Press releases Monday 27 April to Friday 1 May 2009

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) NHS may have overpaid first wave private treatment centres up to £927 million in England
(2) "Animals have more protection than detainees," say experts
(3) Liver expert calls for worldwide treaty on alcohol

(1) NHS may have overpaid first wave private treatment centres up to £927 million in England
(Independent sector treatment centres: learning from a Scottish case study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1421

The NHS in England may have overpaid the first wave independent sector treatment centres by as much as £927 million for clinical services, warn researchers in an article published on bmj.com today.

They believe that the time has come to call a moratorium on all private contracts until the centres have been properly evaluated and investigated.

The £5bn independent sector treatment centre (ISTC) programme aims to provide extra capacity to the NHS and reduce waiting times for elective surgery. It is part of the government's policy to use NHS funds to contract with for-profit multinational healthcare corporations to deliver clinical services.

Until now, all contracts have been confidential. But, following an appeal under the Freedom of Information Act in Scotland, the only Scottish ISTC contract is now in the public domain.

This provides the first opportunity to evaluate contract performance against the claims made for the policy. So Professor Allyson Pollock and Graham Kirkwood at the University of Edinburgh analysed this contract together with a private sector report on the centre's value for money.

They found that the contract reporting requirements do not conform to NHS standards.

They also highlight concerns over the "take or pay" payment mechanism for ISTC contracts. The first wave schemes are based on patient referrals rather than actual treatments delivered. This means that providers are paid a guaranteed amount even if they don't treat the contracted volume of patients.

For example, the Scottish ISTC contract is £18.7 million over three years, £5.7 million a year for referrals. The contract payments are based on 90% take or pay on referrals, but it carried out only 32% of contract referrals worth £1 million in the first thirteen months of operation. This means that in the first year of operation it performed only 18% of the total annual contract value.

Scottish health boards may have overpaid up to £3 million in the first year of the contract, say the authors. If the same findings apply in England then as much as £927 million or almost two thirds of the total first wave contracts worth £1.54 billion might have been overpaid to ISTCs.

The second phase of contracts is valued at over £3.5 billion, but neither the payment mechanisms nor the payments made for these have been published.

The authors also point to concerns over availability and quality of data, making it impossible to assess ISTC performance and value for money against NHS operated treatment centres.

Finally, they warn that, not only are ISTCs selecting the low risk patients, but they are choosing easier procedures within the contract. In either case "the impact may be serious and destabilising for the NHS both financially and for training."

"The time has come for to call a moratorium on all ISTC contracts, until all the contracts have been published, and the ISTCs properly evaluated and investigated," they conclude.

Contact:
Professor Allyson Pollock, Centre for International Public Health Policy, University of Edinburgh, Scotland, UK
Email: allyson.pollock@ ed.ac.uk

Under the American Psychological Association's (APA) code of ethics, animals have more protection than detainees, say experts on bmj.com today.

Kenneth Pope, an independent psychologist, and Dr Thomas Gutheil, a professor of psychiatry at Harvard Medical School, maintain that the APA has enforceable standards that support the "humane treatment" of laboratory animals but that detainees who may be vulnerable or at risk are not afforded the same protection.

Given the controversy surrounding the interrogation of prisoners at sites like Abu Ghraib and Guantánamo Bay, the authors question whether the different ethical stances of psychologists and physicians are justified.

After 9/11, the APA changed its code of ethics which now runs contrary to Nuremberg principles and differs to how doctors operate, say the authors. The new code allows its members to set aside any ethical responsibilities that are in irreconcilable conflict with government authority, they say.

Whereas doctors should "not conduct, directly participate in, or monitor an interrogation with an intent to intervene, because this undermines the physician's role as healer", in 2005 the American Psychological Association adopted a policy that allowed consultation and monitoring of individual interrogations with the intent of intervening.

The differences between physicians and psychologists are partly historical, argue the authors.

While acknowledging the many admirable stances taken by the APA, the authors argue that one of the fundamental differences between physicians and psychologists is that physicians have the concept of "first, do no harm"”. They add that there were some reports that psychologists were not only complicit in America's aggressive interrogation regime but that they had actually designed tactics and trained interrogators.

Interrogation techniques linked to psychologists include hurting the detainee, using snarling dogs, using forced nudity, imposing long periods of standing, depriving detainees of sleep, using pornography and shackling detainees into painful "stress positions".

In conclusion the authors argue that no-one "regardless of professional discipline, specialty, or status - should be able to evade ethical responsibilities and escape personal ethical accountability by 'just following the law' or 'just following orders'... history has shown what can result when professionals follow this kind of fallacious ethical reasoning."

Contact:
Thomas G. Gutheil, M.D., Professor of Psychiatry, Harvard Medical School, USA
Email: GutheilTG@cs.com

(3) Liver expert calls for worldwide treaty on alcohol
(Personal view: A dent in our sobriety)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1737

Governments across the globe must unite and act now to develop a worldwide treaty on alcohol to reduce the growing burden of alcohol related harm, warns a liver specialist in this week's BMJ.

Rarely a day passes by when, as hepatologists, we don't see a patient whose psychological or physical wellbeing has been marred by alcohol, writes Dr Debbie Shawcross from the Institute of Liver Studies at King's College Hospital in London.

In the UK, the death rate from alcoholic liver disease has doubled in the past 10 years, while its incidence has risen eightfold in the under 35s as a culture of binge drinking has evolved among young people. As such, the incidence of cirrhosis is expected to increase exponentially and there will be a 500% greater need for liver transplantation in the next decade.

After attending a "symposium on alcohol" at last year's British Liver Conference in Edinburgh, the author recalls patients she had seen early in her career and several recent experiences.

Firstly, she thought about two young girls she had seen walking past her house on the way to school. It was only 7.30am, yet both girls were swigging bottles of bright blue "alcopops." Who had sold these drinks to them, she asks? Did they drink at lunchtime and after school too? And what was their weekly intake?

Then she moved on to thinking about a man in his early 20s. He came from a respectable family, had good qualifications, and had a well paid job. He was diagnosed with cirrhosis and only just made it out of hospital. But he didn't attend follow up appointments and the author doubts whether he stayed abstinent.

Another young man was admitted to hospital with alcoholic hepatitis, but his Muslim upbringing meant that he hid all evidence of his addiction from his family and his faith. "It was only as his alcohol withdrawal syndrome was reaching its terrible crescendo and he quite literally began crawling up the walls that he finally admitted to his alcohol addiction," says the author.

"I dread the day when the young schoolgirls drinking alcopops will be referred to my clinic or, worse still, present with multiorgan failure," she adds. "In moderate quantities, alcohol may well be salubrious and socially far more acceptable than tobacco or illicit drugs, but governments across the globe must unite and act now to develop a worldwide treaty on alcohol to reduce the growing burden of alcohol related harm," she concludes.

Contacts:
Dr Debbie Shawcross, Senior Lecturer and Honarary Consultant in Hepatology, Institute of Liver Studies, King’s College Hospital, London, UK
Email: debbie.shawcross@kch.nhs.uk

FOR ACCREDITED JOURNALISTS

Embargoed press releases and articles are available from:

Public Affairs Division, BMA House, Tavistock Square London WC1H 9JR

(contact: pressoffice@bma.org.uk)

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)