints received by the ombudsman are accepted for formal investigation or intervention, although many more are examined unofficially.

Today's report said: "The committee is of the view that a complainant whose complaint is rejected by the service provider should be able to seek independent review.

"The legal and operational framework of the ombudsman's office should be reviewed to make it effective for this wider purpose."

The number of complaints about the NHS is rising and now tops one million a year.

The number of patients seeking independent review from the ombudsman has also risen.

Experts believe the rise could be down to a mixture of factors including worsening NHS care, increased demand for healthcare and better awareness of the complaints process.

MPs also used today's report to calls for stronger safeguards for patients in the government's reform of the NHS.

Foundation trusts, which all hospitals will become under the plans, do not currently have a duty to supply data on the complaints they receive, but this must change.

The committee also condemned the activities of claims management companies (CMCs), which collect claims, assess their likely value and then sell them on the personal injury lawyers or legal firms.

MPs said claims are sometimes sold to the highest bidder without regard as to whether that lawyer is best placed to help the patient.

These "claims farmers" are worrying because they "encourage people to go straight to litigation rather than use the complaints resolution mechanisms" and can "unduly contribute to the rising costs of litigation to the NHS".

The report adds: "The committee therefore proposes that the government review the regulatory structure within which these businesses operate in order to ensure that patient and taxpayer interests are properly safeguarded."

MPs also scrutinised the government's plan to end legal aid for clinical negligence cases, saying the public will judge these proposals by how they alter access to justice.

Tory MP Stephen Dorrell, chair of the committee, said: "The legal and operational framework of the health service ombudsman should be widened so that she can independently review any complaint which is referred to her following rejection by a service provider.

"The ombudsman's current terms of reference prevent her from launching a formal investigation unless she is satisfied in advance that there will be a 'worthwhile outcome'.

"We have concluded that this requirement represents a significant obstacle to the successful operation of the complaints system.

"Patients should be able to seek an independent review of the findings of internal reviews by care providers; the terms of reference under which the ombudsman works prevent her from properly fulfilling this role. This needs to be changed."

Peter Walsh, chief executive of Action against Medical Accidents, said: "This report could not be more timely and underlines the need to rethink current proposed health and legal reforms.

"Like us, the committee welcomes the introduction of a 'contractual' duty of candour, as announced by the government recently, but sees that this must be augmented by making such a duty a condition for licensing by the Care Quality Commission.

"We urge the government to take this step without delay."

The report covers the complaints system in England.

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The small mental health services struggling to fit in

As health provision is restructured in the face of cuts, there are fears that small, voluntary mental health services are the casualties

Housed in a nondescript building among a row of shops, Camden Psychotherapy Unit (CPU) is a small community-based voluntary mental health service providing long-term psychotherapy for residents of Camden, in north London. A typical patient might have long-standing problems with depression or anxiety that antidepressants or less intensive "talking therapies" such as cognitive behaviour therapy have failed to address.

It treats around 80 patients a year, most of whom are on low incomes or on benefits and would not be able to afford this kind of treatment privately. Many are self-referrals, for whom the long waiting lists for therapy in the statutory sector are a major hurdle to recovery, says unit head Ora Dresner. Because CPU is not in a traditional clinical setting, vulnerable people, who would find the "institutionalised" environment of hospitals intimidating, feel comfortable approaching, she adds.

Dresner, who has been at CPU for almost two decades says the service, which is now threatened with closure, plugs a gap in statutory provision.

The unit costs £7,000 a month to run – just £33 per counselling session. But last autumn it learned that, due to changes in local commissioning of psychological services, its funding from Camden primary care trust would be withdrawn from the end of this month. Since then, local GPs, senior psychiatrists and former patients have tried to save the centre.

CPU supporters say that amid efforts by health bodies to calibrate services in the face of cuts and reorganisation of provision of therapies, some voluntary organisations no longer slot into new commissioning criteria.

As a small, specialist voluntary sector service, Dresner says CPU is "not in a position" to apply for funding under the new tender requirements. She approached a large bidder, Camden and Islington NHS foundation trust, suggesting CPU become a partner in its bid, but was unsuccessful.

Campaigners argue that concerns about closures and cutbacks are being echoed in small voluntary organisations across the country and it would be wrong to see the problems faced by CPU as some kind of inevitable, if regrettable, fallout of restructuring health provision.

Robin Anderson, a consultant psychiatrist, says the threatened loss of small services need to have a spotlight shone on them because they are often innovative linchpins in an otherwise inflexible, monolithic system. "Commissioning is an issue. There are massive cuts across the health service. It's a tough time and the weak go against the wall. You get to a point where [an organisation] doesn't fit in to the structure."

David Bell, president of the British Psychoanalytic Society, says services like CPU are a crucial part of the broader fabric of services and that when they disappear an already overstretched mental health system is put under even more pressure.

"Mental health services in general are seriously underfunded and there is a scarcity of the kinds of therapy that CPU provides.

"Here is a service that grew up organically from its community. Many of the people who go to CPU would find other services alien. It is staffed by highly qualified professionals and has a very low drop-out rate. It provides for an underserved portion of the population and it stands as a beacon for good, local services. Once it's gone you can't re-establish it," he says.

Seven years ago, a counsellor at Benedict Vallis' GP's surgery suggested that she needed long-term, intensive therapy and recommended CPU. "It was a lifeline for me. Simple as that," Vallis says. "From the moment I was there I felt supported. I felt I was part of something that would make a difference in my life, and it did."

Dresner hopes to stretch resources at CPU to allow it to operate for another year, while trying to raise funds from alternative sources. She says: "If we close, a choice will have been taken away from people who really need it. It would be a tragedy."

• To find out more about the service or to make a donation to the CPU fundraising campaign, go to camdenpsychotherapy.org.uk

Mary O'Hara

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Doctors reject coalition's changes to health plans

British Medical Association delegates call for the controversial health and social care bill to be withdrawn despite recent amendments, saying it will not protect the NHS

Doctors have dismissed the coalition's changes to its health plans as inadequate to protect the NHS and demanded that the controversial health and social care bill be withdrawn altogether.

Delegates at the British Medical Association's annual conference defied calls from the union's leadership and backed a motion that demanded further big changes to key elements of the bill.

Large majorities of the 500 delegates at the BMA's annual conference in Cardiff voted for a motion, underlining the fact that many medics remain fearful for the NHS's future, despite the recent concessions over the bill.

Doctors' representatives expressed serious unease that changes to the bill agreed by ministers after the NHS Future Forum report do not go far enough.

The government was also accused by Labour today of retaining key elements of the controversial reforms, despite promising to change them in the wake of its NHS "listening exercise".

The shadow health secretary, John Healey, said that despite ministers tabling 180 amendments to the bill, the Tories' long-term aim of breaking up the NHS and establishing a "full-scale market" remained intact.

The BMA conference passed a motion that said the government's response to the forum's report earlier this month "fails to satisfactorily address the concerns of the profession". It identified four key areas of continuing anxiety about the reformulated bill, which has begun a second period of scrutiny in the House of Commons by a public bill committee of MPs.

Speakers argued that the Secretary of State for Health's duty to provide comprehensive health services in England – which ministers said they would restore after it was removed in Andrew Lansley's original version of the bill – was still not guaranteed. They rejected the reassurance of the BMA's leader, Dr Hamish Meldrum, that legal advice taken by the union meant that the minister would remain ultimately responsible in the future.

Delegates also voiced dissatisfaction that the health regulator, Monitor, would still promote competition between hospitals as envisaged by Lansley in his NHS blueprint, which led to a split in the coalition, despite David Cameron agreeing to replace it with a duty to promote integration of services instead. They voted by 70% to 22% to defy Meldrum's advice that the duty to promote competition "has gone" as part of the government's rethink.

Delegates also backed, by 93% to 5%, the part of the motion that argued "that competition should not be forced on the NHS by imposing any duties on commissioners to promote choice as a higher priority than tackling fair access and health inequalities".

Meldrum warned that a vote to withdraw the bill altogether would weaken the BMA's position in ongoing negotiations with the government. Delegates nevertheless voted by 59% to 35% for the union to continue to call for the bill to be withdrawn rather than simply amended.

The vote is a setback for Meldrum, but will make little difference to the passage of the bill through the Commons, especially as Liberal Democrat MPs' fears about it have now been successfully neutralised.

A Department of Health spokesman said: "This vote is disappointing, because only a few weeks ago the doctors' union said there was much in our response to the listening exercise that addressed their concerns, and that many of the principles outlined reflected changes they had called for.

"The independent NHS Future Forum confirmed there is widespread support for the principles of our plans to modernise the NHS, including handing more control to doctors, nurses and frontline professionals.

"The bill has changed substantially since the BMA first voted to oppose government policy. Our plans have been greatly strengthened in order to improve care for patients and safeguard the future of the NHS."

Denis Campbell

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NHS forum GP admits private patient doubts

GP who led government reform bill's 'listening exercise' says changes could leave hospitals vulnerable to EU competition law

The government is facing renewed pressure over its health bill after the GP who led its "listening exercise" admitted he should have done more to flag up concerns about private patients in NHS hospitals, and grassroots doctors meeting in Cardiff demanded further changes.

Labour warned that the health secretary, Andrew Lansley, was still planning to create a "full-scale market" after Steve Field acknowledged that the government would leave hospitals vulnerable to European Union competition law due to the presence of private patients in NHS hospitals. Concerns about a backdoor privatisation of the NHS prompted David Cameron and Nick Clegg to appoint Field to lead the Future Forum review.

As Field was addressing MPs, who are considering the bill again at committee stage, doctors in the British Medical Association defied their leadership to pass a motion at their annual conference criticising the "respray" of the health and social care bill.

Field said a majority of NHS staff who attended his meetings had raised concerns about government plans to lift a cap on the number of private patients using NHS hospitals.

Labour said lifting the cap, which was introduced in 2006, would help foster a free market approach in the NHS.

Field said: "If you wanted a gut feeling from what was happening in the listening exercise – the feeling was actually the private cap should stay because people felt that would provide the protection. But it should be reviewed and put at a reasonable level."

He admitted he had second thoughts about failing to mention the cap in his report. "To be honest, we didn't put as much in our report as perhaps we could have done. In fact, it was one area, when we reread the paper at the end, we might have been stronger on."

Field said he had decided not to address the cap because of mixed feedback from hospitals – at University Hospital Birmingham the cap is set at 1% while the Royal Marsden in London's cap is set at about 30%.

"So University Hospital Birmingham couldn't bring money in which would actually help its NHS services," Field said as he pointed out that lifting the cap would leave hospitals more vulnerable to competition law. "On the other hand, if you opened the cap it may be more likely to be under … EU law, and from competition and from Monitor. So when we weighed up the proposals and the problems that might arise we chose not to go into any great detail."

John Healey, Labour's shadow health secretary, said: "Steve Field is right and this was a serious omission from the Future Forum report. Removing the private patients' cap is a vital feature of the government's plans to turn the health service into a full-scale market, which will see NHS patients waiting longer and open up hospitals to greater challenge under competition law."

Sue Slipman, the director of the Foundation Trust Network, said it was right to lift the cap. Slipman told MPs: "Depending upon the range of patient choices, it isn't necessarily the case that there would be fewer NHS patients if you expand the facilities as a result of the money you can [raise]. It depends where you invest that money.

"The term 'private patient cap' is a misnomer. This is all money that can be brought into the system as a result of any service which may derive from private patients. So, for example, if you run laundry in your hospital and any of that laundry is used by those who supply services to private patients, this counts against the cap. We believe that the lifting of the private patient cap would enable public providers to being more money into the NHS to benefit NHS patients."

The BMA membership rejected leader Dr Hamish Meldrum's attempts to reassure them that key elements of the bill should not damage the NHS.

Their motion said there was still anxiety about:

• The role of the NHS regulator Monitor. They fear it will still promote competition between hospitals, even though Meldrum insisted that "competition has gone" as Monitor's main duty as a result of changes following the NHS Future Forum.

• Competition potentially being forced on the NHS through an extension of patients' right to choose where they are treated.

• The health secretary's legal duty to provide a comprehensive health service in England.

Dr Clive Peedell, a member of the BMA's ruling council, said: "Grassroots doctors have seen through the smoke and mirrors of this government, which pretends that it has made major changes to the bill but hasn't. Despite David Cameron's claims that they have listened to our concerns and made significant changes, the main levers for the marketisation and privatisation of the NHS remain intact in the nill."

Dr Jacky Davis, a council member, said: "We are being sold a respray job, two write-offs welded together, and we need to look under the paintwork to see what's there."

The overhauled bill would still allow "any qualified provider" – including private healthcare firms – to treat NHS patients, while competition would simply be rebranded as patient choice, she claimed.

The vote is a setback for Meldrum, who also saw delegates vote to mandate the BMA to campaign for the withdrawal of the bill, which the BMA leader had warned would make negotiations with government difficult, especially after the union helped secure some key concessions.

A Department of Health spokesman said: "This vote is disappointing because, only a few weeks ago, the doctors' union said there was much in our response to the listening exercise that addressed their concerns, and that many of the principles outlined reflected changes they had called for.

A separate call to scrap the bill altogether was defeated by 54% to 45% after Meldrum pleaded with members to "vote with your heads, not your hearts" and not take action that would leave the BMA marginalised and unable to influence the bill's remaining parliamentary stages.

Nicholas Watt

Denis Campbell

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Abortion providers alarmed over counselling plans

Government plans for women to receive compulsory counselling 'independently' will delay treatments, charities say

Charities which provide abortions could be stripped of their ability to also counsel women, under plans being considered by the government.

Measures which would mean women must be referred to an "independent" organisation for counselling were being considered, said the Department of Health (DoH).

The announcement has sparked alarm among abortion providers who warned the change would delay women accessing the treatment they needed and insisted there was no evidence that the current system was not working.

Charities including the British Pregnancy Advisory Service (BPAS) and Marie Stopes offer the compulsory counselling women must undertake before they make a decision on termination.

Pro-choice advocates expressed alarm at the announcement, which came after two anti-abortion MPs called for amendments to the health and social care bill that would strip abortion providers of their counselling role. There are concerns that faith-based groups with strong anti-abortion positions could step in and win contracts to provide the counselling in place of the charities.

Conservative MP Nadine Dorries and Labour MP Frank Field propose that counselling would have to be provided either by a statutory body or a private organisation that does not itself provide abortions.

The DoH statement appears to hold out the possibility that the MPs' proposals could become a reality without the need for a vote in parliament.

A spokesman said: "The Department of Health wants women who are thinking about having an abortion to be able to have independent counselling. However, we do not believe it is necessary to set out this requirement in primary legislation as the necessary legal mechanisms already exist to enable this.

"We are inviting interested parties to meet with the public health minister, Anne Milton, and Department of Health officials to discuss the matter."

The development comes after the Guardian revealed last month that the government had drafted in an anti-abortion organisation, Life, to sit on a new sexual health forum. At the same time, BPAS was omitted from the forum, which will have a role in helping to draft sexual health strategy.

Ann Furedi, chief executive of BPAS, said: "We are extremely concerned to learn that the Department of Health is reviewing care pathways for women considering abortion and looking into a ban on counselling by abortion providers.

"This appears to be in response to calls from the MPs Nadine Dorries and Frank Field for women with unplanned pregnancies to be 'independently' counselled, a move they hope will reduce the number of abortions.

"In recent years, delays for women in need of abortion care have been reduced significantly and last year nearly 80% of procedures took place within the first 10 weeks of pregnancy."

"Pregnancy Advisory Bureaux (PABx) run by charities like BPAS that offer abortion are already licensed and regulated by the Secretary of State, and must conform to a core set of principles regarding the information and counselling."

Tracey McNeill, vice president and director UK and west Europe for Marie Stopes, said: "We should be focusing on how abortion counselling is delivered and not by who. What is essential is that we ensure women get comprehensive and unbiased information. As a service provider, our advice line 'OneCall' speaks with 500,000 people a year who repeatedly tell us how valuable it has been to talk to our impartial and non-judgemental counsellors."

Diane Abbott, the shadow minister for public health, accused the government of planning to undertake "sweeping changes" without a proper debate and proper scrutiny in parliament.

"I am deeply concerned that nobody has voted for this. I think the way the government is going about these changes, behind closed doors and without discussion with women and in parliament is showing arrogant disregard for millions of women and families across the country," she said.

"If the government wants to change this, the public must be given a say, and parliament must be given a vote."

Dorries used her blog to welcome the ministry's statement, which she described as a direct response to the amendment laid down by her and Field.

She said: "Legislation is required to prevent abortion providers establishing subsidiary counselling organisations in order to circumnavigate the new requirement.

"The statement sets out the objective to remove the financial vested interests of the abortion provider and the provision of counselling. The statement also states that primary legislation is not necessary to achieve this outcome. If this is the case, why hasn't this happened before now?

"My intention is for vulnerable women to have access to the best possible care as quickly as possible. For counselling to be optional, independent and to present no delay whatsoever to the abortion process."

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Response: Our mental health service is far from crisis, it's a world leader

Improved staffing levels and care are the real story

In your front-page story it was claimed that mental health is "in crisis" and that "society will be overwhelmed" because of unsafe wards and too few psychiatrists (Mental health in crisis over staff shortages, 21 June). Then Darian Leader wrote that our whole understanding of mental ill-health is mistaken, and even its most serious symptoms, delusions, are actually a "crucial resource" in overcoming it (How psychiatry became a damage limitation exercise, 22 June).

In fact, the report on which the "crisis" story was built is a summary of reports from earlier years, drawing heavily on the 2009 Care Quality Commission (CQC) survey of mental health inpatients but omitting its overall finding. When asked to rate the quality of their care, 73% of patients said it was excellent, very good or good; 12% said it was poor – 12% too many, of course, but hardly evidence of a service in crisis.

The article had a misleading way with statistics. Wards are unsafe because "several dozen" patients take their own lives each year – that the number has halved in the last decade goes unmentioned. "Just 85%" of wards provide gender-segregated sleeping accommodation. Why "just"? And why not quote the CQC figure of 92%? "Less than 45%" of patients said they always felt safe on the ward. The true figure was 45% (no "less than"); those who said no, they did not feel safe, numbered 16%.

Despite the fall in suicides, psycho-analyst Darian Leader accuses wards of creating a suicide problem because "suicide is exorcised as a legitimate choice". Treating delusions, he claims, might be harmful – instead we should "question our prejudices about normality".

These views, left over from the 1970s anti-psychiatry movement, must have been read with disbelief by the families who have to cope with the delusions that transform and terrify their loved ones. Was this a useful commentary on modern mental health care? And why illustrate it with an image of an 1860 asylum ?

Listen to the patients, Leader concludes, but governments and clinicians have listened. Hence the strengthening of community care in recent years, praised by the World Health Organisation as the model for other countries to follow. Hence the expansion of psychological therapies and the switch to modern drug treatments. It is these improvements to specialist services, plus large increases in staff (over 1,000 new consultant psychiatrist posts), that have allowed this year's mental health strategy to highlight prevention and mental wellbeing, and laid the foundations for a national programme on the mental health of offenders.

No one who has worked on mental health wards is naive about the challenge they face. But, thanks to skilled staff and voluntary sector projects like Star Wards, they have become safer and more therapeutic. Many units have been rebuilt or refurbished. Most patients are in single rooms. Staff, say patients in the CQC survey, treat them with respect and dignity. And if we want to recruit more doctors into psychiatry, these are the things – not dramatic headlines – that they need to know.

Louis Appleby

Hugh Griffiths

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David Cameron hits out at Ed Miliband in NHS row

Heated exchanges at prime minister's questions as Labour leader says PM 'can't be trusted' with health service

David Cameron has launched a scathing attack on the Labour leader, Ed Miliband, after being put on the back foot over the NHS.

Miliband continued his strategy of challenging Cameron on policy detail at prime minister's questions, asking him to state the cost of NHS redundancies before revealing the figure of £852m.

The Labour leader then asked the prime minister to guarantee that none of those pocketing redundancy payments would be rehired in one of the hundreds of new bodies set to be created as a result of the NHS reforms.

But Cameron sought to steer the debate away from health and on to the union strikes due to be staged on Thursday.

He accused Miliband of choosing not to ask him about the forthcoming industrial disruption because he was in the "pocket of the unions".

"That's what we see, week after week – he has to talk about the micro because he can't talk about the macro," the prime minister said.

"What the whole country will have noticed is, at a time when people are worrying about strikes, he can't ask about strikes because he is in the pocket of the unions."

The heated atmosphere prompted the Speaker, John Bercow, to appeal to MPs to "calm down and reflect on what the public thinks of this sort of behaviour".

Cameron was forced on the defensive after Miliband rattled off a list of new NHS organisations which he said would see the total number of NHS bodies grow from 163 to 521, despite a promised cull of quangos by the government.

These included "pathfinder consortia, health and wellbeing boards, shadow commissioning groups, authorised commissioning groups, a national commissioning board, PCT clusters, SHA clusters, clinical networks and clinical senates", Miliband said, adding: "Is this what you meant by a bonfire of the quangos?"

Cameron said £5bn was being saved through the reduction of bureaucracy, and that the government was implementing the £20bn cost savings set out by Labour.

"The difference is ... we are going on with putting more money into the NHS, money that the party opposite doesn't support, so there will be more nurses, more doctors, more operations in our health service and a better NHS compared with cuts from the party opposite," he said.

Miliband again asked him whether staff made redundant would be rehired "to do their old jobs at your new quangos".

Cameron said: "I know that you have this extraordinary vision of how the NHS is run, but it's not the prime minister who hires every person in every organisation in the NHS."

The Labour leader said people would notice that Cameron "could not be trusted with the NHS".

"Isn't the truth [that] he promised no top-down reorganisations, he is doing it," Miliband said.

"He promised a bonfire of the quangos; he's creating more. He promised a better deal for patients, and things are getting worse. What people are asking up and down this country is, what is he doing to our NHS?"

Cameron steered the debate away from the government's policies by launching into the Labour party's links to the trade unions.

"What the whole country will have noticed is, at a time when people are worrying about strikes, he can't ask about strikes because he is in the pocket of the unions," said Cameron.

"What the whole country will have noticed is, at a time when Greece is facing huge problems over its deficit, he can't talk about Greece because his plan is to make Britain like Greece.

"What the whole country will have noticed is, at a time when the economy is the key issue, he can't talk about the economy because of his ludicrous plan for tax cuts."

Hélène Mulholland

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Wednesday, June 29, 2011

Prime minister's questions: 29 June 2011 - video

Tory MP Bob Blackman asks David Cameron about Thursday's strikes by teachers and Ed Miliband gives David Cameron a grilling over NHS cuts

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Scottish public service review urges radical reform to counter funding shortfall

Without more integration of services and greater community involvement, a funding gap of £3bn will develop within five years, commission says

Public services in Scotland should be heavily streamlined and conform to much stricter quality standards to help cope with steep cuts in funding, a commission set by Alex Salmond has recommended.

The inquiry, headed by Campbell Christie, a former head of the Scottish TUC, found that public services in Scotland are often inefficient, poorly run, poorly targeted and failing to adapt to the tougher financial climate.

In a report published on Tuesday, the commission said radical, far-reaching reform was needed to help Scotland's public sector cope with falling incomes and a rising demand for services.

It said the Scottish government's income was likely to fall cumulatively by £39bn over the next 16 years after rising continuously for the 10 years after devolution in 1999, since when it had risen by 60% in real terms.

Scottish government spending hit £30bn in 2009-10, but public services were still failing to tackle inequalities and poverty, the document said. It found that one-third of public spending went on dealing with the effects of preventable problems such as chronic ill-health, illiteracy and crime committed by children brought up in the care system.

The Christie commission's report will make uncomfortable reading for Salmond and the Scottish government. The first minister has been repeatedly criticised by opposition parties, unions and the business sector for delaying tough decisions on spending while continuing to fund free prescriptions, free university education, free personal care and a long-term freeze in council tax.

The National Endowment for Science, Technology and the Arts has estimated that extra demands on public services – particularly with an ageing population and chronic ill-health – would need £27bn in extra spending by 2025.

If public services remained unchanged, a funding gap of £3bn would emerge within five years, Christie said, and the predicament was worsened because Salmond's government was either cutting or freezing taxes.

Christie said: "Our public services are now facing their most serious challenges since the inception of the welfare state.

"The demand for public services is set to increase dramatically over the medium term – partly because of demographic changes, but also because of our failure up to now to tackle the causes of disadvantage and vulnerability, with the result that huge sums have to be expended dealing with their consequences.

"This rising demand for public services will take place in an environment of constrained public spending. In the absence of a willingness to raise new revenue through taxation, public services will have to achieve more with less."

John Swinney, the Scottish finance secretary, said there was a pressing need to "redesign public services" and improve efficiency and services.

He did not respond in detail to the commission's proposals, but said a new cabinet subcommittee on public service reform would meet for the first time next Tuesday.

He added the government already planned to cut quangos by 25% and merge service.

"We are determined to go further, delivering an ambitious reform programme, which puts citizens and communities at the centre," he said. "That is why the Christie commission's report is both timely and important.

"It recognises that much has been done, but argues – rightly – that further, fundamental reforms must now be considered and urgently progressed."

Richard Baker, Labour's shadow finance secretary, said the party had proposed similar reforms. Ministers were "duty bound" to publish an action plan and timetable for reform.

"The SNP made a number of big promises during the election such as no compulsory redundancies in the public sector. That pledge is already starting to unravel, so ministers – in the light of this important report – need to explain how they plan to reshape our public services for the better now," he said.

The Ernst and Young Item Club report earlier in June predicted that 50,000 public sector jobs would be lost in Scotland by 2015.

A statistical report by the Scottish government, released on Monday, said 11,600 public sector jobs were cut last year, bringing total public sector employment to 575,600.

National Health Service posts in Scotland were cut by nearly 1,640 over the last six months of last year, including 711 nursing and midwifery jobs.

Meanwhile, the Scottish government is expected to press ahead with merging Scotland's police and fire services, despite widespread opposition to a single police force and limited backing for one national fire brigade.

The commission said fundamental reorganisation of services was needed along with a new set of statutory powers and duties common to all public bodies alongside giving Audit Scotland greater authority to improve performance and save money.

Greater integration and mergers of services and public agencies was also needed, alongside greatly increasing community involvement and influence. The core purpose should be to tackle inequalities through preventative action.

The Convention of Scottish Local Authorities (Cosla), the local government umbrella body, welcomed the report and promised to implement many of the changes voluntarily and in advance of the Scottish government's formal response.

It would strengthen community planning, focus on early intervention, introduce internal reforms. Its president, Pat Watters, served on the Christie commission.

In a joint statement by its "presidential team" of four vice-presidents, Cosla concluded: "From our point of view, this is both a significant and a useful report that we fully back.

"The extent to which it has the significant effect on public services in Scotland we all want to see depends largely on how many of our public sector partner organisations have the same commitment to radical change as we have."

Grahame Smith, the general secretary of the Scottish TUC, welcomed the commission's refusal to endorse increased privatisation or "marketisation" being favoured by ministers in England, but criticised its limited remit on considering taxation and economic policy.

Smith said the report would do little to help the Scottish government in tackling the immediate funding problems it faced.

"In identifying service integration as its big idea, the report opens up the potential for longer-term change," he said.

"This will not be easy, but the commission is right to recognise that such change must be developed around democratically elected councils and involve greater community engagement."

Severin Carrell

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BMA calls for ban on smoking in cars

Doctors also vote for a minimum price on alcohol and limits on licensing hours at their union's conference in Cardiff

Doctors have called for tougher controls on cigarettes and alcohol, including a ban on smoking while driving.

The British Medical Association (BMA) voted in favour of more restrictions on licensing hours and introducing a minimum price of 50p per unit of alcohol at its conference in Cardiff.

BMA members who back the plans hope the association will persuade the government to pass new tobacco and alcohol laws across the UK.

Those against stricter regulations say they would intrude on people's liberty – and labelled a ban on smoking while driving as being "unenforceable".

But supporters insist the measures, if implemented, would improve the nation's health and save the NHS money.

Douglas Noble, a London doctor, described smoking in cars as a toxic threat to people's health and called for legislation to ban it completely.

"In-car particle concentrations are 27 times higher than in a smoker's home and 20 times higher than in a pub in the days when you could smoke in public places," he said.

"It would be safer to have your exhaust pipe on the inside of your car than smoke cigarettes.

"This would protect non-smokers – particularly pregnant women and children. There is also evidence linking driving and smoking to a higher rate of road traffic accidents."

The effects of cigarettes and alcohol on the nation's health has been a key issue during the BMA's week-long conference in St David's Hall, Cardiff.

As well as backing calls for a blanket ban on smoking in cars, delegates supported two motions for more restrictions on the sale of alcohol.

Dr Sue Robertson, a member of the BMA's Scottish council, said 24-hour drinking in the UK, introduced in 2005, needed to be scaled back.

"Less time selling drinks equals less drinks being sold," she said. "In one day in Scotland alone, alcohol will cost £97.5m in terms of health, violence and crime.

"The annual healthcare costs of alcohol in England alone are £1.7bn to £2.4bn."

Delegates also heard calls for a minimum price on alcohol, and opinions that such a move would stop supermarkets offering the cut-price drinks deals that have put many pubs out of business.

Robertson said a charge of at least 50p a unit would reduce problems such as underage drinking as well as saving the NHS £1.3bn in 10 years.

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Simon Hoggart's sketch | Quangos rise from flames

Miliband asked how many quangos there would be in the reformed NHS. The number would rise from 163 to 521

No wonder the prime minister was rattled yesterday. Not only did Ed Miliband land a couple of blows – not something that happens every week – but the Speaker ticked him off not once, but twice. This is the equivalent of the head boy reproving the headmaster. Oh, and the bald patch has doubled in length. It is now the same shape, size and colour as two goujons of plaice. Larry, the Downing Street cat, must look at David Cameron hungrily.

Miliband kicked off with his by now predictable habit of asking a question to which he knows the answer but of which he imagines Cameron is ignorant. In this case it was to ask how many quangos there would be in the new, reformed NHS. Not knowing the answer, or at least not being prepared to admit that he knew it, the prime minister replied that everyone loved his reorganisation, especially people in the NHS.

So Miliband provided the answer. The number would rise from 163 to 521. If true, this does seem an awful lot. The Labour leader produced a list of some. "Pathfinder consortia, health and well-being boards, shadow commissioning groups, authorised commissioning groups, a national commissioning board, PCT clusters, FHA clusters, clinical networks and clinical senates."

(I expect they had those in ancient Rome. "I'm feeling a bit peaky, Bilius."

"Take two leeches and call me in the morning, Nausius.")

Was this what Cameron had meant by the bonfire of the quangos?

Miliband also extracted some blood from the £852m he claimed it would cost in redundancy payments for NHS staff. Could Cameron promise that none of those people would be re-employed in their old jobs? He could not. Instead he talked about today's festival of strikes, which is what he wanted to talk about in the first place. He began to rave. Labour wanted the whole country to be like Greece, he said – at considerable length.

The Speaker intervened. "We're very grateful!" he said crisply, which is John Bercow-speak for "Shut it, sunshine!"

Cameron looked furious. But the Speaker wasn't finished with him yet. After he had spent 56 seconds – eternity at question time – talking about crime in London, Bercow interrupted him again. "Prime minister's questions are principally for backbenchers," he said, which was – if you picked the bones out of it – a thunderous reproof, if a little unfair. After all, the title of the session does imply prime minister's answers as well. If not perhaps at such enormous length.

Cameron must have thought all the ills of the world were heaped on his shoulders when Sir Peter Tapsell arose. As the alarm sounded in the Hansard office, and a team of Japanese calligraphers were sent to immortalise his words on parchment (there is always time, as Labour cheers are loud and long when Sir Peter speaks), the prime minister must have assumed he was about to receive yet another majestic bollocking from the father of the house.

Not so. Sir Peter merely hoped that, given the chaos in the EU, we would be able to negotiate a spanking new treaty.

Simon Hoggart

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Thursday, June 23, 2011

Have your say on our NHS reforms coverage

What is next on the agenda for the NHS reforms and what should we be looking at?

Two months and thousands of words later, our live blogging of the NHS reforms has come to an end in its current form.

Under the guidance of Randeep Ramesh and Rowenna Davis, the blog covered the government's "pause" in the progress of the NHS bill, devoting days to how the proposed reforms might affect cancer care, mental health services, GPs, technology within the NHS, medical training, nursing and much more.

The government has announced its response to the consultation period and an amended NHS bill will now continue its progress through parliament.

The debate over the reforms goes on – and we'd like you to tell us how you'd like us to cover the bill's progression, let us know about anything you think we've missed, or make more general suggestions about our coverage of the NHS.

Is something happening in your local area that hasn't been covered? Or are there important parts of the government's plans that you feel haven't been interrogated enough?

Let us know in the comments below or email us at randeep.ramesh@guardian.co.uk

Laura Oliver

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America's epidemic of over-prescribing | Cory Franklin

Aggressive marketing has been a major factor in pushing drugs on patients well beyond the point of clinical usefulness

If all the drugs were thrown in the ocean, everyone would be better-off … except the fish.

– Oliver Wendell Holmes

That maxim of 19th-century American physician and author Oliver Wendell Holmes is an overstatement today, but still contains a grain of wisdom. For generations of physicians, the prevailing teaching was not to prescribe too many drugs in order to avoid unwanted side-effects and drug interactions. No longer.

Even considering remarkable technological advances – organ transplants, robotic surgeries, lasers, electronic medical records – the greatest difference in American medicine since the 1970s is the increase in the number of medications prescribed to patients today. To treat chronic diseases and control symptoms, the average American takes about 12 medications annually, compared to seven, 20 years ago. Patients who once came into the office carrying their medications in a purse, or pocket, now need a shopping bag.

In the 1970s, spending on drugs totalled roughly 5% of total US healthcare costs. Today, that has doubled and is rising quickly. Admittedly, new drugs used to treat conditions once treated with surgery may actually bring down costs, since surgery is generally more expensive. Simply citing increases in spending on drugs and ignoring the offset in surgical costs gives a misleading picture of the overall costs of prescription medicines. Still, spending on prescription medications has increased by a staggering $200bn in two decades.

Why the exponential rise in drug prescription? There are a number of reasons, some legitimate, others not so. The average American is older, heavier, with more hypertension, high cholesterol, diabetes, osteoporosis and arthritis than a generation ago – all conditions effectively treated with medications.

Direct marketing to patients is another trend toward increased prescriptions. After government restrictions on direct consumer advertising were relaxed, patients became more "proactive" in approaching their doctors for the latest treatments they have heard about: searching the internet or watching Super Bowl commercials, as the saying goes, "Ask your doctor about …"

Finally, in an effort to please their shareholders, pharmaceutical companies have done hugely effective marketing campaigns. Skilfully employing influential doctors as speakers and on advisory panels, the companies have expanded the markets for their products. These same doctors often write guidelines about who are candidates for drug treatment. The indication between "treating disease" and "expanding market share" blurs when candidates for therapy include not just the sick, but those with risk factors for future disease who might get sick.

Recently, a number of studies in cardiovascular medicine have cast doubt on conventional wisdom regarding drug treatment strategies. Researchers have discovered overly aggressive control of blood sugar and blood pressure with more medicines in type II diabetes did not prevent heart attacks and, in fact, led to higher rates of complications. In one study, diabetic patients taking an average of 3.4 drugs to lower systolic blood pressure to less than 120 had more complications than those who took only two drugs to lower their pressures to under 140. As one researcher put it, for diabetics with heart disease, "Getting good blood pressure control is good. Getting perfect blood pressure control may not be so good."

In another study, two different cholesterol lowering drugs used together were no better than a single drug. A past president of the American College of Cardiology said, "Pushing harder with more drugs and higher doses doesn't necessarily help patients across the board." A New England Journal of Medicine editorial commenting on the findings said that while the belief that aggressive treatment of cardiac risk factors in diabetics was logical and understandable, in certain situations it turned out to be risky. "Lower is not necessarily better."

The lesson for patients and physicians alike is that patients should heed their doctors' advice (the reported results do not apply to all patients), but slavish attention to a particular treatment number, by either patient or doctor, is not always warranted, especially if it results in a potentially harmful polypharmacy regimen. The president of the American Heart Association emphasised, "We're not treating by the number. We're treating by the patient."

Doctors should periodically reassess a patient's need for a particular medication, rather than just automatically add new drugs to their regimen. Patents must understand what medications they are getting, and why. They should also realise every medicine has the potential for adverse reactions.

When it comes to prescribing medications, more is sometimes less. The point of prescribing drugs is clinical effectiveness, not necessarily some hypothetical norm. We can only hope that, in the brave new world of reformed healthcare, physicians will exercise moderation by prescribing drugs judiciously. They will see fewer shopping bags in their offices … and the fish will be safer.

Cory Franklin

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