Sunday, June 29, 2008

Doctors,nurses, perfusionists, and other personnel in short supply

By Randall F. White, MD, FRCPC
29 June 2008

At St. Paul’s Hospital in Vancouver, where I practice, 50 heart surgery cases have been cancelled since April 2008. The spokesperson quoted in The Province on June 26 said that the hospital sometimes lacks enough perfusionists to keep the cardiac operating rooms open. The opposition health critic in the legislature blames the government for its 2006 decision not to fund a perfusionist training program at Thompson Rivers University in Kamloops.

A few days before, The Province newspaper reported that BC Children’s Hospital in Vancouver has cancelled 50 surgeries since April because of a shortfall of at least 10 intensive-care nurses. The same week, The Globe and Mail reported that a small town in BC is so desperate for doctors that it is raising money to build a new health clinic for physicians who have yet to be hired. The public is painfully aware of the physician shortage. The 2008 Health Care in Canada survey found that 19% of people named it second only to wait times as the leading problem in our system.

In January 2008, the Canadian Medical Association launched a campaign to raise political capital for increased domestic training of physicians, an appropriate advocacy issue for Canadian physicians. But at the same time, the CMA leadership, including president Dr. Brian Day, advocates for a second tier of health care. They haven’t explained how this second tier would be staffed given the immediate need for 26,000 physicians to bring Canada up from a ratio of 2.1 doctors per 1000 population to 3 per 1000, the mean among OECD nations.

Doctors aside, private hospitals and clinics require nurses, perfusionists, and other personnel who are in short supply and who require expensive, lengthy training. These facilities would take such personnel from existing institutions, including St. Paul’s Hospital, BC Children’s, and the others that serve most Canadians. Wealthy people who can afford to pay a premium could avoid wait lists and cancellations while the rest of Canada would endure even more such failures of the public system.

This pattern occurred in Australia after the introduction of a privately funded, privately owned tier of hospitals. According to the Australian Medical Association, wait times and crowding in the public hospitals have reached a crisis. The same would happen in Canada; in fact, we have a crisis despite having no official second tier. So let’s forget tier two, train more health professionals, and make our existing system work better.

Wednesday, June 11, 2008

Sceptical Reflections on the BC Pharmaceutical Task Force

By Randall F. White, MD, FRCPC

9 June 2008

The BC minister of health, George Abbott, assembled a task force in 2007 to review policy on pharmaceutical coverage under the province’s PharmaCare program. According to the Web site, the program “subsidizes eligible prescription drugs and designated medical supplies, protecting British Columbians from high drug costs.” Abbott’s appointments to the panel surprised even cynics.

Adrian Dix, the opposition health critic, called the composition of the nine-member task force “highly debatable” because five of the members had ties to the pharmaceutical industry. It included Russell Williams, the president of Canada's Research-Based Pharmaceutical Companies, a leading industry lobbying group. The conflict of interest was glaring, yet aspects of the province’s decision-making that displease industry were open for review.

Most provinces turn to the Common Drug Review that for decisions about covering medications. For therapies that fall outside the Common Drug Review, BC has an independent review process called the Therapeutics Initiative (TI), which also provides education for clinicians on its Web site Therapeutics Initiative The TI review process has been praised for outcomes such as preventing widespread use of COX-2 inhibitors in BC, medications which turned out to have a poor risk/benefit ratio.

The task force released its report in April 2008, and just as critics expected, the recommendations lean hard on efforts to protect tax payers and public health at the expense of Big Pharma’s profits. The report concluded, without substantiation, that the TI is “widely regarded as being in need of either substantial revitalization or replacement.” The panel even recommended that the TI cease educational activities, suggesting that they have not been “unbiased and evidence based.”

In barely concealed contempt for the TI, which is housed at UBC and is explicitly designed to keep the evaluation process shielded from industry influence, the panel suggested a new process that includes “disease-specific experts.” Although experts have a lot to offer, the fact is that many are involved in research and education funded by Big Pharma: more conflict of interest. In an egregious example, Dr. Joseph Biederman, a renowned child psychiatrist and researcher at Harvard, was recently found to have concealed a large sum of pharma income New York Times

What about a government’s conflict of interest in inviting industry to craft public policy? Big Pharma spreads its money around, including to Abbott’s party, the BC Liberals. The Pharmaceutical Task Force illustrates how commercial interests influence health policy, and why Canadians should hesitate to allow commercialization of other aspects of the health care system. Once corporate interests are let in, their lobbyists want a say in whatever government does.