This Week's News 27-31 July 2009

10

Support Slips for Health Plan
Wall Street Journal

30/07/2009

By LAURA MECKLER
WASHINGTON -- Support for President Barack Obama's health-care effort has declined over the past five weeks, particularly among those who already have insurance, a Wall Street Journal/NBC News poll found, amid prolonged debate over costs and quality of care.
In mid-June, respondents were evenly divided when asked whether they thought Mr. Obama's health plan was a good or bad idea. In the new poll, conducted July 24-27, 42% called it a bad idea while 36% said it was a good idea.
Among those with private insurance, the proportion calling the plan a bad idea rose to 47% from 37%.
Declining popularity of the health-care overhaul reflects rising anxiety over the federal budget deficit and congressional debate over the most contentious aspects of the legislation, including how to pay for it. The poll also shows concern over the role of government in determining personal medical decisions.
Trying to regain momentum, Mr. Obama is shifting his pitch to new consumer-protection rules for insurance companies, part of a bid to win over Americans who already have coverage.
David Axelrod, one of the president's top advisers, acknowledged that the White House's months-long focus on controlling medical costs hasn't worked. "Consumer protections are a lot more tangible," he said.
On Wednesday, Democratic leaders in the House reached accord with conservative party members to move their bill through the last of three committees, although the full House won't vote on the measure until at least September. "Failure is not an option," said California Democratic Rep. Henry Waxman.
The White House is eager to show progress and build public support before Congress breaks for summer, when opponents plan to continue their campaign. "If this bill hangs out there over the August recess my guess is it will get shredded," House Minority Leader John Boehner (R., Ohio), said.
In the Journal poll, only two in 10 people said the quality of their own care would improve under the Obama plan; just 15% of those with private insurance thought it would. Twice as many overall, and three times as many with private coverage, predicted their own care would get worse.
"You can't pass a substantial health reform unless privately insured people see there's a benefit for them," said Bill McInturff, a Republican pollster who conducts the poll with Democrat Peter D. Hart.
Support for former President Bill Clinton's health plan hovered in similar territory in 1994 on its way to defeat. But the Clinton plan never made it as far in Congress as the Obama effort has this year. Indeed, the poll showed strong support among respondents for ideas common to all of the pieces of health-care legislation being considered by Congress.
When given several details of the proposal, 56% said they favored the plan compared with 38% who oppose it.
The description given to poll respondents didn't include a public-insurance plan, which divides the public, nor specifics about what income levels might be taxed to fund the plan.
The poll had a margin of error of 3.1 percentage points for the overall sample.
Mr. Obama has focused sharply on cost control for businesses and Americans who have seen premiums rise faster than wages.
White House officials believed this would give those with insurance a stake in the debate.
But those efforts have been hurt by the debate in Washington, which has been dominated by the $1 trillion, 10-year price tag for covering the uninsured. That makes it hard to persuade people that the bill will lead to reduced costs, said Mr. Axelrod.
"People are properly skeptical about any proposals out of Washington that speak to cost because they've been singed by past experience," said the senior Obama adviser.
At a town hall meeting in Raleigh, N.C., Wednesday, the president outlined a series of policies, many of which the insurance industry has agreed to accept.
The president said, for example, he wants rules that would require insurers to cover people with pre-existing conditions, cap out-of-pocket expenses, bar insurers from dropping people who become seriously ill, ban annual or lifetime coverage caps, and allow adults to stay on their parents' plans through age 26.
"If you've got health insurance, then the reform we're proposing will also help you because it will provide you more stability and more security," Mr. Obama said.
On the question of how to pay for the measure, the poll found only one idea with majority support: a surtax on the rich, the approach taken in the bill moving through the House, but which isn't expected in the Senate version.
Public support for fining businesses that don't offer insurance dropped from last month, with half of those polled now in favor. Only four in 10 liked the idea of taxing insurance companies that offer particularly generous health plans, an idea that has gained currency in the Senate Finance Committee.
The poll found that Mr. Obama's overall ratings have fallen amid worries over the economy, with the decline due almost entirely to dwindling support by Republicans. His score is solid by historical standards but no longer at the high-flying levels of his early weeks.
Overall, Mr. Obama's ratings fell on a series of measures. His job approval now stands at 53%, down from a high of 61% in April. That is three points higher than President George W. Bush had in June 2001, following a contentious election victory.
The proportion of people who said it was very or fairly likely that Mr. Obama would bring "real change" dropped to 51% from 61% in February. The share of those who said he could be trusted to keep his word fell to 48% this month from 58% in April.
Mr. Hart, the Democratic pollster, said rising concerns over employment and the economy explained Mr. Obama's falling ratings.
"He seems embroiled in so many of the issues of the day without much sense of relief on the economic front," he said.
The poll also found a rising sense of partisanship. More than three in 10 surveyed said the current Congress has been more partisan and divided than in the past, compared with just 11% who said it has been less partisan.
In February, people were more likely to blame Republicans by a two-to-one margin. This month, they were divided over who to blame, with most saying both parties were at fault.
On other issues, the poll found:
Strong support for Sonia Sotomayor, Mr. Obama's nominee for the U.S. Supreme Court. Forty-four percent of people said they strongly or somewhat supported her confirmation with 30% opposed.
Falling support for the economic stimulus plan, with 34% in favor, down from 44% in February; 43% now say it is a bad idea.
Two-thirds of people said they knew enough about the controversy surrounding the arrest of Harvard professor Henry Louis Gates Jr. to form an opinion. Of them, about one in three said both Mr. Gates and the police officer were equally at fault, 27% said Mr. Gates was more at fault and 11% said the officer was more to blame.
—Jonathan Weisman in Raleigh, N.C., contributed to this article

Write to Laura Meckler at [e-mail]

Printed in The Wall Street Journal, page A1

Back to top

Europe

1

Retaining health manpower in developing countries
The Lancet, UK

25/07/2009

Volume 374, Issue 9686, Page 291

Laxmi Vilas Ghimire a

Correspondence
I was pleased to see the undergraduates' concern about health-care delivery in developing countries (May 16, p 1665).1 As they discuss, compensation could be a solution to the problem of migration, but it would only be a temporary one. The main reasons health-care workers migrate are to look for better opportunities, a better lifestyle, better education for their children, and safe working conditions. So unless home countries are able to give some hope in these regards, the migration of health-care workers from developing to developed countries will continue. The following options might help further.
Bonding systems could require medical or nursing graduates to serve for a minimum number of years in the home country before going for further training. Such a scheme has helped rural Nepal keep hold of more of its young doctors in recent times. Increasing facilities such as schools, police posts, and the availability of telephone networks and the internet could help doctors to remain in the rural setting of developing countries where they are urgently needed.
Finally, increasing both the numbers and skill sets of mid-level health-care workers such as health assistants and community medical assistants could boost the backbone of the health-care service in rural settings. Additionally, because the qualification is not internationally recognised, such workers are less likely to migrate. So, rather than producing more doctors, shifting the focus to mid-level health care workers might help developing countries, at least in the delivery of basic health care and to move towards achieving the Millennium Development Goals.
I declare that I have no conflicts of interest.
References

1 Agwu K, Llewelyn Mon behalf of undergraduates in International Health at UCL. Compensation for the brain drain from developing countries. Lancet 2009; 373: 1665-1666. Full Text | PDF(49KB) | CrossRef | PubMed

a Vanderbilt University, Nashville, TN 37232, USA

2

ANALYSIS-Shortage of doctors could damage healthcare reform
Reuters, UK

23/07/2009

By Andrew Stern
CHICAGO, July 23 (Reuters) - A growing shortage of primary care doctors could place a major burden on the U.S. healthcare system if President Barack Obama succeeds in extending medical insurance to millions of Americans who currently lack it.
As healthcare legislation works its way through the U.S. Congress, most of the focus has turned to how to finance a reform that could cost $1 trillion in the next 10 years and aims to cover most of the 46 million uninsured Americans.
Less attention has been paid to what might happen if millions of new patients join a healthcare system that is unprepared and unequipped to handle the load.
The United States already has a shortage of between 5,000 and 13,000 primary care doctors, according to the Robert Graham Center. Add millions of previously uninsured people and the shortfall will balloon to as many as 50,000 doctors.
"I don't think (the doctor shortage) will be the thing that dooms the reform bill" being debated in Congress, said Dr Robert Phillips, director of the Robert Graham Center, a non-profit organization that analyses healthcare policy.
Obama and other reform advocates argue that billions of dollars and many lives could be saved by extending preventive care to many who do not now have access to it.
But some lawmakers worry that such gains may not be realized because of a lack of primary care doctors who are usually patients' first healthcare contact.
Solving the problem will take time and money.
"It's a system that's not serving our country well; we need transformative change and it's going to cost money," said Dr Cecil Wilson, president-elect of the American Medical Association, which represents 250,000 doctors.
The country needs more medical schools, more residency slots, and better pay for primary care physicians who currently make much less money than specialists, Wilson said.
Insurers routinely pay more for procedures performed by specialists than for checkups by primary care doctors. A primary care physician typically earns between $125,000 and $200,000, while specialists often earn several times more.
Some experts argue the problem is more an inefficient healthcare system than a shortage of doctors.
POOR AREAS UNDERSERVED

The Altarum Institute, another non-profit group that analyses medical policy, found affluent areas of cities tend to have plenty of primary care physicians, while poor urban areas and rural regions are underserved.

There is also a perceived shortage of nurses, who may be called upon to take on more tasks when preventive care becomes the norm.
Congress is weighing incentives for primary care physicians, such as bumping up payments for primary care services by 5 percent from the government-run Medicare program, and writing off medical school debt in exchange for service in the National Health Service Corps, which places doctors in underserved areas.
But expanding the ranks of primary care doctors could take years -- if the incentives work at all. Phillips said primary care doctors' Medicare compensation will have to be raised by 50 percent to have an impact.
Primary care doctors -- family physicians, pediatricians, and general internists -- comprise one-third of the 682,000 U.S. doctors, about the same proportion as two decades ago, but their numbers are seen dwindling as retirees are not replaced.
Of the 18,000 U.S. medical school graduates each year, a growing number are choosing to enter specialties such as cardiology, gastroenterology or plastic surgery.
At Northwestern University's Feinberg School of Medicine in Chicago, only 5 percent of students overseen by primary care physician Dr Russell Robertson are interested in becoming family doctors. The trend is damaging healthcare, he said.
"When primary care providers exceed the number of specialists treating patients, healthcare outcomes are better across the board. And by a positive coincidence, healthcare costs are lower," Robertson said.
Feinberg medical student Jacob Chacko said his classmates are choosing which practice to pursue based on perceived job satisfaction and nagging worries about how to repay skyrocketing school loans.
"We know there is intense demand for primary care physicians but most medical students hope, possibly naively, that they will be in demand no matter what they go into," Chacko said.

(Editing by Alan Elsner)

3

2008 Workforce Census Published - Royal Pharmaceutical Society Of Great Britain
Medical News Today, UK

28/07/2009

The Royal Pharmaceutical Society of Great Britain has published its fourth Pharmacy Workforce Census, reflecting the working patterns of pharmacists registered in August 2008. The reports findings reveal changes in workforce patterns since the last census in 2005, together with new and emerging trends in the workforce. Census forms were sent out to all pharmacists with a registered address in Great Britain.
The survey achieved a high response rate of 69.6%. Key findings included:
- The Register increased by 1.7% overall between August 2007 and August 2008. The Register has grown by about 2% annually since 1991; therefore the increase is in keeping with the previous upward trend.
- Pharmacists reported working the same mean number of hours as the 2005 census (35 hours), although men worked longer hours than women. The proportion of pharmacists working 49 hours or more per week has risen by 1% since the last census.
- There has been a slight increase in the numbers of actively employed pharmacists working part-time, with these pharmacists representing a significant proportion (32.3%) of the working population. Part-time working (defined as working 32 hours or less) was most prevalent in the primary care sector (39.5%).
- More than a third of pharmacists (41.9%) reported that they usually worked long hours and this figure rose to 52.2% for male pharmacists.
- Almost a third of pharmacists (30.3%) felt that they didn't have enough time to socialize with their family and friends and a similar proportion (30.7%) wanted to reduce their working hours, but felt they had no control.
- Male pharmacists consistently recorded higher scores for the work-life balance measures than females, indicating that men may perceive they experience more problems with worklife balance than females. The only exception to this was in the case of pharmacists working part-time: male part-timers recorded lower work-life balance scores than females working part-time.
- More than one in ten pharmacists (13.0%) are considering leaving the sector in which they currently work within the next two years. A similar proportion (10.9%) are considering quitting the profession altogether.
The findings provide full and fundamental data for the General Pharmaceutical Council (GPhC) when it is established in 2010, and will be used to help inform workforce planning and policy development across the profession. Findings relating specifically to work/life balance will also inform initiatives such as the Society's ongoing workplace pressures campaign. Sue Ambler, Head of Research and Development at the Society said: "Thank you to all those pharmacists that took the time to complete and return the census questionnaire. The data will be utilised to help identify how both the GPhC and the new professional leadership body can further and strengthen support for pharmacists in their advancing and evolving roles." A copy of the report is available on the Society's website: http://www.rpsgb.org.uk/pdfs/census08.pdf
Notes
The research on which the Census report is based was commissioned by the Research Division at the Society. The research was undertaken by a team at the School of Pharmacy, University of Manchester and funded by the Department of Health. The 2008 Census report is the Society's fourth. The first census was conducted in 2002, the second in 2003 and the third in 2005.
Source

Royal Pharmaceutical Society of Great Britain

4

Top health workers nominated
Teletext, Scotland, UK

26/07/2009

Residents are being invited to nominate individuals and teams for the NHS Highland Staff awards.
The awards are now in their fourth year and were set up to recognise and celebrate those who go the extra mile to improve health and patient care.
They cover services including community staff, support workers and volunteers. The closing date is August 14.

5

Nurses And Midwives Looking For Real Reforms, Australia
Medical News Today, UK

27/07/2009

The Federal Secretary of the Australian Nursing Federation, Ged Kearney and the Assistant Federal Secretary, Lee Thomas will be available for comment on the Prime Minister's address on the challenges of Health Reform and the release of the NHHRC report.
The ANF understands the complicated nature of Australia's health system and the challenges it faces and will welcome initiatives that bring real reform to health funding, addressing the duplication and inefficiencies that currently exist. Vital to this is a renewed focus on Primary Health Care delivered by the right professional at the right time.
The ANF expects to see initiatives leading to better use of the health workforce which will bring people greater access to relevant, community focused health care from a variety of appropriately skilled health professionals. Critical to this is appropriate initiatives in residential aged care which is part of the health care system, and must be an integral part of overall reforms.
Source

Australian Nursing Federation

6

Merlin Welcomes US Aid to Pakistan, More Is Needed
Reuters AlertNet, UK

29/07/2009

Source: Merlin - USA

Lucy Dorick, Director, Merlin USA

Website: http://www.merlin-usa.org

Reuters and AlertNet are not responsible for the content of this article or for any external internet sites. The views expressed are the author's alone.
Merlin USA welcomes the US government's $165 million pledge to provide much-needed humanitarian assistance resulting from the spreading conflict in Pakistan.
Despite this contribution, the international community has yet to meet the UN funding target of $543 million launched in an emergency appeal last May. More than 2.3 million people, who have fled their homes seeking safety, are in great need of assistance.
The current crisis in Pakistan has prompted the largest internal displacement since the Rwandan genocide and Merlin calls on international donors to step up funding to avoid a humanitarian disaster. "The international community must step up their contributions to ensure these families stay healthy while they endure this great upheaval in their lives," said Lucy Dorick, Director of Merlin USA.
"And we must think ahead. What will these families go home to? Will they have clean water and enough food? Will there be health clinics and the staff to run them?"
Merlin medical teams are working around the clock to battle against disease outbreaks and provide medical care to vulnerable families. Providing treatment to 14,000 people each week, teams are operating eight static health clinics and eight mobile clinics are operating in camps and host communities. An additional 12 clinics, half of them are mobile, are dedicated to treating malnutrition.
As more displaced families begin the process of returning home, Merlin is coordinating with the local health authorities to support access to health in the secured areas of the Swat Valley. Improved security allowed Merlin staff to carry out a health assessment in the Buner area, and we are now operating nine health facilities, including 3 in local hospitals, which Merlin is refurbishing and providing support.
Please help us save more lives. Support Merlin USA: www.merlin-usa.org

[ Any views expressed in this article are those of the writer and not of Reuters. ]

7

GPs who work alone are six times as likely to come before GMC
British Medical Journal, UK

23/07/2009

Helen Mooney

1 London

Figures published by the UK General Medical Council show that GPs who work on their own are six times as likely to attend a disciplinary hearing than those working in group practices.

Figures released under a freedom of information request by the BBC’s Newsnight programme show that 17 GPs who work alone and 67 GPs who work in group practices came in front of a GMC fitness to practise hearing in the past year.

The NHS in England, Scotland, and Wales has 38 728 GPs in multiple practices and 1589 GPs working on their own for the same period.

This means that there was roughly a one in 100 chance each year of a GP who works alone coming before the GMC, and a one in 600 chance of a GP in a group practice doing so.

A spokeswoman for the GMC said, "The vast majority of doctors in the United Kingdom do a good job in often difficult circumstances. We receive around 5000 complaints each year and, after initial inquiries have been made, around 1800 are investigated by our fitness to practise directorate. Each complaint is looked at individually and on its own merits."
The government has been keen to expand larger practices in recent years, and last year the former health minister Ara Darzi launched a plan for a network of polyclinics, which are health centres where patients can access a range of services in one place.
Lord Darzi’s plan envisaged many doctors working with other health professionals in new facilities that could handle minor injuries, childbirth, and dental and psychiatric care.

However, the BMA has been opposed to such proposals. It is concerned that polyclinics will be too big to offer patients continuity of care.

Richard Vautrey, deputy chairman of the BMA’s General Practitioners Committee, said that the GMC figures are unreliable because they are so small. He said that it is important that primary care trusts support GPs who work alone as much as those who work in surgeries.

"PCTs [primary care trusts] can provide protected learning for solo GPs so that they can meet their colleagues and share best practice while retaining the best of small practices," he said.

Dr Vautrey also criticised the increased bureaucratic burden that the government has placed on surgeries, which he said affects solo GPs more heavily. He also said that singlehanded practices had suffered from a lack of funding for their premises in the past few years.

Steve Field, chairman of the Royal College of General Practitioners, advocated a "federation model" for GPs.

"As medicine is developing I believe that singlehanded GPs should work more closely with other doctors and be federated with other practices for the provision of care or commissioning or both, to share best practice and audit results," he said.

Cite this as: BMJ 2009;339:b3036