Bad news for taxpayers, good news for patients, in the UK

Chancellor Gordon Brown announced, in April 2002, that spending on the national health service (NHS) in the UK will exceed £100 billion in 5 years time (Table 1). ($1 {approx} £0.62; http://www.ecb.int/home/eurofxref.htm). This means spending would increase by an average of 7.4% in real terms for each of the next 5 years—funded in part by a 1% increase in national insurance contributions. More impressively, over the 5 years, the NHS budget will rise by 43% in real terms, and will have doubled since 1997. Mr Brown dismissed calls for alternative funding methods for the health service; general taxation was the equitable option, he said.


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Table 1. UK government spending
 
Mr Brown said the increase in NHS investment would be pegged to reform, including a new system of independent scrutiny of patient complaints. New financial incentives for hospital performance, greater freedom for high performing hospitals and trusts, devolution of power and resources to front-line staff, and reform of social services’ care for the elderly would also be introduced. Earlier, a report commissioned by the government, written by former NatWest bank chief executive Derek Wanless, had called for NHS spending to more than double by 2022. His report said the health service had been underfunded by £200 billion over the last 30 years. He called for an initial 5-year period of high growth to catch up, followed by a lower level of sustained investment. His was the first major review of the future needs of the NHS since it was established in 1948. The Conservative party criticised Mr Brown’s decision to publish the report just hours ahead of the budget, accusing him of trying to stifle debate on its findings.

Assisted suicide, euthanasia, mercy killing...

In the Netherlands, euthanasia became legally acceptable on 10 April 2001, when the Dutch Senate voted 46 to 28 to approve legislation allowing doctors to kill patients under certain circumstances. The euthanasia must be performed with "due care", in response to a "voluntary and well-considered" request from a patient who sees "no other reasonable solution" to "lasting and unbearable" suffering. The patient’s request may have been made years earlier, before incurring an illness or injury. There is no requirement that the patient be terminally ill. This was an evolution from ‘mercy killing’, a special "criminal liability exclusion" to Articles 293 and 294 of the Dutch Criminal Code.

On 26 October 2001, Belgium legalized physician-assisted death and voluntary euthanasia. On 11 December 2001, the Swiss National Council voted against two measures, one attempting to expand the practice of hastening death and a second to restrict it. The Council later passed a motion requiring the government to propose legislation creating legal guidelines for assisted death. Currently, Swiss law does not expressly prohibit or allow the practice of hastening death. Instead, physicians abide by rules created by the private Swiss Academy of Medical Sciences.

The debate continues elsewhere. On 19 March 2002, Diane Pretty appeared before the European Court of Human Rights to appeal a 29 November 2001 ruling by Britain’s highest court. Pretty, 43, has amyotrophic lateral sclerosis (ALS), known in the USA as Lou Gehrig’s disease. The disease has paralyzed her from the neck down and makes it impossible for Ms Pretty to hasten her death unassisted. Her lawyers argued that current law infringes on Ms Pretty’s human rights by subjecting her to degrading treatment (a frightening and painful death) and fails to respect her privacy. A decision by the Court of Human Rights is expected soon.

The French Health Minister Dr Bernard Kouchner has opened the debate, but it will be up to the next French Parliament to decide whether a new law is needed. In the meanwhile, in the USA, on 17 April, a federal judge in Oregon rejected an effort by the Justice Department to block the state’s assisted suicide law. In a decision sharply critical of Attorney General John Ashcroft, the judge said Mr Ashcroft lacked the authority to decide "what constitutes the legitimate practice of medicine". The law took effect in 1997 and has, according to the court, been used to help end the lives of ~70 people.

Oregon is the only state that sanctions assisted suicide. The Justice Department said it had not decided whether to appeal. It referred reporters to Assistant Attorney General Robert McCallum, who said: "The Department remains convinced that its interpretation of the Controlled Substances Act as prohibiting the use of federally controlled drugs to assist suicide is correct." The judge left open the question of whether Congress itself could pass a law overriding a state’s determination of what constitutes a legitimate medical practice. But, he wrote, "there is no indication in any federal statute, including the drug law, that Congress delegated to federal prosecutors the authority to define what constitutes legitimate medical practices".

The New York Times, 18 April 2002, reported that Dr Greg Hamilton, a spokesman for Physicians for Compassionate Care, which opposes assisted suicide, said that the decision ignored a need for national standards in this area: "Assisted suicide is not a legitimate medical practice in Oregon or anywhere in the world."

Investing in ‘pharma’ part 1

Mathias Wolf in the Tribune de Genève, 15 April 2002, reminds us that, until recently, the prevailing opinion was that investing in shares of major pharmaceutical companies was at least a defensive, and sometimes an excellent, decision. This opinion was supported by a history of stable growth and positive long-term prospects, because of an ageing population. But this feeling is changing as market conditions change in the USA, the major source of income for most of the companies. These changes will inevitably affect the rest of the world.

In the USA, medical services are financed by insurance schemes provided by employers. This means that 80% of employees and their families belong to one or another ‘managed care organization’ (MCO). The profit margin of such MCOs is minimal (4%) and they need to keep strict control of costs. Generic drugs are a fantastic opportunity for them. In the USA, generics, after 1 or 2 years of marketing, often cost 10–15% of the price of the original product, and obviously replace the original agent. Thus, the antidepressant Prozac, which had up to 20% of the American market, now represents <6% of it. Therefore, Eli Lilly had to issue a "profits warning", a way of saying it was going to make less money, in 2001. The stock market is therefore looking at ‘pharma’ with suspicion, and negative news of minor importance can lead to dramatic plunges in share prices. One wonders what will happen to AstraZeneca if generics of Prilosec, their best-selling anti-ulcer drug, are launched in the USA next year.

Investing in ‘pharma’ part 2

Wall Street analysts and institutional investors got hold of important research abstracts, in early April 2002, from the then upcoming American Society of Clinical Oncology (ASCO) conference, by using their connections, but you now have access to them through the ASCO website. Some of that information has trickled down to the general investing public. ASCO tries to keep a clamp on leaks prior to its annual meeting, which took place on 18–21 May 2002 in Orlando, FL. Research abstracts were supposed to be posted on the ASCO website for members only. Some words of caution for investors looking to play the ASCO investing game: Remember that research abstracts are typically based on a preliminary analysis of clinical testing data. These abstracts have to be submitted to ASCO 6 months in advance, so a lot may have changed by the time final results are unveiled at the meeting.

NIH Director and Surgeon General

On 26 March, President Bush officially announced the nomination of Elias Zerhouni, MD, to head the National Institutes of Health (NIH). The President also announced the nomination of Richard Carmona, MD, MPH, FACS, to be the Surgeon General. Dr Elias Zerhouni was Executive Vice Dean of the Johns Hopkins University School of Medicine in Baltimore. He was trained as a radiologist and served as ‘radiologic consultant’ to President Reagan.

Dr Zerhouni most recently established a multimillion-dollar Institute for Cell Engineering at Johns Hopkins. He has reportedly stated that he opposes any type of research on cloned human embryos. In announcing the nomination, President Bush said, "Dr Zerhouni shares my view that human life is precious and should not be exploited or destroyed for the benefits of others. And he shares my view that the promise of ethically conducted medical research is limitless. As director of the NIH, Dr Zerhouni will be at the forefront of our efforts to promote biomedical research with a careful regard for the bounds of medical ethics."

Dr Richard Carmona is a clinical professor of surgery and public health and a clinical assistant professor of family and community medicine at the University of Arizona and CEO of the Pima Health Care System. He also serves as chairman of the State of Arizona Southern and Regional Emergency Medical system. President Bush said that Dr Carmona will focus on three urgent issues as Surgeon General: assuming management of the 5600 Public Health Service Commissioned Corps; heading a new initiative on prevention and life-long healthy living; and speaking to the nation regularly on the dangers of alcohol and drug abuse. Both candidates must be confirmed by the Senate before taking their new positions.

Swiss drug costs are among the highest in Europe

In Le Temps, 26 March 2002, there was a report about a study carried out by the Institute for Health Economy of Winterthur. Everyone knows that Switzerland is an expensive country, but the price differences with neighbouring countries are often difficult to understand. The Institute’s researchers looked at the 70 highest selling drugs in Switzerland. They found that these cost 5% less in Germany, 4.6% less in Austria, 18% less in Italy and even 21.6% less in France. Drug costs represent 20% of the costs paid by insurances in Switzerland, and increased by 6% in 2000, according to insurance company Swica. Heinz Müller from Interpharma, representing the pharma industry, said that because the new drugs are more effective, many patients no longer need to be hospitalized, and thus there is a saving to the health sector. He also reminds us that the true cost of drugs to the health sector was 11%, as the state subsidizes many costs that insurance does not need to pay for completely (such as university and state hospitals).

Perhaps not everyone knows that...

...complications of axillary dissection for breast cancer appear to be independent of the type of surgery and the length of follow-up. These are the conclusions of a survey, from St Elisabeth Hospital, Tilburg, the Netherlands, of 148 patients who had received an axillary dissection as part of breast cancer surgery. The study aimed to assess the value of a registration method of morbidity of the arm and shoulder, which includes the measurement of range of movement, strength and pain. Of the 148 patients, 77 had undergone axillary dissection 6–12 months earlier, while the remaining 71 patients had undergone the procedure >5 years earlier. Some 12% of the patients showed a difference of >20° in abduction, ventral elevation or dorsal elevation, while pain or loss of strength were measured in half the patients. However, shoulder movement, pain and arm strength were not significantly different between the patients who underwent mastectomy and those who underwent breast-conserving surgery. In addition, no significant differences for these parameters was seen between the patients who underwent axillary dissection 6–12 months previously and those who underwent it >5 years earlier [1].

...the results of surgical cytoreduction for unresectable hepatic metastases of colorectal cancer (CRC) may be improved by combined therapy with irinotecan and floxuridine. This is the conclusion of a phase II study, from the John Wayne Cancer Institute, Santa Monica, USA, which sought to evaluate treatment of unresectable hepatic metastases of CRC refractory to systemic 5-fluorouracil. The study involved 185 patients with unresectable 5-fluorouracil-resistant CRC hepatic metastases who had undergone surgical cytoreduction. Patients were randomized postoperatively to receive either hepatic arterial floxuridine and systemic irinotecan (n = 71) or no further treatment. At a median follow-up of 20 months, fewer recurrences were observed in patients in the irinotecan–floxuridine arm who were untreated for both hepatic and extrahepatic recurrences; and progression-free and overall survival were longer for patients who received irinotecan–floxuridine. The 2-year survival rate was significantly better for patients receiving adjuvant therapy compared with patients receiving no additional treatment [2].

References

1. Ernst MF, Voogd AC, Balder W et al. Early and late morbidity associated with axillary levels I-III dissection in breast cancer. J Surg Oncol 2002; 79: 151–155.[ISI][Medline]

2. Litvak DA, Wood TF, Tsioulias GJ et al. Systemic irinotecan and regional floxuridine after hepatic cytoreduction in 185 patients with unresectable colorectal cancer metastases. Ann Surg Oncol 2002; 9: 148–155.[Abstract/Free Full Text]





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