Rationing. The problem of limited resources

Health care resources dilemma

a problem of limited resources

Health budgets in the developed world are under pressure from an ageing population with greater health needs, increasing obesity, and the cost of new drugs and technologies.   

Flash glucose monitoring by Free Style Libre has rightly been hailed as a major advancement in diabetic care for type 1 diabetes. A sensor in a patch measures glucose levels and patients can get glucose readings by scanning it with a mobile phone app. It avoids the numerous finger prick tests that a diabetic needs to make in a day and an provide continuous readings over 24 hrs thus illustrating the blood sugar control much more accurately than before. Patient can adjust their insulin requirements accordingly, However like most advancements it is expensive. It has been available on prescription privately. There was an outcry when Theresa May, who is a Type 1  diabetic was shown wearing it with many stating that it should be funded by the NHS so that those poorer than her could benefit.

Image result for theresa may freestyle libre

Last month it was agreed the NHS should fund it. However most CCGs [clinical commissioning groups who are responsible for budgets in an area] will only fund it for those with poorly controlled insulin dependant diabetes, not other diabetics and some CCGs will not fund it at all. NICE [the National Institute of Clinical and Care Excellence] was set up to look at the evidence regarding drugs and technologies and to produce guidelines for their use. It takes into account the cost of such drugs or devices. If it meets NICE criteria CCGs are supposed to prescribe it. It was formed to achieve consensus on treatment and funding to avoid what is termed the postcode lottery. However as the rows over Freestyle Libre show, this has not really ended.

In all health systems there is not the money to cope with rising demands. There is a limited budget for the NHS and if more money needs to be spent in one area, it means less in another, unless taxes rise substantially. What gets funded by the NHS is often an ethical dilemma.  The fourth pillar in medical ethics is the one of Justice which includes the fair distribution of resources. We usually state that the NHS should pay for peoples needs, not necessarily for their wants. Should the NHS pay for IVF – is a baby a need or a want, gastric bypasses for obesity, cosmetic surgery, Viagra? What do you think?


Image result for the four ethical pillars medicine


Medical School Interview Course -all proceeds to MSF.

Dear Mona. I do hope all is well with you? I thought you might like to know that so far no one who has had an interview has had a rejection! It is impressive and two thirds of the Medics have offers. I am sure this is partly due to your excellent help with the preparation. Kind regards as always


Course Outline
10.00: Introduction
-What are interviewers looking for?
-Why do you want to do medicine?
-How should you discuss your work experience?
: Interview Technique
-Body language, voice tonality, dress
-Sell yourself without sounding arrogant
-The STAR Technique
-Discussing your personal statement. How to discuss extra-curricular activities, hobbies, gap year etc
-How to discuss articles that you have read.
-Common questions asked at interview: what are they looking for?

11.30 Coffee Break

– MMI Practice


13.40: Ethics
-GMC Good Medical Practice and Duties of a Doctor
-The Four pillars, confidentiality – when should this be broken, competence, consent,
-How to approach any ethical scenario: discussing conflicts between the principles
-The slippery slope argument
-Difficult scenarios and how to practice on your own.
-Topical ethical cases e.g. euthanasia and Kier Stamer/Debby Purdy, Gillick competence, Fraser laws, HFEA,

Coffee Break

More MMIs

– The NHS structure and function
-GP commissioning
-What is meant by ‘privatisation of the NHS and cherry picking?’
-NICE guideline/evidence based medicine
-The multidisciplinary team

END 17.30

1st December – 1 course only

£122 Voluntary donation to Medicin sans Frontiers

Address: Chatfield Health Care, 50 Chatfield Rd. London SW11 3UJ.


‘Self Inflicted’ conditions should not be treated by the NHS. {Past BMAT question}


images (2)

People injured whilst participating in extreme sports should not be treated by a publicly funded health service. Explain the reasoning behind this statement.  Suggest an argument against this statement. To what extent, if any, does the statement justify a change in public attitudes to personal risk taking?

The statement states that people who voluntarily take risks with their health because they participate in extreme sports such as sky diving cannot expect tax payers to pay for their medical care if injured. It is a statement regarding social justice[fairness] because health systems such as the NHS are cash limited so that funds spent on such people will mean that less money is available for treatment for others. In a private or insurance based health system people who take risks would probably have to pay a higher premium.

 A person’s autonomy has to be respected. They have a right to decide how to live their life and to do extreme sports if they wish. It is important to be non judgemental and act in the best interests of that patient which means treating injuries. If those participating in extreme sports are denied medical treatment for their injuries a slippery slope may be created in which those suffering from illnesses which may be in part also ‘self inflicted’ such as smoking or obesity related diseases may in future also find themselves excluded from state funded treatment.

At present ethical principles held by most, including the medical profession would value the principles of autonomy and beneficence over the idea that in doing so we would not be fair to others. The statement does put a valid argument to change attitudes to personal risk taking however because of the reasons outlined in paragraph two I disagree with a change of attitudes in this ‘rights versus responsibility debate.’    

Organ donation – Opt in or out? Topical issue and past BMAT question.




Over 80% of adults in England say they would definitely, or would consider, donating their organs, but only 37% of the UK population have registered as donors on the organ donor registry. The UK Government has started a consultation this month and states that it may introduce an opt out system by 2020 where all are considered potential organ donors unless they make the effort to opt out.

The Welsh government adopted the system in 2016. Within the first 6 months the scheme had saved dozens of lives after revealing that in the first six months, of the 60 organs that were transplanted, 32 came from people whose consent had been “deemed”. ie  those who choose to do nothing, if they are 18 or over, have lived in Wales for more than 12 months and die in Wales, they will be regarded as having consented to organ donation. Families still have the right to over rule and refuse but it has led to an increase in the desperately short supply of organs. Many  die while on the waiting list for an organ.

There is a massive under supply of organs for organ transplant and each year many patients die while waiting for a suitable organ that may have saved their life. However some feel uneasy about the concept of the ‘State owning your organs and being able to do what they want with them’ even if you can opt out of the system. They argue that the poorly educated, those with a leaning disability  and immigrants would find the procedure of opting out difficult.

Various suggestions have been made. A few years ago, because of the shortages of organs NHS Blood and Transplant suggested that people who agree to donate their organs when they die could be given priority if they themselves need a transplant. This, however met with a backlash from the Church of England and patients’ groups, who say ‘such a change would mean doctors treating two patients differently – something which would undermine medical ethics.’


Ethical scenarios regarding organ donation are common – try this one.

An ex-alcoholic patient [who is a mother of two children], a seven year girl, a 75 yr old war hero and a homosexual man need a liver transplant. Who should have it?


A doctor should never be judgemental. As in most complex situations a decision would only be made after consulting with senior doctors, the hospital ethical committee and the hospital legal team and/or your medical defence body. All of these are sources of valuable advice and it is important to share responsibility for any decision with them. Remember doctors work in teams not in isolation.

The case for the ex-alcoholic woman to be given the liver transplant

Some people may say that her illness was self inflicted but that is no reason to discriminate against her. Ex-alcoholics may relapse and start drinking again but many diseases affecting the liver such as auto-immune diseases may also affect a new liver and she should not be denied treatment because of this. Being the only parent to a child is a very important role but it is wrong for a doctor to value one life more than another and positive discrimination may lead to a slippery slope where people in certain important roles, e.g. national leaders, have priority in transplant waiting lists.

The case for the seven year old girl and the war hero.

Some people would say that the war hero has served his country, paid his National Insurance tax and deserves to receive his liver transplant on the NHS. Others would say that he has lived a reasonably long life while the young girl who probably has most of her life ahead of her is more deserving.  The NHS and NICE does sometimes look at QALYs [quality added life years] when deciding to fund certain expensive treatment. If a treatment costs less than £20,000 for each extra year of good health it extends life by, it will be funded. In this scenario the girl would probably benefit by gaining more QALYs than the war hero. However the use of QALYs has been denounced as ageist and it is considered wrong to discriminate because of age.

The case for the homosexual man 

His entitlement is as valid as anyone else – it would be discriminatory and completely unacceptable to think otherwise.


A doctor should never be judgemental and never value any one life above that of another. For this reason transplants and ‘who gets the organ’ problems are decided in this country solely on:

1. clinical urgency [who needs it most],

2. The best match [whose tissue type is most similar and least likely to reject the organ]

3. the length of time they have been on the waiting list.


Is Medicine A Science Or An Art? [past BMAT questions and interview questions.]

Question;  There is more to healing than the application of scientific knowledge.Explain this statement. What else is important in medicine



Medicine is both a science and an art. It has a proud scientific basis;, the application of evidence based medicine and rigor of scientific logic but a consultation with a doctor often involves a lot more than making a diagnosis and treating.

The ‘art’ of medicine renders all appointments interesting and none routine. A good doctor-patient relationship and the development of trust is therapeutic in itself. Patients are much more likely to follow advice and treatment. We are familiar with the term ‘the doctor as the drug’. A doctor’s reassurance has been shown to reduce pain scores, panic attacks and other conditions even if no treatment is given. In General Practice, where patients are seen with many different conditions over a long period of time, even visits for minor conditions can augment an important  relationship where communication skills, sensitivity and empathy all play their part, often subconsciously.

I am reminded of the story of a team of management consultants who were asked to make efficiency savings for an orchestra. They saw that there were a number of violins all ‘doing the same job’ and cut the violins down to one. Then they started to look at other instruments. More and more cuts followed. At the end they had replaced the entire orchestra with a CD player – it did the same job and cost less didn’t it?  But of course something was lost!

Question: Not everything that can be counted counts and not everything that counts can be counted (Albert Einstein). What do you think is meant by this statement?Give examples of things that count in medicine which cannot be counted. To what degree should they count?

This essay question and the one above are describing the importance  of subjective experience such as  ’the art of medicine’. You could do a similar answer for this question. 

Gene editing could bring about the end of malaria.

genetic engineering

Imperial College London  researchers used CRISPR-cas 9 gene editing technology to wipe out a population of caged mosquitoes that are able to transmit malaria. They targeted the double sex gene, a genetic sequence that leads to male and female traits. Females with two copies of the mutated gene could not develop properly and could not reproduce but males fertility was unaffected and they transmitted the gene down to offspring. After 11 generations, they found that 100% of these mosquitoes were affected causing the population to collapse. The double sex gene is highly conserved and unlike previous attempts to alter fertility of male and female mosquitoes resistance has not been observed.


Concerns have been expressed how this might affect the ecosystem but malaria was wiped out in Southern Europe with out major repercussions. There are about 4,000 different species of mosquito. The double sex gene is different in different insects so it should be possible just to wipe out the handful of species that cause disease leaving the rest to play their part in the ecosystem.

Whether this will work outside the laboratory is not known as yet but it raises exciting possibilities that we may be able to eradicate what is the most dangerous animals on Earth – the African malarial mosquito.

Remembering the 1918 flu pandemic


1918 Flu Pandemic Commemoration

Last week we remembered the 100th anniversary of one of the most lethal pandemics ever known to man. Known as the Spanish Flu it actually started in the USA and spread quite quickly around the  world during World War One.  It infected about 1/3rd of the world’s population [50-100 million] and killed about 10% of those affected, some  50 -100 million – more than died in battle in the first world war.

Usually influenza viruses are deadly in the very young or old who have a weaker immune system. In this case it was young, fit adults that seemed particularly susceptible. The virus originated from birds and had recently crossed over. It had not ‘adapted to humans’ and was very ‘visible’ to the human immune system. It therefore triggered a particularly large immune response which caused massive inflammation. People died from the overreaction of the immune system which lead to a ‘cytokine storm’ with white cells and ‘fluid filling up the lungs and drowning the sufferer. Therefore those with a highly reactive immune system, rather than the old, were those most likely to be severely affected.

It was known as the Spanish Flu because it was reported most in Spain as was not involved in the war and had not been subjected to press censorship. The other European countries and the USA had downplayed the pandemic as not to affect morale.  One  hundred years on annual flu epidemics are part of winter life. An influenza pandemic is a global outbreak of a new influenza A virus that is very different from current and recently circulating human seasonal influenza A viruses. Influenza A viruses are constantly changing, making it possible on very rare occasions for non-human influenza viruses to change in such a way that they can infect people easily and spread efficiently. The Centres of Disease Control monitors flu strains in order to be ready for the next flu pandemic. Flu pandemics still represent one of the greatest threats to mankind.

Fake News, The Kremlin, Russian BOTS and MMR


Measles is becoming a major problem again. In the first half of the year in Europe 41,000 people contracted measles and over 14 have died. In 2002 the USA declared itself to measles free but that sadly is no longer true. The vast majority of those infected in developed countries had never been vaccinated.

Measles is one of the most contagious diseases known to man, it requires vaccination rates of 95% to contain it and create ‘herd immunity’ and prevent epidemics.  A twenty year old fraudulent study by the British doctor Andrew Wakefield still holds enormous influence over the vaccination debate. This study, published in the Lancet, linked MMR to autism  but the findings were widely rejected.  The study was based on a tiny sample, other studies tried to replicate the results and failed.  It was full of flaws and he had carried out unnecessary, invasive investigations on children and he had not disclosed large payments made to him by anti-vaccine lawyers. He was struck off and lost his license to practice in May 2010. Study after study has shown that there is no link between  measles and autism yet it is still a commonly held belief by many and Andrew Wakefield is held up as a hero by the anti vaccine movement. He lives in a palatial home in the USA, is supported by Donald Trump and is dating the supermodel Elle Macpherson.

Image result for andrew wakefield

Russians, thought to be backed by President Vladimir Putin’s government have made use of social media to influence elections such as the US election and the Brexit vote and erode trust in US and European Governments by spreading “fake news”. Kremlin-sponsored social media accounts have promoted the discredited views of Andrew Wakefield to sow doubt in the West over the safety of vaccines. Russian government “trolls” voiced support for Vaxxed, a film made recently by Andrew Wakefield.  One site claimed that three quarters of the children in a Mexican village had died as a result of vaccination.[An example of a pro Russia anti-vaccine site is   https://prepareforchange.net/2016/03/05/putin-exposes-vaccines]

Infectious diseases were the most common cause of death 100  yrs ago. According to WHO and most experts, vaccinations have contributed more than even antibiotics to the amazing success in the fight against infectious diseases. When a small group of Spanish invaders arrived in South America they were able to conquer it because of the diseases they bought with them as the natives had no immunity. Measles and other viruses led to the death of  an estimated 90% of the population of modern day Mexico!

Why do vaccines now cause so much uncertainty and parental angst?  In part vaccinations have become a victim of their success. We have learnt not to fear diseases such as a polio and diptheria; they have become remote and ‘unlikely’. We are tantalising close to eradicating polio but smallpox is the only disease that has been truly eradicated world wide, probably because of compulsory vaccination. Italy and France recently made MMR compulsory to try and halt the rising incidence of measles; should we do so as well? What do you think?


What’s in a name?

junior doctor

Dame Sally Davies, the Chief Medical Officer of England has said that name ”junior doctor’ or ”doctor in training”  is confusing. Patients often fail to differentiate junior doctors, who carry out most of the medical work in a hospital and  may have been doctors for over 10 years from medical students or even ‘work experience students’.  She stated that doctors needed job titles that give them “the respect they deserve”.

The abolition of doctor’s white coats and the trend for younger doctors to introduce themselves simply by their first name adds to the confusion. There have been many moves to democratise hospital care to to equalise  the ‘power imbalance’ in the doctor patient relationship but this undoubtedly reduces the respect given to them and anxious patients  feel more confident in a show of authority.

It was thought that poor understanding of the role of junior doctors meant less support for them during the junior doctor strike and I remember trying to explain that trainee doctors were fully qualified to a patient who wondered why they got paid at all if they were training.

Dame Sally Davies feels that a name change would help morale but she has also been criticised by doctors and others who feel this is a distraction and there needs to be a change in working conditions so that junior doctors feel valued instead. The Times last week asked readers for suggestions for new names. One reader remembered a poorly skilled surgeon who was referred to as ‘the Hippocratic oaf’ another suggested that since a slang name for doctors is a ‘quack’ junior doctors could be called ‘quacklings’. Perhaps not restoring respect but amusing all the same. It seems that we will probably return to a similar nomenclature as in the past with the terms senior house officer, registrar and senior registrar making their appearance again as they seemed to work in the past and in fact were never totally abandoned.

Names are important. It is why companies spend so much choosing a brand name. Studies have shown that names have an affect of the life chances, jobs and the  character of children. A girl named Joy is apparently more likely to be happy and one named Rose more ‘feminine’. Trump was given a ‘head start in business’ by his name. Thinking about doctors in South West London were I work I know of Dr Cream, who used to be a dermatologist, Professor John Studd a gynaecologist, Mr John Dick a urologist who took over from Ms Waterfall [one of the  earliest female urologists]. All coincidence?

Medical mistakes. Dr Bawa Garba wins right to practice as a doctor again.Why it matters.

Dr Bawa Garba was found guilty of gross negligence manslaughter in November 2015 and contributing to death of 6 yr old Jack Adcock. The medical practitioners tribunal  suspended her for 12 months but the GMC appealed to the High Court and won stating that in order to maintain public confidence in the medical profession she  should be struck off the medical register.

A look behind the cover story shows however that there were a catalogue of alarming factors which contributed to an unsafe working environment in which mistakes could happen to the best of doctors. It was her first day, she had just come back from 13 months maternity leave and had not had an induction, she was unfamiliar with the hospital and the 6 wards on four different floors she was supposed to cover. She missed the hand over ward round that morning because she had to attend to a cardiac arrest and was therefore  completely unfamiliar with the patients. The consultant on duty that day was absent [he was lecturing on a different site] as was the other registrar, her paediatric SHO had been told to go down to the lab for a few hours and collect results as the hospital IT system was not working . She was doing the work of  4 doctors. She had not eaten or drunk anything all day.  Jack’s parents had given the little boy a drug, enalapril without telling the medical staff, it was not written up on the drug chart and it was not recorded. It lowers blood pressure and made it more likely that he went into cardiac arrest. Dr Bawa Garba wrongly mistook Jack for another boy because he had changed beds that morning and thought he was the original boy in that bed and not for resuscitation so halted it after a few minutes [this however was not thought to have made a difference. Jack was already too far gone.]

Professions concerned with safety such as pilots and medics talk about the Swiss Cheese Model where a catalogue of  problems leads to a disaster. Normally the holes in Swiss cheese do not line up but occasionally they do. It is not usually a single error made by one person but problems in the environment and therefore changes in the environment and checks and balances can lead to improved safety. Air safety has improved substantially using this attitude.

The judgement of the senior judges in this case has caused confusion and outrage. Justice Ouseley acknowledged that Bawa Garba  ‘before and after the tragic events was a competent, above average doctor’ but also stated that the events were something she had been trained to cope with.  He shows a complete misunderstanding of the work of doctors. No amount of training can enable you to do 4 doctors work safely.

What is also concerning is that as doctors we are encouraged to reflect on how we can improve our performance. It seems that Dr Bawa Garna’s reflections were used as evidence against her. This has led to calls to boycott the reflective portfolio that all trainees write and doctors some doctors are stating that in this current culture it is unwise to admit mistakes. Consultant cardiologist Peter Wilmhurst, a prominent campaigner for transparency and safety in medicine has referred himself to the GMC because he says that over four decades of practice he must have made mistakes some of which would have led to the deaths of patients, and he has encouraged other doctors to do the same. Doctors now fear that they will be made scapegoats when systems fail. Hence the campaign that followed #I am Hadiza.

Crowdfunding raised £350,000 to appeal against the High Court Ruling and I am pleased to report that this time on 13/8/18 the High Court raised the restriction and supported the medical practitioners tribunal original decision to suspend her for 12 months . Jeremy Hunt, until recently the Health minister, ordered a review into whether medical manslaughter laws are fit for purpose. This review is eagerly awaited by anxious doctors who see a growing gap between ideal practice as described by the GMC and what can be realistically achieved given rota gaps [covering for colleagues] and multiple sick patients requiring attention at the same time.