Month: January 2018

What will UK health officials do with all that excess demand?

Ever growing numbers of drug_shortageUK citizens are turning to private, self-paid, health care in the UK.

Mark Hellowell’s excellent piece “How the NHS will die” examines the forces at work, and ponders what actions may be taken to resolve this ‘excess demand’ problem. When the problem manifested in the late 1990s, UK officials ultimately resolved it with 10 years of public expenditure increases. Few predict public expenditure increases sufficient to resolve the problem will be forthcoming this time around.

Health officials invariably pursue efficiency gains to close such gaps. Efforts to do just that in outpatient drug spending, however, appear to be rebounding with a vengeance – to eat up ever larger chunks of the healthcare budget. For much of the past year, the Department of Health has been forced to resolve widespread drug shortages with month-to-month agreements to reimburse pharmacies at prices much higher than the official NHS tariffs. The Times put the extra costs for April – November 2017 at ₤200M. Ben Goldacre and co at Oxford give a tally through December of ₤285M. And, the unpredictable reimbursement of higher-than-official prices works more as a band-aid than a solution, since the shortages don’t appear to be diminishing.

Am I being too pessimistic? Are promising developments underway that I’m missing? Silver linings to accompany the gray cloud?

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Updating practitioners as knowledge changes: the (discouraging) case of dietitians

I’ve become increasingly interested in the mechanisms through which health systems bring about practice changes among frontline providers. Pharmaceutical companies appear to do much of the work to reach and educate providers, if the practice change involves deploying a new pharmaceutical product. For the many other changes, I’ve yet to identify any approach which reliably and rapidly works across health systems. Health systems rely heavily on practitioner retirement and new entry – where the new entrants are educated on the new practice in their professional education. As the rate of medical knowledge accumulation accelerates, dissatisfaction with existing mechanisms is sure to grow.

 

Among medical knowledge domains, nutrition science has experienced relatively rapid change in the past 15 years. Naturally, this makes me curious about dietitians. How is the profession dealing with the changes? More to the point (for those of us interested in health systems): how well are different countries’ mechanisms for deploying practice change responding to this particular challenge?

 

A July 2017 paper by McArdle et al in the Journal of Human Nutrition and Dietetics presented some alarming answers to this question in the UK. McArdle and co-authors studied dietitians’ practice – focusing on what they advise diabetic patients with regard to carbohydrate consumption. NB: this is a domain where the appropriate advice has changed substantially in the past few years; in a nutshell, dietitians should be advising carbohydrate restriction.

 

The inestimable Zoe Harcombe synthesized the key findings thus:

This article shows that dietitians generally are confident in their advice – diabetes specialists especially so. Yet, fewer than one third (29.4%) of dietitians would recommend carbohydrate restriction even 50% of the time. More, (32.2%), would never, or hardly ever, recommend carb restriction. In the uncommon circumstances when carb restriction is supported, 92% of dietitians would advise type 2 diabetic patients to consume more than 30% of their total energy in the form of carbohydrate. Only 1 in 320 would advise the therapeutic level of carbohydrate for the treatment of type 2 diabetes.

dietitian old photo
Let me just check my class notes…..

Health services research regularly confirms how difficult it is to change the practice of doctors. Apparently this applies to dietitians as well. Given how many people are suffering with diabetes, I’d say we can’t afford to rely on the “wait for retirement” mechanism to work.