By BRIAN GORE
Montreal family physician and director of professional services at Maimonides Geriatric Centre. When I meet colleagues at family-medicine conferences - which I've been doing over the 30 years that I've practised in Montreal - our conversations in recent years have turned from the latest medical treatments to what will happen to our patients as we cut back or retire.
Despite the constant problems with practice succession, the one corner of our professional lives that we still appreciate is the presence of McGill medical students in our offices.
These students are bright, enthusiastic and exceptionally keen to learn the art and science of what we have learned and are eager to share. This process of mentoring is an essential part of the learning experience for the next generation of family physicians. Nevertheless, many hurdles are driving them away from becoming family physicians.
Here's a summary of some of those obstacles:
The Quebec-restrictions on practising - first the Activités médicales particulières (AMPs, the obligation to perform a certain number of hours a week of specific medical activities), followed by the more repressive PREMs (plans regionaux d'effectifs medicaux, the system that sets the number of positions for doctors per region) are huge barriers. They cannot comprehend how limiting access to family practice in times of a shortage of almost 1,200 family physicians in Quebec will improve the situation for primary care services. Higher medicalschool enrolment might result in more graduates, but the PREM bottleneck has been chasing new physicians either into private practice off medicare, or out of Quebec altogether.
They are perplexed know-ing that in the Montreal region alone, at least onethird of practising family physicians (approximately 700) will be retiring soon, yet only 61 PREM permits for Montreal have been granted to graduates this year. Astonishingly, 30 new family physicians have been refused a Montreal permit. The net addition of family physicians on the island this year (the number retiring minus the new doctors) is a paltry 12.
With a 78-per-cent income disparity (after office expenses) between family physicians and specialists in Quebec for 2009-10, it is no wonder that fewer than 35 per cent of medical students choose family-medicine residences. That is why each year in Quebec, 50 to 75 family-medicine residency positions go unfilled while virtually all other specialties are full. Regrettably, then, promising local students will continue to flee a family-medicine career.
What initiatives would make young doctors reconsider becoming a family physician? My own experience and discussions with colleagues suggest these solutions:
Keep experienced family physicians in practice longer to help the next generation transition into established practices. Use negotiated incentive programs for both the new and senior family physicians to work together.
Develop mentorship programs with the medical schools for students and family-medicine residents in GP offices, clinics and family medicine groups.
Create an attractive en-vironment for practising with electronic health records, technological and other professional support, and updated medical equipment.
In times of doctor short-ages, restrictions on access to practice make no sense. AMPs and particularly PREMs should be eased or abolished throughout Quebec.
To accept the medical re-sponsibility for between 1,000 and 1,500 patients, family physicians' income must be comparable to that of their specialist colleagues. The present 78-per-cent income differential is unacceptable.
Finally, financial incen-tives in the form of bursaries or loan forgiveness should be offered to medical students choosing family medicine and willing to remain in Quebec, at least until the family physicians/specialists ratio vastly improves.
As we, the front edge of the physician baby boomers, progress toward retirement, we know that there will be large numbers of patients with nowhere to turn for continuing health care.
The last generation that was to renew our profession is absent, and the new medical students are continuing to be exposed to the dark side of a family-medicine career. We need the government's open ear to act responsibly and expeditiously to stop the deterioration in community practice and rekindle our primary-care profession. Otherwise we are facing a bleak future in Quebec's primarycare system.
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Hope for health in Nigeria (Editorial)
The Lancet, UK
Volume 377, Issue 9781, Page 1891
Celebrations are afoot in Abuja. On May 19, the two Houses of the Nigerian National Assembly finally passed the National Health Bill into law, after 7 years of inaction and procrastination. The controversial bill, which promises to provide all Nigerians with a basic minimum package of health services, was originally proposed in 2004 and passed in May, 2009, before being withdrawn for bureaucratic reasons. It has effectively lain untouched since. The Nigerian Medical Association estimates that 7 million children and 385 000 mothers have died in the interim.
As the most populous country in Africa (one in four Africans live in Nigeria), providing universal health care is no easy task. But even allowing for the difficulties posed by providing health care to a large population, the country still underperforms. Life expectancy at birth averages just 54 years for both sexes. Maternal mortality is 608 per 100 000 livebirths, and the mortality rate for children younger than 5 years is more than double the global average at 157 per 1000 livebirths. Nigeria is the only country in the African continent to have never eradicated poliomyelitis, and only 3% of HIV-positive mothers receive antiretrovirals. Just 6% of the country's gross domestic product (GDP) is spent on health and there are enormous inequalities in its allocation between the rich and poor areas of the country.
The bill provides a framework for the regulation and provision of national health services, defines the rights of health workers and users, and stipulates guidelines for the formulation of a national health policy. Its promises will not change everything for Nigerians, but the bill does allow them to finally hold the government to account for their right to health, including equitable access to care. Never before has there been such momentum towards making a real commitment to improving health in this country.
The bill pledges to develop a national health policy that includes 60 billion naira (about US$380 million) devoted to primary health care each year, commitments to the provision of essential drugs, and comprehensive vaccination programmes for pregnant women and children younger than 5 years of age. It rightly devotes a whole section to strategies to reduce the crippling effect of the brain drain on health care; there are as many Nigerian doctors working in the USA as there are in the public health-care sector of Nigeria. The bill thus commits to providing adequate resources for ongoing education and training of doctors, including a continuing professional development programme. The health bill stipulates the need for measures of accountability, which are central to the bill's success. The country's performance and the state of citizens' health need to be assessed by an independent authority, and the government must be accountable for delivering on their promises.
On May 29, many Nigerians celebrated again as Dr Goodluck Jonathan was inaugurated as President for the next 4 years. The zoologist succeeded President Umaru Yar'Adua after his death last year, and in April, 2011, Jonathan was re-elected in what is widely considered the most transparent and legitimate election Nigeria has ever held. This is an exciting time for the country: it has a leader with a clear mandate, its economy is flourishing (it is predicted to have the highest average GDP growth of any country over the next 40 years), and efforts are being made to reduce its sporadic civic and religious tensions and endemic corruption.
However, until now, health has been lamentably absent from Jonathan's declared priorities. Although progress has been made in poliomyelitis eradication and health-systems strengthening since he came to power in May, 2010, these are only two of hundreds of indicators in dire need of improvement. Many societal groups grew concerned over his neglect of a health agenda. On May 18, thousands of women protested about the delay in the passage of the health bill outside the National Assembly. Their efforts were rewarded with the passing of the bill the very next day. At the time of going to press, all that remains outstanding is presidential assent to make the National Health Bill a federal law.
This auspicious turn of events gives cause for hope. Perhaps President Jonathan is more devoted to rectifying the appalling state of health in Nigeria than has been apparent thus far. If he really is committed to providing equitable and affordable universal health care for all of his people, he should sign the National Health Bill immediately. There is no better way to say “thank you” for electing him.
For more than 5 years, Ethiopia's Federal Ministry of Health has relentlessly followed a vision of supporting community-based health care. The idea was that the only way for one of the poorest countries in the world to improve health services would be to build an operation up from the communities, as opposed to focusing on the top tier of health care—improving major hospitals—and building down. That gave birth to the hiring, training, and the deployment of more than 30 000 health extension workers, almost all women, most of them high-school graduates with 1 year of training, to work in pairs in villages all over this rural nation of 85 million people.
Success soon followed. The number of women dying in childbirth decreased. The number of children immunised increased. And the number of families gaining access to clean water soared. Ethiopia had created a model to improve primary health care for others to follow. Mission accomplished? Not even close.
Health Minister Tedros Adhanom Ghebreyesus and his senior team have started two new reforms to push community-based care deeper into families as well as to expand the responsibilities of the ministry officials and measure whether they are doing their jobs properly. Observers say that the much-heralded Ethiopian health reform is about to go through another major overhaul. The next rounds of change start with Tedros himself and extend to families in tiny villages on Ethiopia's periphery.
What does that mean? In the communities, the ministry hopes to eventually create what it is calling the Health Transformation Army. This army—it will take years to build—will consist of a member from every family in the country dedicated to promoting good health. To achieve this ambitious task, the ministry will first work through communities to identify and train people to help educate, say, five families each about healthy practices.
At the same time, inside the 600-person federal ministry, Tedros, an avid reader of books on leadership and management, has started to roll out a new strategic planning and management evaluation programme called Balanced Scorecard. It basically allows ministry staff—starting with the senior leaders and reaching to the health extension workers in villages—to manage their performance as measured against the country's top health priorities.
At St Paul Hospital in Addis Ababa, the lessons are being put into practice. For the first workers going through the course—from janitors to doctors—they hear about the mission of the hospital and their role in fulfilling it. “Before I took the course, I was just coming to work every day, putting in hours, and didn't see the larger picture”, said Lina Mohammed, an emergency room physician at the hospital. “When you see the bigger picture, the vision for the hospital, which is to provide better quality of care for everyone who comes here, it gives what you do a different meaning. I think it really will improve the quality of the place.”
Rosann Wisman, director of the Ministerial Leadership Initiative for Global Health (MLI), a five-country programme at Aspen Global Health and Development in Washington DC, USA, which helps health ministries attain more ownership of their programmes, said the Balanced Scorecard initiative was not easy for the ministry to start. But she said the Ethiopian leadership stuck with it, and now the model was scheduled to be used throughout the government.
“Why would a ministry of health want to take on a management accountability system that a Fortune 500 company also would want to do?” said Wisman, whose organisation has helped the health ministry to put in place the Balanced Scorecard system. “It's because ministries like Ethiopia are increasingly sophisticated about having a clear set of priorities to build a strong team and have accountability right down to the front lines of health care. The question is not why are they doing it, but why shouldn't they be doing it.”
Additionally, said Mark Dybul, the former US global AIDS ambassador under the Bush administration and now affiliated with Georgetown University, Washington DC, USA, and the George W Bush Institute, Tedros has overseen a “radical shift” in the management philosophy at the ministry. “Tedros has been restructuring the ministry around the health of people and communities, not around fighting diseases”, Dybul said. “Everyone is collectively responsible for the ultimate outcomes, such as the mortality of infants and mothers. Say a person used to be responsible for malaria and had succeeded in goals such as getting so many therapies out to the field, or so many bednets to villages. But Tedros will say, fine, but what is the child mortality rate, and, if it's not declining, you are responsible for that. They are collectively responsible for the health of the region. That is really radical. We don't have that elsewhere. It's visionary.”…Continued.
Full Text: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60795-2/fulltext
Alex Duval Smith
Experts gathered for Africa's first mobile health summit on Tuesday hailed the use of phone technology as a new frontier in improving patient care in poor countries. But a government minister in South Africa, which is hosting the summit, called for caution over issues of regulation, confidentiality and cost to patients.
The debate came as the World Health Organisation released a major report (pdf) charting the worldwide use of mobile phone technology in healthcare. It finds that 83% out of 122 countries surveyed use mobile phone technology for services that include free emergency calls, text messaging with pill reminders and health information and transmission of tests and lab results.
Mobile health is already firmly established enough for the WHO to have set up a special unit five years ago, the Global Observatory for eHealth, staffed by four people in Geneva.
Its manager, Misha Kay, estimated that up to 40 African countries are using mobile health services. He said large countries with several phone operators – such as Ethiopia, Nigeria, South Africa and Kenya – are leading the way. "The momentum is huge. What is happening is important. Millions of people in Africa still do not have access to any healthcare. With mobile technology they can at least have some," he said.
The report says there are now more than 5bn live mobile phone subscriptions and that 85% of the world's population is covered by a wireless signal. In Africa, mobile penetration exceeds infrastructure development – including paved roads, and access to electricity and the internet.
The report praises an initiative in the Democratic Republic of the Congo where Population Services International (PSI) supports a free hotline to complement its family planning campaigns. In Ghana, funding from a US university provides free mobile-to-mobile voice and text services between the 2,000 GPs who serve the country's 24 million population.
Elsewhere, the report singles out for praise a private hotline in Bangladesh, called HealthLine, which has taken 3.5m calls since it was set up in 2006.
The four-day Cape Town summit brings together principally mobile operators, handset manufacturers, providers of tele-medicine equipment, health insurance companies, the pharmaceutical industry and government representatives.
Chris Ross, managing executive for commercial development at the British-South African Vodacom company, said healthcare would provide the next wireless breakthrough in Africa, after mobile money schemes that allow transfers between people who do not have bank accounts. "Someone who is ill often cannot travel, but now we can reach them. Doctors, who are in short supply in Africa, can give mobile health workers all the information they require to run community health clinics.
"The industry wants to use mobile devices to enhance the lives of our customers. That makes business sense. We can go to the likes of the pharmaceutical companies, to governments and private organisations who will fund the transactions," said Ross.
But the mobile health environment remains unregulated in Africa. No rules exist, for example, to stop pharmaceutical companies from giving away mobile phones to medical professionals as part of promotional campaigns.
South Africa's deputy communications minister, Obed Bapela, called for a regulatory framework: "We view mobile health with a mixture of enthusiasm and caution," he said. "We're enthusiastic that technology will help fast-track the delivery of services and reduce transport costs for poor people. At the same time, we're cautious about issues of confidentiality and the vulnerability of patients that arises around cyber security issues. We also need to look at whether the mobile operators are just looking at an opportunity to make more money. That element should be balanced against the cost to the consumer."
Kay called on the stakeholders in mobile health to adopt a "more strategic approach to planning, development and evaluation to increase the impact of mHealth [mobile health] and prove that it actually works. Only 12% of respondents to our survey had done any work on the effectiveness of their efforts'.'
Ironically, the conference and the WHO's endorsement of mobile health comes just days after radiation from mobile phones was classified as a possible cancer risk by the same body.
In the little village of Mortimer, near Reading, Berkshire, Bill Walters sits most of the day in the conservatory he built before his hip gave out. He can get up the stairs with crutches, but the pain, he says, half-way up and breathing heavily with the effort, is "excruciating". Doctors agree he needs a hip replacement. On 9 December he was told the waiting time was 18 weeks. He now has a "pencilled-in" date in July, when he will have been waiting for 31 weeks.
A little over a year ago, David Cameron stood at a lectern in the first televised leaders debate of a British general election and declared his passionate devotion to the NHS following the illness and death of his son, Ivan. "What it did for my family and my son I will never forget," he said. His party would make an exception of the NHS, he promised, sparing the axe and increasing spending in real terms so that "we improve it, we expand it, we develop it".
Bill Walters could be forgiven for wondering how Cameron's pledge squares with his present pain. Waiting lists like the one he is on are growing. The Patients Association, hearing hundreds of stories from people complaining of delayed and cancelled operations, put in freedom of information requests to every acute NHS Trust in England in January, asking about nine common surgical procedures including hip and knee replacements. Among the 62 Trusts that replied, it concluded, 10,757 patients had not received an operation because they were unfortunate enough to need it in 2010 instead of 2009.
Guardian Focus Podcast: How will the changes to budget affect the NHS? Link to this audio Cameron and the health secretary Andrew Lansley keep repeating their pledges that the NHS's budget is being protected and will increase in real terms every year of this parliament. But on the ground the reality is very different. An array of financial pressures is forcing primary care trusts (PCTs) and hospitals across England to get used to having less money to spend just at a time when their costs are rising. NHS bosses are gloomy. Increasingly their NHS organisations are having to ration access to healthcare just when demand for it is growing. More and more of them are shrinking their workforces – by as many as 1,600 staff over the next four years, in the case of the Heart of England NHS Trust, which runs hospitals in Birmingham and Solihull.
No wonder health policy experts warn that even when the health and social care bill has finally ceased to be controversial for the coalition, the NHS's difficult finances could prove to be a rolling bad news story ministers had not anticipated.
But how can a solemn undertaking to give the NHS more money translate into delays and cuts? The answer lies, in part, in the growing numbers of us who, like Bill, have every expectation of living long into retirement and every hope that the NHS will sort out our infirmities. Average life expectancy in the UK rose from 71 in 1960 to over 80 in 2009. Demographic change is adding £1bn a year to NHS costs, the influential health thinktank the King's Fund says.
But the NHS also has to find an extra £1bn this year to cover pay increments, guaranteed cash fillips which many of its 1.4m staff get in any year. January's VAT increase will cost another £250m. Some £200m has to be found to fund the government's Cancer Drugs Fund. Transitional costs of the NHS preparing for the big shakeup anticipated in the stalled health bill will be around £500m, according to the regulatory impact assessment for the legislation itself. Then there is the unknown cost of the NHS being expected to provide brilliant but increasingly expensive new technologies, from fertility treatment to novel cancer drugs.
Plus, crucially, PCTs are being forced by the NHS to get their finances in order so they are not carrying debts which their successors, the new clinical consortiums due to start commissioning care in 2013, would refuse to assume.
NHS leaders have to contend with all that but then also confront the biggest challenge of all: the need to make £15bn-£20bn in efficiency savings by April 2015, to try to plug the widening gap between the demands being placed on the service and its ability to meet them. This is the so-called Nicholson challenge, named after the service's chief executive, Sir David Nicholson.
The NHS was launched in 1948 with a budget of £437m, which would equate to £9bn now. In 1997, when Labour came to power promising to restore an underfunded health service and make it as successful as the best in Europe, the budget was £35bn. By the time they left office, it was around £110bn – and yet productivity, in terms of the amount of healthcare we get for the money (not an easy thing to measure) has gone down. The Office for National Statistics estimates that between 1995 and 2008, it fell by 3.3% – an average of 0.3% a year. Some people say the money was soaked up by increases in doctors' pay (allegedly up to 40% went on salary increases). Lansley says the NHS under Labour was inefficient – which bolsters his argument that it can make savings – but Labour and sympathisers say performance is incredibly hard to measure. You can count the number of hip operations, or ambulance trips or treatments for depression, but since some patients end up coming back, does that translate into fitter, healthier, happier people?...Continued
Full Text : http://www.guardian.co.uk/society/2011/jun/08/nhs-health-service-cuts-report