The Ether Way

Misplaced PA Cath

Large patient for PA cath placement.    Introducer into IJ, out IJ, thru intercostal muscles, into PA.   SG cath then placed into PA, then to RV, then  back to PA and seemed to wedge and look OK.  Clinically significant hemopericardium....(not from my hospital)

 

Wait Times – Where are we now? Where are we going?

As its budget inexorably worsens, the NHS is cutting back expenditures, and wait-times are rising.  The story from this past week is here:

http://www.bbc.co.uk/news/health-14034835

This particular story includes all sorts of claims that are difficult to reconcile.  They are most likely a consequence of different sources using different metrics, or seeing the same data from a very different perspective. For example, one paragraph states that the NHS is meeting its goals for the timely provision of services, and the next states that a third of trusts are failing (at least some of the time). ‘Most’ state that quality will not suffer, but 53% believe access will get worse. The story also alludes to elected officials attacking NHS managers for how they manage their trusts.  Of this I am certain: it is impossible for the managers in question to accomplish all of the components of their mission with the budget they have been given.  My guess is that they do a brilliant job in a difficult circumstance. The elected officials in this instance have shifted the responsibility for these hard decisions, and therefore the fallout associated with making them, to the trust management, instead of taking them on for themselves.  These decisions are intensely unpopular, and quite possibly career suicide for the manager or politician who ends up holding the bag for them.  This kind of have-your-cake-and-eat-it-too is only possible with publicly funded health care. They cannot accomplish the missions outlined in their charter with the resources allocated.  It is up to the elected officials to 1. Raise taxes (never popular) 2. Change the charter (which would require admitting that they cannot accomplish their stated mission) or 3. Assume responsibility for where the cuts will take place(and likely lose their next election).  Better to blame the NHS bureacracy and push the problem into the future for as long as possible; this is the same strategy adapted by both parties in the US for Social Security and Medicare. Individuals, small groups, and even insurance companies are far more effective at recognizing these circumstances, and dealing with them. This kind of magical thinking is the provenance of politicians and their policy analysts; the rest of us know we cannot get something for nothing.

Lest anyone think that access is the only strife associated with the NHS, this recent news item makes it clear that the British Medical Association and the government cannot come to terms about how the NHS will be managed going forward:

http://www.bbc.co.uk/news/health-13942819

I doubt that anyone knows what the future holds for the NHS. 

My research and reading about these topics has allowed me to stumble onto the writings of John C Goodman, who is a health policy analyst in the US.  Whether you agree or disagree, he is very much worth reading.  In this piece, appropriately titled ‘Rationing by Waiting’, he points out that physicians and hospitals do not rush to recruit patients from low-end providers. In this sense, Romney care might foreshadow how health care in the US might transform.

http://healthblog.ncpa.org/rationing-by-waiting-4/

and

http://townhall.com/columnists/johncgoodman/2011/07/09/what_difference_has_romneycare_made/page/full/

The first lesson here is that government run health care in the US has already produced the same kind of access issues that the NHS has been struggling with for decades. Access is much less of an issue for US citizens with private insurance, and are even less so for anyone, anywhere, who has the cash in their pocket to pay for what they want from a premium purveyor (e.g. the Mayo clinic). The second lesson is this: health care is like anything else, the more you pay, the more you get.  The less you pay, the less you get, and the less pleasant your experience is likely to be.  You can’t buy a Mercedes for the same price as a KIA, and you’re not going to get Mayo quality care at Medicaid rates.  Anyone who says otherwise is…..

And no, I don’t see the world the same way that Mr Goodman does.  For instance, in this column, he overstates the scope of a problem, but has an interesting solution:

http://townhall.com/columnists/johncgoodman/2011/04/16/how_safe_is_your_hospital/page/full/

This is worth a read for anyone with an interest in the topic.