Wednesday, June 18, 2008

Health Overview and Scrutiny Committee

Health Overview and what?

Today was my first meeting of the Council's Health Overview and Scrutiny Committee. Even though healthcare is provided mainly by the NHS, the Council has a duty to scrutinise what's going on in Birmingham. After the usual formalities, we got stuck in.

Health Inequalities - The Term

Cllr Deirdre Alden's the Chairman and she opened with a comment that 'health inequalities' is a government term that we're kind of stuck with. It's not all that helpful because one (unacceptable) way of removing health inequalities would be by making everyone as unhealthy as the unhealthiest people!

What are Health Inequalities?

We had a presentation on the subject. I examined the BMJ's definition of 'health inequalities' on two counts. Firstly, it uses the term '...inequalities are claimed to exist...'. The implication is that perceived health inequalities may not be inequalities at all.

Secondly, it's measured by 'when different groups... consume different amounts of health care.' This is different to a group's need for healthcare and there could easily be a disparity between the two - it's just easier to measure consumption than need. The presenter agreed with my comments.

'I live in Ladywood, therefore I won't live as long'

There were loads of diagrams that supported the presenter's general assertion that how long you live for depends on where you live in Birmingham. This is in part related to access to services etc.

I for one don't particularly like this approach - it risks creating a victim culture. I suggested that this difference really exists because location is a very good indicator of socioeconomic status, and it's this that's the real cause of the difference. For example, people on lower incomes are more likely to smoke or have a poorer diet. I didn't face any real challenge to this assertion.

Stop Smoking Services and Under-16s

I was interested to know why the graph measuring this only includes people aged 16 or over. Once we'd established that under-16s can access these services, we were told that the number doing so was 'small'. Personally I don't care how small this number is, these are the people we should be concentrating on most! I asked for future figures to include under-16s.

Speak English?

I asked whether there was any evidence that your ability to speak English affected your access to healthcare. This is a particularly important issue in Britain right now, and in Birmingham in particular. The presented told me that there wasn't much evidence above 'anecdotal' evidence. This surprised me somewhat.

New Acute Hospital

An organisation called 'Towards 2010', which is part of a Primary Care Trust, talked about many things, including a planned new acute hospital. This will be built in Sandwell but also serve the people of Birmingham.

One of the things I feel can get overlooked in hospital planning is the visual impact of such a massive building landing on people's doorsteps. As Douglas Adams once said, 'It can hardly be a coincidence that no language on Earth has ever produced the phrase, "as pretty as an airport"'. I would argue that the same applies to hospitals.

I'd be worried if in the rush to produce the best possible hospital for the lowest possible cost, this aspect were completely overlooked. I do feel that it at least should be on the list of requirements for the architectural and planning briefs. Doubtless there are requirements for the numbers of car parking spaces and other functional issues. I didn't get a positive answer that architectural merit had really been considered so far.

The architectural merit of a hospital should never be a priority for the NHS. However, there's certainly evidence that how buildings look affect our health. I appear to be in good company; my second quote comes from Sir Winston Churchill, 'We shape our buildings and afterwards, our buildings shape us.'

New Boots Walk In Centre for the City Centre - or not..?

I was surprised to find a line in the presentation that read, 'Boots Health Care Floor including Walk In Centre - July 2008'. The strong suggestion in the presentation is that the Walk In Centre is a new thing. However, I have a distinct memory of walking into an NHS Walk In Centre in Boots a few years ago. It turns out that it's not a new thing, but the 'Health Care Floor' is. Hmm...


We had a final presentation from a chap from the National Institute for Health and Clinical Excellence. This has the controversial job of deciding whether drugs are cost-effective enough to be prescribed on the NHS; in other words, whether the improvement to someone's life is worth the cost of a certain drug.


Cllr Jane James did a great job of getting down to brass tacks on the subject of Lucentis, which is very expensive but can prevent blindness in some people. It's approved for use in Scotland but not in England (NICE doesn't cover Scotland). Our presenter effectively said that it hadn't been approved on the grounds of cost, but there's some attempt at the moment to get the drug company to share the financial risk of approving the drug. There's certainly a risk that people will go blind by the time Lucentis is approved (if it ever is), which is bound to cost the state and society more in the long run. Or I guess you could move to Scotland...

UPDATE 19/06: Apparently the issues around Lucentis are more complex than the information that came out in yesterday's meeting, but I believe the essential fact remains that it's not available to prevent blindness in England (as appropriate), for whatever reason.

NICE's Economic Model

I asked the presenter about the economic model that NICE uses to frame its decisions. I'd heard that NICE doesn't publish an 'executable' version of its model (i.e. one in which you can change the figures), but it does publish a 'paper-based' version. Our presenter confirmed this, one of the reasons being that they don't want drugs companies and others to fiddle with the model until they get the 'right' result, and then submit their evidence accordingly.

I must say that I don't understand this approach. NICE should come clean, publish the model and stand by its decisions. I was further confused when our presenter admitted that it would be possible for someone to recreate the 'executable' model from the public information, so I really don't know what purpose this policy serves, other than potentially increasing levels of suspicion around how NICE arrives at its decisions.

Who's NICE's Customer?

Aside from the drugs approval role, NICE has a very important role in offering clinical and other guidance to NHS organisations - Primary Care Trusts and so on. I wanted to look at how it does this, so time for an analogy.

The Police IT Organisation was wound up last year because it never delivered what it was supposed to. One of the reasons given in the Home Office report is that there wasn't a customer. The Home Office paid for PITO, but individual police forces were supposed to be the beneficiaries. However, police forces weren't obliged to listen to PITO and in any case they had no incentive to because they weren't paying. It strikes me that an almost identical situation exists in terms of NICE's guidance.

NHS trusts don't pay for NICE's guidance and they don't have to take it. Does this weaken NICE's position? Our presenter thought not, but when I asked him whether he would prefer NICE's guidelines to be binding, his 'gut feel' was that they should be.

We'll see whether NICE fares any better than PITO.

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