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Richard Smith

Richard Smith: Leapfrogging to universal health coverage

28 Oct, 14 | by BMJ

richard_smith_2014Low and middle income countries have the chance to create health systems that will perform much better than those in high income countries. Copying health systems that look increasingly unsustainable would not be wise. Instead, low and middle income countries can “leapfrog” to something better, and the World Economic Forum has a project to make that happen. I heard about it in New York last week.

A plot of health adjusted life expectancy against the health expenditure of individual countries shows a plateau in the late 1960s at an expenditure of about US$500 per head adjusted for purchasing power. Yet most high income countries are spending more than US$2500, with the US spending US$8000. To be blunt, these high expenditures don’t look like “value for money.” more…

Richard Smith: The joy of a hernia repair

14 Oct, 14 | by BMJ

richard_smith_2014I had a hernia repair recently, but the day turned out to be one of the pleasantest I’ve had in a long time. Can that really be true?

Oddly, I looked forward to the day. It was partly the thought of being “made whole,” partly it being a different day from the normal, and partly a chance to experience the NHS doing what it does well. more…

Richard Smith: A tobacco company CEO writes to his marketing department

8 Oct, 14 | by BMJ Group

richard_smith_2014Dear all,

I see a great opportunity for us. You won’t believe this, but I’m at a public health conference in Sousse in Tunisia. I’ve come with my twin brother, a professor of public health. I am, of course, incognito. My brother asked me—yes, asked me—to come. Despite what you might think, we agree on most things—but differ radically on tobacco. We are twins, our connection goes deep. He hoped that by getting me to come to this conference he might get me to change my views. Unfortunately for him—and we’ve discussed this—the effect has been the opposite: I see a huge chance to grow our business. more…

Richard Smith: Improving health through the community in Tunisia

3 Oct, 14 | by BMJ

richard_smith_2014Tunisia, like all low and middle income countries, is having to respond to non-communicable disease after making good progress in reducing infectious disease and improving child and maternal health. Premature deaths from cardiovascular disease increased there by 35% between 1990 and 2010; they increased by 112% in Egypt and by 61% in Saudi Arabia—but fell by 21% in the United States. How best Tunisia might respond was discussed recently at a meeting in Sousse, organised by the Department of Epidemiology, University Hospital Farhat Hached.

Tunisia doesn’t have to start with a blank sheet. High income countries have already experienced the transition from infectious to non-communicable disease, and the aspiration is that countries like Tunisia can learn from the successes of high income countries without having to repeat their mistakes. more…

Richard Smith: Using data to improve care and reduce waste in health systems

30 Sep, 14 | by BMJ

richard_smith_2014Annual expenditure on healthcare in the United States is currently $2.8 trillion, and about a third of it is wasted, says the Institute of Medicine. The sum wasted is about five times the GDP of Bangladesh, a country of 160 million people. This is waste on a spectacular scale, and reducing it while improving the quality of care is the main aim of the information technology developed by Optum, the services part of the UnitedHealth Group, said Richard Migliori, a former transplant surgeon and chief medical officer of the UnitedHealth Group. I don’t come to tell you what to do, said Migliori speaking last week to the Cambridge Health Network, but I hope to at least elicit your sympathy. more…

Richard Smith: Patients harmed by misdiagnosed preferences

25 Sep, 14 | by BMJ

richard_smith_2014Linda is 58 and has been diagnosed with breast cancer. She would have preferred not to have surgery but was convinced by her surgeon that it would be the best option. After her operation, the hospital contacted her to apologise as she had not had breast cancer. She’d been misdiagnosed. An inquiry, legal action, and compensation followed.

Susan is 78 and has also had breast cancer. She too did not want surgery but was told that it was the best treatment. Six weeks after her operation, she met a friend of the same age who had also had breast cancer. She had been treated with hormone therapy, having been told that she would probably die of something else before her breast cancer. Susan felt profound regret, but no action followed.

These two women have both been damaged by the health system, said Al Mulley, director of the Dartmouth Centre for Health Care Delivery Science, at a meeting at the Health Foundation last week. And, he said, misdiagnosis of preferences is everywhere. For example, three quarters of surgeons think that losing a breast is the main anxiety of women with breast cancer, but only 7% of women rank that as their main anxiety. more…

Richard Smith: Is it time to stop using the word poverty in Britain?

19 Sep, 14 | by BMJ

richard_smith_2014Is poverty yet another word that is so misunderstood we should stop using it—at least in Britain? John Lanchester, a friend of mine, argued so in the Observer. Can he possibly be right?

Lanchester doesn’t seem to be arguing that we should stop using the word poverty when we mean “absolute poverty.” When the Millennium Development Goals were set absolute poverty was defined as having to live on an income of less than $1 a day, but subsequently it was raised to $1.25. In 1980 half the world’s population lived below that line, now it’s a fifth—1.2 billion people. Few people, if anybody, would dispute that having to live on such an income is to live in poverty. Using this measure, Asia might be expected to eradicate poverty by 2030, but the Asian Development Bank has just argued that the rate should be $1.51, meaning that nearly 60% of the population of Bangladesh—a country I visit regularly—is living in poverty. more…

Richard Smith: Is global health too medicalised?

16 Sep, 14 | by BMJ

richard_smith_2014When I teach young doctors in Amsterdam about responding to NCD (non-communicable disease) in low and middle income countries, I ask them how they would allocate 100 units of resource. I give them four buckets.

One bucket is for treating people with established disease: patients with heart attacks, strokes, cancer, and chronic obstructive pulmonary disease. The second bucket is for treating metabolic risk factors, such as hypertension, hyperlipidemia, and raised blood glucose. The third bucket is for acting on the four risk factors—tobacco use, poor diet, physical inactivity, and the harmful use of alcohol—recognising that many of the interventions will be political, actions like raising the price of tobacco. The fourth bucket is for working on social determinants, such as poverty, housing, globalisation, and urbanisation. I ask the doctors not only how they will distribute their resources, but what they will do with the resources. more…

Richard Smith: Simon Stevens, chief executive of NHS England, live

12 Sep, 14 | by BMJ

richard_smith_2014When Simon Stevens, chief executive of NHS England, was buying his Sunday papers a few weeks ago he encountered an elderly woman complaining that her newspaper didn’t contain the television section. It did, as the newsagent pointed out to her before asking her, “Would you like me to walk you home?” Stevens was struck that this was a “dementia friendly community” in action. He followed the story by emphasising that the traditional “factory model of health and social care” will not solve society’s problems, including the rise in dementia. Without a redesign of health and social care services, the NHS will not be sustainable. “We don’t exclusively own the problem or the solution,” he said. more…

Richard Smith: “Psoriasis is my health”

5 Sep, 14 | by BMJ

richard_smith_2014To most doctors psoriasis is a disease to be fought, contained, and even cured, but is this far too narrow a view? John Updike, one of the greatest writers in English of the past century, had psoriasis for almost all his life, and he writes in Self-Consciousness: “Psoriasis is my health. Its suppression constitutes a poisoning of the system, of my personal ecology,” and “psoriasis is normal, and its suppression abnormal.” How can doctors who study disease and a patient who sees deep inside himself have such different views? The patient comes first, and so it is the doctors who must learn. more…

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