Monday, 28 January 2013

Talk : Financial Incentives for Healthcare

Nottingham Café Scientifique recently hosted a talk by Prof. Ruth McDonald, Professor of Healthcare Innovation and Learning, Nottingham University Business School, entitled “Financial incentives for healthcare – are they bad for our health?”

The talk considered whether the public could trust doctors to ‘do the right thing’ for patients or whether financial incentives were required to do this.

In addition, the talk was based on experience of evaluating some of these recent ‘Pay for Performance’ initiatives in England and California. It described what happened and looks at the lessons we can learn from this.

Why Incentives?
Prof McDonald explained that there had been a number of instances of incentivised contracts being introduced to NHS staff, including GPs (2004), Pharmacies (2005) and Dentists (2006). Prior to these contacts, these groups had been paid simply on the basis of the number of patients they treated, without reference to whether they were being effective at improving patient health. The contracts aimed to align payment with government policy goals, such as reducing obesity, or the number of smokers.

Hartley Road GP surgery

GP Contract 2004
General Practitioners usually operate as self-employed partnerships of doctors and, in 2004, their contracts were radically overhauled to try and incentivise GPS to improve patient outcomes and also to make general practice a more attractive career for medical graduates (at the time there was concern that the average age of GPs was quite high and that there were not enough graduates coming through to replace them).

25% of earnings in the new contract were related to achievement of a series of “Quality and Outcomes Framework” targets, of which there were some 146! - this was in contrast to the previous contract that had tied earnings exclusively to the number of patients on the practice roll. The QOF targets covered four main areas:

• Clinical standards (chronic disease areas such as coronary heart disease (CHD), hypertension or diabetes).
• Organisation standards (patient records, information for patients etc).
• Patients' experience (number of services and how they are provided
• Additional services.

Software was used to allow GPS to monitor their performance against the targets and also to promot them to ask appropriate questions during consultations.

The new contracts were negotiated with the medical profession and agreed via a ballot, so it was certainly not something that was imposed unilaterally.

To sweeten the deal, the new contracts ended the requirements for GPs to provide out-of-hours cover (something that had been a significant disincentive to entering the profession) and also gave practices a “Minimum Income Guarantee”, which required new money to be made available.

So, what were the effects of the new contract?

It is worth noting that there was no historical baseline data against which the impact of the new contracts could be compared, but what can be said is that there was a very high level of target attainment by GPs.

Reassuringly, GP’s did not just reach the targets and then stop - they continued to put resources in to improve performance further, despite it not having any financial benefit for them. In addition, it was found that, over time, the new system resulted in better outcomes for those in lower socio-economic groups, which improved the equity of the NHS GP system.

More disappointingly, it was found that there was little or no change in the prevalence of key chronic diseases such as CHD, asthma or diabetes.

There were also a number of adverse effects of the new contracts…

The government of the day had estimated that GPs would attain some 70% of the targets and had structured the contracts accordingly - but in practice GPs attained around 90% of the targets, resulting in significantly higher incomes for GPs, and extra expenditure for the Government.

Prof McDonald had been curious as to where the “70%” target had come from and had eventually tracked down the source to Tony Snells, clinician who was working in the Health Department at the time. Dr Snells had been approached in a corridor by one of the group drafting the legislation who asked him what percentage of the targets GPs were likely to meet. Dr Snells said that he didn’t know, but the policy drafter was persistent and asked Dr Snells for an estimate, so the Doctor suggested, off the top of his head, that 70% might be a good starting point.

Unbelievably isn’t it?

Morale and co-operation also suffered in some cases. Earnings for practice nurses typically increased by around 3% (nurses had a much wider and more responsible role under the new contracts) - but GP earnings increased by around 38% ! Nurses in one practice who received a token bonus from their GPs would become discouraged when finding out that nurses at another practice had been given payments of several thousand pounds.

Related to the increased role of nurses was a concern that GPs were not getting experience of the more minor and routine ailments of their patients and that this was having a detrimental effect on their overall skill and competence.

Lastly, once the Government realised how much they were “overpaying” GPs, they changed the contract to impose extra tasks on GPs, which led to a loss of trust between the two camps.

Mary Potter Health Centre

Pharmacy Contract (2005)
The Pharmacy contracts introduced in 2005 also had the aim of encouraging improvement in patient outcomes. One example of this was the “Medical Use Reviews” or MUR’s, where pharmacists discuss the medication that a patient is using to ensure that the patient understands all the medication they are taking and review whether it all remains appropriate.

Pharmacies were paid £28 per MUR, but had to get the patient to sign a form. Inevitably, it didn’t look very good that the pharmacist was being paid for giving advice.

On the other hand, pharmacists were often under a heavy workload and found it difficult to make time for MUR’s.

Dental Contract (2006)
Like the GP’s contracts, the changes introduced with the 2006 Dentists contract were far reaching and included the curtailment of open ended funding and patient registration. Treatment had previous been according to a comprehensive schedule that defined specific payments each different type of treatment.

In the new contract, this was changed to collect treatments into one of three bands of “Units of Dental Activity” or UDA’s.

Band 1 (1 UDA) - covers diagnosois, planning and maintenance
Band 2 (3 UDAs) - covers fillings, root canal treatment, extractions etc
Band 3 (12UDAs) - covers complex treatment that includes a lab element, e.g. bridges
Given that root canal treatment can take a lot longer than an extraction - but is paid the same - it is perhaps no surprise that the years following the introduction saw a dramatic increase in extractions, and, possibly, also a decrease in root fillings :

Thankfully, there is much work currently underway to try and devise dentistry contracts that do not contain such perverse incentives.

Other Initiatives
Dr McDonald also commented on a number of other initiatives that has been trialled in recent year such as CQUIN and “Best Practice Tariffs”. However these schemes suffer from the fact that they encourage health providers to adopt a “low risk” approach to target setting as ambitious targets may result in loss of some of the funding. One can imaging the health providers thinking something along the lines of :

“If we try really hard, we might be able to get a 15% improvement in [an outcome], but if we fail we will lose some of the money, so we are better off aiming for 5% so that we get all the available funding”

In contrast, Dr McDonald mentioned the “Advancing Quality” initiative as an initiative that had worked well, with the project having been estimated to have saved some over 900 lives, which was an outcome to unusually positive that it was reported in the prestigious New England Journal of Medicine.

The NEJM compared the initiative to similar project “the HQID program” in the US and commented that,although the UK initiative was a “tournament” in which the bonus’s were paid only to the best performing institutions, “Face-to-face communication, pan-regional participation, and the smaller size of the program in England may have made interaction at these events more productive than interaction at the similar shared-learning events that were run as “webinars” in the HQID.”

The article commented that the greater probability of the UK institutions performing well enough to get a bonus’s was also higher than in the US scheme.


Other comments
Dr McDonald also made a number of interesting comments during the talk or in the Q&A session afterwards…
•As the US healthcare system is largely based on private insurance, it focuses its IT resources on billing, rather than patient care, or the kind of software that prompts doctors to ask questions aimed at early intervention to reduce key chronic conditions. One notable exception to this is the Veterans Administration, who have a large, country-wide IT systems which they offered to make available to other healthcare providers.

•One questioner asked why GP’s were not just simply made salaried civil servants, to which Prof McDonald commented that she had shared this view until she had met some very committed GPs in Liverpool who had made the switch from being an independent practice to being salaried NHS GPs’ - and had found that they then faced the leaden hand of NHS bureaucracy. For example, they could no longer advertise for a receptionist in the local cake shop but now had to go through the NHS regional recruitment process. And neither could that offer tea and coffee to their patients as this was against NHS rules. Collectively, these rules and regulations had caused a number of the partners to quit or consider leaving the GP profession.

•When talking about healthcare spend, it is worth remembering that the US spends some 16% of GPD whilst the UK spends only 8%.

•Patient choice is a topic of much discussion and Prof McDonald felt that that the offering of choice did not deliver benefits in terms of outcomes. For another perspective on this you can read this report by the Kings Fund.


Image Sources: All BFTF's own.

Sunday, 6 January 2013

David Aaronovitch, Star Wars and FSC

BFTF was in the book-buying mood yesterday and seemed to have hit the jackpot when the Dorling Kindersley Hardpack epic "Star Wars Year by Year - A visual chronicle" came into view. It was a great looking book that described, in words and pictures, the develoment of the Star Wars films, including premininary sketches of the spacecraft, character deveopment (Luke Skywalker was originally called Luke Starkiller for example) and information on the cultural references that George Lucas was drawing on.

BFTF wanted to buy two! One for BFTF and one for a Star Wars loving friend.

But, on closer inspection, there was a deal-breaker.

The book wasn't printed on sustainably sourced paper (such as FSC)

So, with a tearful eye, BFTF put the book back on the shelf and walked out of the store and, later, send this message to DK via their feedback form:
"Saw [the book] in a shop today. Looked awesome! Would love to buy two (one for me, one for a Star Wars fan friend).

But I shan't, because it does not appear to be have been printed on sustainably sourced paper (e.g. FSC certified) and I don't want to buy books that may have been printed on paper made from illegally or unsustainably cut trees.

Can you please advise when DK expect that all of its print output will be printed on sustainably sourced paper?"

Moving on to a bit a later in the day, and a different bookshop, BFTF noticed a book by David Aaronovitch entitled "Voodoo Histories - How Conspiracy Theory has shaped the Modern World". A brief click through revealed suggested that it had some very interesting background on the development of a number of the 20th century's most enduring conspriacy theories (such as the Protocols of the Elders of Zion, the death of Diana and the Obama "birther" theories). Importantly, the book also seemed to take a look at the world-view of people who believed in such theories.

Conspiracy theories are something that worry BFTF quite a bit. Over the last few months, BFTF has had a number of conversations with people who genuinely think that the Moon-landings may have been faked. BFTF has pointed out to them a few of the reasons why the evidence for the faking of the moon-landings is very poor.

And asked them rheotorically that, if the US actually HAD managed to convince (or otherwise silence) thousands of programme workers, amateur radio enthusiasts around the world and the entire Russian intelligence community - would they then go and try to pull the same trick again with Apollo 12, 13(yes, BFTF knows that one didn't land on the Moon), 14, 15, 16,and 17?

In one case, BFTF explained that BFTF had actually interviewed Prof Farouk El-Baz, head of Apollo astronaut training about a number of aspects of the programme - and then asked the "denier" whether they thought that the Prof was lying to BFTF or whether they thought that the Prof had had the wool pulled very comprehensively over his eyes?

Anyway, back to the issue at hand.

Would Voodoo Histories pass the sustainability test?

Happily, the answer to that is a resounding Yes, as Vintage Books is a company within the Random House Group. And according to the blurb inside the book:
"The Random House Group Limited supports The Forest Stewardship Council (FSC), the leading international forest certifi cation organisation. All our titles that are printed on Greenpeace approved FSC certifi ed paper carry the FSC logo. Our paper procurement policy can be found at"
Result! The book was bought and BFTF looks forward to reading it in due course.

BFTF also sent a message to Vintage via their feedback form thanking them for using FSC certifed paped and mentioning that BFTF would not have bought the book had this not been the case.

Voodoo Histories

Related Posts
Heirarchy of Disagreement
Sustainable paper at Orion Books
FSC at Random House
A message to WHSmith
Challenging FireAngel on sustainability

Thursday, 3 January 2013

Report - A study of the EDL

Faith Matters have recently published a report entitled "A Study of the English Defence League" which investigates what draws people of faith to right wing organisations and the effect that the EDL has on community cohesion and interfaith relations.
The report really is worth reading, and the links it reveals between the EDL and extremist faith groups are frightening.

The fact that the EDL fundraised in the US has echoes of the notorious NORAID campaigns that funded the IRA in the 70s and 80s.

The report makes a series of key points:

There is a need to maintain resilience as the EDL's message is tailored to play on historical angsts Between faith groups and their campaigning with faith groups is thought out.

Christian institutions on a national level, bar a few locally, have not been robust in condemning the actions of the EDL which disrupt communities and who attempt to divide Christian and Muslim communities.

Religious institutions need to recognise the fact that a small number of radicals within their communities might be drawn to right--‐wing organisations…

The EDL has European and international links which allows it to fundraise at an international level. British authorities need to look at their international money flows, especially when extremist groups are involved…the ability to raise funds from the US need to be highlighted, since US residents promoting street based social unrest in the UK by donating to the EDL needs to be curtailed.

Religious communities should emphasise that the actions of small groups of extremists should not be allowed to represent their whole faith. Each group should publicly denounce their actions robustly at local and national levels

Seeing some rather nasty comments come up for moderation, so thought it worth pointing out that comments basically saying "xx are scum" will be deleted and not published.

Wednesday, 2 January 2013

Proof that activism really can work

BFTF often hears people saying that there is no point challenging governments or companies because :

"they will do what they want to do anyway"

"what can I as a single person do"

"they won't listen to me"

All of the above fundamentally attitudes fail to understand a number of basic truths about collective action.

Firstly, that if the Afro-American community in the 1960s, or disenfranchised British women at the turn of the century, or Black South Africans in the 1980s - had taken the approach suggested by the quotes above then none of these groups would have won the basic human rights that they did. Such is the power of sustained, organised, collective action.

Secondly, whilst we cannot all do everything, we can all do something. And that whilst results are not within out gift, our efforts are. Many guests on the BFTF radio show have commented that it only takes a few, independently written, letters on a particular subject to land in the mailbox of a large company before the company starts to take action to change its policies.

All the same, BFTF would like to offer people some concrete examples of how activism has really made a concrete difference to the policies of a company or government....


April 2014 : Activism pressure forces Tesco and Oriental&Pacific to switch to sustainable Tuna
A month long campaign by Greenpeace, in combination with pressure from television chef Hugh Fearnley-Whittingstall has forced tuna supplier Oriental and Pacific to switch from its current practice of using nets and "Fish Aggregating Devices" (a combnination which kills large numbers of other marine creatures as "bycatch") to a more benign longline fishing method.

As UnderCurrentNews comments :
" 'Greenpeace today welcomed the move, which puts Oriental & Pacific on a par with other major UK tuna brands. But Tesco still comes in for stinging criticism. The supermarket had previously committed to making its own-brand tuna sustainable, but as soon as it fulfilled that promise it then introduced unsustainable Oriental & Pacific tuna, in a stroke undermining its public commitment to protecting the oceans,” the activist organization explained."

See also this report


Feb 2014 : Orcas no longer to be displayed at Winter Olympics
A campaign by (and others) to stop the display of two Orcas that had been caught from the sea specifically for display at the Winter Olympics has achieved success. The Orcas will not longer be displayed there - but they remain at risk of being sold to other dolphinariums. Sumofus wants "White Sphere", the company responsible, booted out of the International Association of Amusement Parks and Attractions (IIAPA), the world’s largest trade association for amusement parks and aquariums (see here)


Jan 2014 : Burberry commit to eliminating dangerous chemicals from their production processes
A campaign by Greenpeace had resulted in Burberry implementing a pretty comprehensive programme (pdf) to eliminate certain chemicals from their manufacturing process.

BFTF is a bit disturbed by the focus on the presence of very low levels of chemicals in the actual clothing - just because you can detect something does not mean it is at a dangerous level. Indeed, Greenpeace itself admits that "as far as toxicologists know, these concentrations don't present an acute risk for children".

In contrast, it is hard to find any information on the dischages to local water systems that occur during the manufacturing process, which is where, BFTF suspects, the real damage is being done.

But if one digs hard enough, items like this, very interesting, this article can be found, in which a Mr Li Changlin, who lives downstream from a major textile works in Dongguan, China is quoted as saying "We used to eat fish and crayfish out of this river...We swam in it. There were green plants on the banks and the water was clear. After 1989, the factories came and the water turned black.". The article also points out discount clothing stores have put a lot of pressure on the textile industry in China, with one industry executive pointing out that "The first thing they say when they sit down in a meeting is, 'How much discount do I get from last year?'".

Another article also describes some of the bad practice in the textile industry in China, and its effects on the river environments.

Also relevant is this Greenpeace Report

Sent Tweet to Burberry saying well done in commiting to eliminate dangerous chemicals from its production processes.


Dec2013 : Giant palm oil trader commits to ending deforestation Making palm oil shouldn’t mean destroying Indonesia’s rainforests. But dangerous and greedy companies are trashing them to grow oil palms. It’s pushing orangutans and tigers ever closer to extinction.

Greenpeace has spent months investigating the palm oil industry. Everywhere they went they came across the same name : Wilmar International, a commodities trader through wose hands pass 45% of the world’s palm oil. The evidence linked Wilmar and its customers to the destruction of tiger and orangutan habitat, human rights abuses and conflict with forest communities.

And throughout the autumn, Greenpeace exposed how Wilmar was laundering this dirty palm oil and selling it to major brands, like Gillette, Ferrero, Cadbury, L’Oreal and Clearasil. Our campaigners in Indonesia protested at Wilmar’s offices and rolled out massive banners in freshly-cleared forest, showing Wilmar’s customers just what they were buying.

Then something interesting happened.

First Ferrero announced a detailed, ambitious plan to only buy forest-friendly palm oil. Then Mondelez (which makes Cadbury) and L’Oreal made an initial commitment to no deforestation (although they’re still working out the details).

And when its customers started moving, Wilmar had no choice but to follow suit.

On 5 December, Wilmar announced that it would stop clearing forests and stop buying oil from companies that it knew were engaged forest destruction. “We know from our customers and other stakeholders that there is a strong and rapidly growing demand for traceable, deforestation-free palm oil,” said Wilmar’s CEO, Kuok Khoon Hong as he launched their new ‘no deforestation’ policy, “and we intend to meet it.”


Jun2013 : Challenging Nestle to stop buying from companies that destroy rainforests
People around the world took part in a Greenpeace campaign to stop Nestle working with companies who were destroying the rainforests. The campaign included 1.5m views of a short Youtuve video, over 200,000 emails sent, hundreds of phone calls and countless Facebook comments.

The end result was that Nestle "developed a plan which will identify and remove any companies in their supply chain with links to deforestation so their products will have "no deforestation footprint".

And that plan is already bearing fruit with Nestle cancelling their contract with the Sinar Mas group ( Sinar Mas is company that is "destroying Indonesia’s rainforests and carbon-rich peatlands.")


Jun2013 : Government considering limiting number of appointments with GPs
Articles such as this one suggests the the Conservative party had, as part of a survey, asked party members whether they agreed or disagreed that "There should be no annual limit to the number of appointments patients can book to see their GP".

38 Degrees swung into action and, within 2 days, had got an epetition of over 180,000 people challenging Jeremy Hunt to :
Please reject proposals to limit how many times we can visit our GP. Being able to visit a doctor, whenever we need to, is at the heart of our NHS. Please confirm that you will never limit access to GPs, and that our NHS will remain free and universal, without any restrictions.

Which resulted in Jeremy Hunt sending a Tweet saying:
"In case being mislead by 'neutral' 38Degrees e-petition, it IS NOT and WAS NEVER going to be Conservative policy to limit GP appointments"

Whilst BFTF is a supporter of 38Degrees, feelings about this particular action are conflicted, for the following reasons:
i) Parties should be able to ask whatever questions they wish of their members without fear of censure, there is nothing wrong with being oontroversial in order to generate a debate.

ii) But BFTF worries that, had the response from the Conservative grass roots been positive, GP visits might have ended up being limited, and this might be done by the back door (the NHS and Social Care Bill, for example was not in the Conservative Manifesto for the last election).

iii) A "Tweet" does not strike BFTF as being strong evidence of Government policy - it's hardly the kind of thing one would like to rely on a in court of law, for example.


May 2013 : Primark and other retailers sign the Bangladesh Safety Accord
Great news from War on Want :

"Global retailers, including Primark, H&M, Tesco, Zara and C&A, have bowed to pressure and signed the Bangladesh Safety Accord. Tens of thousands of you called on Primark to sign the agreement, and hundreds of thousands more around the world joined us in demanding change, following the wholly preventable building collapse which killed over 1,000 people. This is a momentous deal and you helped make it happen.

Together with the Bangladesh National Garment Workers Federation (NGWF) we launched a petition targeting the brands, we organised protests outside UK stores of Primark, we did interviews on TV news channels, we went on national and local radio, we sent thousands of emails, and we bombarded the retailers on their social media pages. And the pressure is paying off."

(NB: The heart of the Accord is the commitment by companies to pay for the renovations and repairs necessary to make factory building in Bangladesh safe. The agreement is legally binding. It will save lives.)


2013 : Telegraph invokes terrorism in article on racial segregation in Israel
A campaign by the The Council for Arab-British Understanding in described in an article by the organisation. The artilcle stated that, on 3 March, the Telegraph published a news article online regarding the introduction of racially segregated bus services by Israel and illustrated it with a picture of a July 2012 suicide bombing in Burgas, Bulgaria that was carried out by a group unconnected to Israel.

Caabu comment that it cannot be right to illustrate a story on wholesale racial segregation by Israel, with a terrorist attack on Israelis. This implies there can be a security justification for comprehensive discrimination against an entire people. In short, the Telegraph have used an image of a terrorist attack, which happened outside of Israel and was not carried out by Palestinians to justify the comprehensive discrimination against Palestinians within Israel.

Following Caabu's highlighting of the issue, The Telegraph have removed the image of the bombed bus and replaced it with an image of a bus in Israel with people queing by it.


2013 : 38Degrees and the Government sell off of the nations Forests
When it was revealed that the Government intended to exempt private healthcare companies from Corporation Tax, the government body Monitor stated that “...Monitor will not be recommending that private sector providers should be exempt from paying corporation tax."

But within a day of 38Degrees members lobbying Monitor they had backed down and hat was a swift turnaround from the beginning of the day, when Monitor had refused to rule out this tax break:

“We have had responses and held detailed conversations with providers from all sectors and we are taking time to analyse the evidence before drawing our final conclusions.”

Accoring to 38 Degrees, Monitor had commented that they were taken aback by the number of 38 Degrees members contacting them - and they were keen to know what they had to do to get us to stop 38Degrees putting them under pressure!


2013 : 38Degrees and the Government sell off of the nations Forests
In late 2010, the government announced a plan to introduce a new law to allow all publicly owned woodlands to be sold off in the future. The government might have expected a few predictable protests, but there was nothing predictable about what happened next.

538,107 people signed the 38 Degrees petition and over 100,000 contacted their local MPs. Some 30 local campaigning groups sprung into action around the country and over 220,000 spread the word on social media.

When the government finally did admit they got it wrong, they promised to set up an independent forestry panel to advise them on what should be done next. Again, 38 Degrees members sprang into action:

34,000 wrote to the panel to tell them what we wanted for our woodlands’ future - more that 80% of all the responses they received

And the Independent Panel on Forestry was critical. They found the government had "greatly undervalued" the benefits woodlands provide for people, nature and the economy. They then called for forest policy to be held in public trust for the entire nation, shielded from political interference – with one member saying, “the tree cycle is wholly different to the electoral cycle.”

And now, after two years, the the government has at last, quietly issued an official announcement confirming that they won't try selling off England's forests again.

BFTF is proud to have been a small part of that effort.


Waitrose, Shell and Greenpeace
Late in 2012, Waitrose announced that they were planning to open a number of shops on the forecourts of Shell petrol stations.

Greenpeace, who were campaigning against Shell's drilling in the arctic, were outraged and wrote to Waitrose three times to ask them to meet with Greenpeace - to no avail.

So then Greenpeace called on the ordinary people of the UK to send an email to Waitrose demanding that they abandon their Shell shops plan. In addition, Greenpeace acivists went to Waitrose stores to talk to managers and customers there.

Very soon, the Waitrose boss wanted to meet with Greenpeace

And soon after, they had put their forecourt shops plan on hold and agreed with Greenpeace that the Arctic should be a protected sanctuary, a move that would make the polar region off limits to oil drillers like Shell.