[Digital health progress hubs-data integration beyond university hospitals]. / Die digitalen Fortschrittshubs Gesundheit ­ Gemeinsame Datennutzung über die Universitätsmedizin hinaus.

The digital health progress hubs pilot the extensibility of the concepts and solutions of the Medical Informatics Initiative to improve regional healthcare and research. The six funded projects address different diseases, areas in regional healthcare, and methods of cross-institutional data linking and use. Despite the diversity of the scenarios and regional conditions, the technical, regulatory, and organizational challenges and barriers that the progress hubs encounter in the actual implementation of the solutions are often similar. This results in some common approaches to solutions, but also in political demands that go beyond the Health Data Utilization Act, which is considered a welcome improvement by the progress hubs.In this article, we present the digital progress hubs and discuss achievements, challenges, and approaches to solutions that enable the shared use of data from university hospitals and non-academic institutions in the healthcare system and can make a sustainable contribution to improving medical care and research.

[Future Developments in Trauma Care in Germany]. / Zukunft der Traumaversorgung in Deutschland.

Trauma surgical care in Germany faces major challenges. The increasing number of cases due to demographic change, combined with reduced bed capacity, requires a rethink in many areas. In order to continue to ensure basic and standard care at a high level and across the board in the future, economic incentives must be created to maintain sufficient locations for trauma care. At the same time, there is a shortage of skilled workers that will worsen in the coming years if appropriate measures are not taken to counteract it. Structural changes will also be needed to improve cross-sector networking between outpatient and inpatient care. With the increase in outpatient care, future shortages of both bed capacity and staff shortages may be buffered.

Treatment gaps and challenges in epilepsy care in the Philippines.

OBJECTIVE: Epilepsy is a neurologic disease that carries a high disease burden and likely, a huge treatment gap especially in low-to-middle income countries (LMIC) such as the Philippines. This review aimed to examine the treatment gaps and challenges that burden Philippine epilepsy care. MATERIALS & METHODS: Pertinent data on epidemiology, research, health financing and health systems, pharmacologic and surgical treatment options, cost of care, and workforce were obtained through a literature search and review of relevant Philippine government websites. RESULTS: The estimated prevalence of epilepsy in the Philippines is 0.9%. Epilepsy research in the Philippines is low in quantity compared with the rest of Southeast Asia (SEA). Inequities in quality and quantity of healthcare services delivered to local government units (LGUs) have arisen because of devolution. Programs for epilepsy care by both government and nongovernment institutions have been implemented. Healthcare expenditure in the Philippines is still largely out-of-pocket, with only partial coverage from the public sector. There is limited access to antiseizure medications (ASMs), mainly due to cost. Epilepsy surgery is an underutilized treatment option. There are only 20 epileptologists in the Philippines, with one epileptologist for every 45,000 patients with epilepsy. In addition, epilepsy care service delivery has been further impeded by the coronavirus disease of 2019 (COVID-19) pandemic. CONCLUSION: There is a large treatment gap in epilepsy care in the Philippines in terms of high epilepsy disease burden, socioeconomic limitations and inadequate public support, sparse clinico-epidemiologic research on epilepsy, inaccessibility of health care services and essential pharmacotherapy, underutilization of surgical options, and lack of specialists capable of rendering epilepsy care. Acknowledgment of the existence of these treatment gaps and addressing such are expected to improve the overall survival and quality of life of patients with epilepsy in the Philippines.

Outreach marketing may be a successful strategy for NHS libraries.

This dissertation study investigates the ways that NHS libraries are currently marketing their services within their organisation and was submitted as part of the MA Library and Information Management at the University of Sheffield in 2019. This paper presents the findings from twelve semi-structured interviews carried out with NHS library managers in the East of England to identify the most and least successful methods, and in comparison with that which is currently in the general marketing literature. The study found that outreach marketing was the most effective and that librarians are currently conducting marketing to the best of their ability, but they lack time and funding to be able to make the most of their promotional campaigns. F.J.

Costs of viral hepatitis B in the Republic of Korea, 2002-2015.

The Republic of Korea has a high prevalence of hepatitis B virus (HBV) infection, and the policies concerning costly antiviral medication have been revised recently. However, in the past 10 years, no related research on costs has been conducted. The objective of this study was to estimate the economic burden of viral hepatitis B and determine the trend of changes in its costs between 2002 and 2015. Claims data from the National Health Insurance Service were used. To identify viral hepatitis B cases, the ICD-10th code B16, B17.0, B18.0 and B18.1 were used based on a primary diagnosis. This study was conducted from a societal perspective regarding both direct and indirect costs. Annual costs were adjusted for inflation by calculations based on the 2015 costs. The number of patients with viral hepatitis B increased from 213 758 in 2002 to 342 672 in 2015. The total socio-economic costs increased from 127.1 million USD in 2002 to 459.1 million USD in 2015, mainly due to the increase in pharmaceutical costs, which accounted for the largest proportion of total costs since 2009-220.5 million USD in 2015, which was ~15 times higher than that in 2002. The healthcare costs for viral hepatitis B accounted for 0.13% of the national health expenditure in 2002, increasing to 0.31% in 2015. The economic burden of viral hepatitis B has increased in the Republic of Korea. It is therefore essential to reduce the healthcare costs of HBV infection by establishing an effective management policy.

Challenges in telemedicine for adult patients with drug-resistant epilepsy undergoing ketogenic diet treatment during the COVID-19 pandemic in the public healthcare system in Brazil.

Hygienic and sanitary measures and social distancing policies implemented during the new coronavirus disease - COVID-19 - pandemic have altered the care and follow-up provided by healthcare professionals for patients with chronic diseases, including patients with epilepsy (PWEs). Telemedicine has become a solution for the healthcare of PWEs in many developed countries. In this short communication, we trace a particular perspective for the application of telemedicine for PWEs undergoing ketogenic diet (KD) treatment, considering the social and economic difficulties faced by healthcare teams in resource-poor countries, such as Brazil. During the pandemic, financial strain was the main impediment to following KD. The pandemic increased socioeconomic insecurity and access to KD-related products, as well as increasing anxiety in 71% of PWE, impacting their KD treatment follow-up. The challenges of telemedicine in Brazil include not only social and economic issues but also access to food, healthcare services, and education for the population, in addition to digital inclusion.

The north-south policy divide in transnational healthcare: a comparative review of policy research on medical tourism in source and destination countries.

Medical tourism occupies different spaces within national policy frameworks depending on which side of the transnational paradigm countries belong to, and how they seek to leverage it towards their developmental goals. This article draws attention to this policy divide in transnational healthcare through a comparative bibliometric review of policy research on medical tourism in select source (Canada, United States and United Kingdom) and destination countries (Mexico, India, Thailand, Malaysia and Singapore), using a systematic search of the Web of Science (WoS) database and review of grey literature. We assess cross-national differences in policy and policy research on medical tourism against contextual policy landscapes and challenges, and examine the convergence between research and policy. Our findings indicate major disparities in development agendas and national policy concerns, both between and among source and destination countries. Further, we find that research on medical tourism does not always address prevailing policy challenges, just as the policy discourse oftentimes neglects relevant policy research on the subject. Based on our review, we highlight the limited application of theoretical policy paradigms in current medical tourism research and make the case for a comparative policy research agenda for the field.

Nationwide Analysis of Intact Abdominal Aortic Aneurysm Repair in Portugal from 2000 to 2015.

BACKGROUND: Results on the management of infrarenal abdominal aortic aneurysm (AAA) from Mediterranean countries are scarce. The aim of this study was to evaluate trends in rate of and mortality after repair of intact AAA (iAAA) in Portugal. METHODS: iAAA repairs registered in the hospitals' administrative database of the National Health Service from 2000 to 2015 were retrospectively analyzed regarding demographics (age and gender) and type of repair (open surgery [OS] or endovascular repair [EVAR]). Rate and mortality were compared among three time periods: 2000-2004, 2005-2009, and 2010-2015. RESULTS: Age-standardized rate of iAAA repair increased consistently across the time periods under analysis from 3.6 ± 0.6/100,000/year in 2000-2004, to 5.6 ± 0.4/100,000/year in 2005-2009 and to 7.1 ± 0.9/100,000/year in 2010-2015 (P < 0.001). The percentage of EVAR among all iAAA repairs rose steeply from 0 to 21 ± 19% and then to 58 ± 7% (P < 0.001). The rate of OS also increased from the first to the second period, but there was a decrease in the third period (P < 0.001). The in-hospital mortality after iAAA repair decreased from 7.5 ± 1.3% to 6.6 ± 1.6% and then to 5.1 ± 1.9% (P < 0.001). This variation corresponded to a decrease in in-hospital mortality after EVAR (from 4.0 ± 3.5% to 2.8 ± 0.9%, P < 0.001) and increased in-hospital mortality after OS (7.5 ± 1.3% to 7.4 ± 1.1% to 8.3 ± 3.7%, P < 0.001). Low-volume centers (< 15 repairs/year) did not present higher mortality rates. The number of EVARs per year in a center presented a positive association with EVAR mortality (Spearman correlation of 0.696, P = 0.004). CONCLUSIONS: The rate of repair of iAAA continues to grow, especially in patients aged ≥ 75 years and did not reach an inflection point yet. This is happening along with decreased repair mortality mainly because of the increased use of EVAR. Hospital mortality for iAAA repair is still a matter of concern, warranting further investigation and planning of vascular surgical services.

Awareness of, attitude toward, and willingness to participate in pay for performance programs among family physicians: a cross-sectional study.

BACKGROUND: The National Health Insurance Administration of Taiwan has introduced several pay-for-performance programs to improve the quality of healthcare. This study aimed to provide government with evidence-based research findings to help primary care physicians to actively engage in pay-for-performance programs. METHODS: We conducted a questionnaire survey among family physicians with age-stratified sampling from September 2016 to December 2017. The structured questionnaire consisted of items including the basic demographics of the surveyee and their awareness of and attitudes toward the strengths and/or weaknesses of the pay-for-performance programs, as well as their subjective norms, and the willingness to participate in the pay-for-performance programs. Univariate analysis and multivariate logistic regression analysis were performed to compare the differences between family physicians who participate in the pay-for-performance programs versus those who did not. RESULTS: A total of 543 family physicians completed the questionnaire. Among family physicians who participated in the pay-for-performance programs, more had joined the Family Practice Integrated Care Project [Odds ratio (OR): 2.70; 95% Confidence interval (CI): 1.78 ~ 4.09], had a greater awareness of pay-for-performance programs (OR: 2.37; 95% CI: 1.50 ~ 3.83), and a less negative attitude to pay-for-performance programs (OR: 0.50; 95% CI: 0.31 ~ 0.80) after adjusting for age and gender. The major reasons for family physicians who decided to join the pay-for-performance programs included believing the programs help enhance the quality of healthcare (80.8%) and recognizing the benefit of saving health expenditure (63.4%). The causes of unwillingness to join in a pay-for-performance program among non-participants were increased load of administrative works (79.6%) and inadequate understanding of the contents of the pay-for-performance programs (62.9%). CONCLUSIONS: To better motivate family physicians into P4P participation, hosting effective training programs, developing a more transparent formula for assessing financial risk, providing sufficient budget for healthcare quality improvement, and designing a reasonable profit-sharing plan to promote collaboration between different levels of medical institutions are all imperative.

Increased risk of tinnitus following a trigeminal neuralgia diagnosis: a one-year follow-up study.

BACKGROUND: Tinnitus due to hyperactivity across neuronal ensembles along the auditory pathway is reported. We hypothesized that trigeminal neuralgia patients may subsequently suffer from tinnitus. Using nationwide, population-based data and a retrospective cohort study design, we investigated the risk of tinnitus within 1 year following trigeminal neuralgia. METHODS: We used the Taiwan National Health Insurance Research Dataset, a claims database, to identify all patients diagnosed with trigeminal neuralgia from January 2001 to December 2014, 12,587 patients. From the remaining patients, we identified 12,587 comparison patients without trigeminal neuralgia by propensity score matching, using sex, age, monthly income, geographic region, residential urbanization level, and tinnitus-relevant comorbidities (hyperlipidemia, diabetes, coronary heart disease, hypertension, cervical spondylosis, temporomandibular joint disorders and injury to head and neck and index year). All study patients (n = 25,174) were tracked for a one-year period to identify those with a subsequent diagnosis of tinnitus over 1-year follow-up. RESULTS: Among total 25,174 sample patients, the incidence of tinnitus was 18.21 per 100 person-years (95% CI = 17.66 ~ 18.77), the rate being 23.57 (95% CI = 22.68 ~ 24.49) among patients with trigeminal neuralgia and 13.17 (95% CI = 12.53 ~ 13.84) among comparison patients. Furthermore, the adjusted Cox proportional hazard ratio for tinnitus in the trigeminal neuralgia group was 1.68 (95% CI = 1.58 ~ 1.80) relative to the comparison cohort. CONCLUSIONS: We found a significantly increased risk of tinnitus within 1 year of trigeminal neuralgia diagnosis compared to those without the diagnosis. Further studies in other countries and ethnicities are needed to explore the relationship between trigeminal neuralgia and subsequent tinnitus.

Direct and indirect costs of cluster headache: a prospective analysis in a tertiary level headache centre.

BACKGROUND: Cluster headache (CH) is the most frequent trigemino-autonomic cephalgia. CH can manifest as episodic (ECH) or chronic cluster headache (CCH) causing significant burden of disease and requiring attack therapy and prophylactic treatment. The few data available on the economic burden of CH come from retrospective studies based on questionnaires, population surveys and medical insurance claims database. Although all these studies showed an important economic burden, they provided different estimates depending on variability of CH awareness and management, healthcare systems, available therapies and use of treatments according to different guidelines. METHODS: This prospective study aimed to quantify the total direct and indirect cost of ECH and CCH over a cluster period, both for the patient and for the National Health System (NHS), using data from subjects who consecutively attended an Italian tertiary headache centre between January 1, 2018 and December 31, 2018. RESULTS: A total 108 patients (89 ECH, 19 CCH) were included. Mean attack frequency was 2.3 ± 1.4 per day. Mean total cost of a CH bout was €4398 per patient and total cost of CCH was 5.4 times higher than ECH (€13,350 vs. €2487, p <  0.001). Direct costs represented the 72.1% of total cost and were covered for the 94.8% by the NHS. The costs for any item of expense were higher for CCH than for ECH (p <  0.001). Mean indirect costs for a CH bout were €1226 per patient and were higher for CCH compared to ECH (€3.538 vs. €732), but the difference was not significant. Days with reduced productive capacity impacted for the 64.6% of the total indirect costs. The analysis of the impact CH on work showed that 27%% of patients felt that CH had limited their career, 40% had changed their work pattern, 20% had changed their place of employment and 10% had lost a job due to the disease. CONCLUSION: Our results provide a valuable estimate of the direct and indirect costs of ECH and CCH in the specific setting of a tertiary headache centre and confirm the high economic impact of CH on both the NHS and patients.

Comorbidity of Alcohol Use and Other Psychiatric Disorders and Suicide Mortality: Data from the South Korean National Health Insurance Cohort, 2002 to 2013.

BACKGROUND: Previous studies have indicated that alcohol use disorder (AUD) and other psychiatric disorders increase the risk of suicide mortality. However, little research has investigated the concomitant effect of comorbid psychiatric disorders on suicide mortality. This study aimed to investigate the effect of comorbid AUD on suicide mortality of individuals with another psychiatric disorder using a national data sample. METHODS: We used the National Health Insurance Service-National Sample Cohort data from 2002 to 2013. We selected individuals with specific psychiatric disorders based on the International Classification of Diseases, 10th revision (F10-F48). Overall, the study included 741,601 participants. We utilized a prioritization process to identify the primary diagnosis for those with multiple diagnoses. All-cause mortality rates and suicide rates per 100,000 person-year (days) and the standardized mortality ratio (SMR) were calculated. Then, we compared the suicide-specific SMR of 3 different groups: (i) specific psychiatric disorder versus general public; (ii) specific psychiatric disorder comorbid with AUD versus general public; and (iii) specific psychiatric disorder comorbid with AUD versus specific psychiatric disorder without comorbid AUD. RESULTS: Patients with any specific psychiatric disorder showed higher suicide-specific SMR compared to the general population. Being comorbid with AUD further increased the risk of suicide among psychiatric patients. In particular, patients with bipolar affective disorders, organic mental disorders, or depressive disorders comorbid with AUD had about 2 to 4 times higher suicide-specific SMR compared to those without AUD (bipolar affective disorder: SMR = 3.01, 95% confidence interval (CI) [1.49, 4.54]; organic mental disorder: SMR = 3.43, 95% CI [1.05, 5.81]; depressive disorder: SMR = 2.06, 95% CI [1.52, 2.61]). CONCLUSIONS: Our data indicate that having a psychiatric disorder increases the risk of committing suicide. More importantly, comorbid AUD further increases this risk of suicidal death for certain psychiatric disorders. This shows the importance of determining whether patients with psychiatric disorders have comorbid AUD to prevent suicide.

Evaluating Canadians' Values for Drug Coverage Decision Making.

BACKGROUND: Decision makers are facing growing challenges in prioritizing drugs for reimbursement because of soaring drug costs and increasing pressures on financial resources. In addition to cost and effectiveness, payers are using other values to dictate which drugs are prioritized for funding, yet there are limited data on the Canadian public's priorities. OBJECTIVES: To measure the relative societal importance of values considered most relevant in informing drug reimbursement decisions in a representative sample of Canadians. METHODS: An online survey of 2539 Canadians aged 19 years and older was performed in which 13 values used in drug funding prioritization were ranked and then weighted using an analytic hierarchy process. RESULTS: Canadians value safe and efficacious drugs that have certainty of evidence. The values ranked in the top 5 by most of our subjects were potential effect on quality of life (65.4%), severity of the disease (62.6%), ability of drug to work (61.1%), safety (60.5%), and potential to extend life (49.4%). Values related to patient or disease characteristics such as rarity, socioeconomic status, and health and lifestyle choices held the lowest rankings and weights. CONCLUSIONS: Canadians value, above all, treatment-related factors (eg, efficacy and safety) and disease-related factors (eg, severity and equity). Decision makers are currently using additional justifications to prioritize drugs for reimbursement, such as rarity and unmet need, which were not found to be highly valued by Canadians. Decision makers should integrate the public's values into a Canadian reimbursement framework for prioritization of drugs competing for limited funds.

The Chang Gung Research Database-A multi-institutional electronic medical records database for real-world epidemiological studies in Taiwan.

PURPOSE: The Chang Gung Research Database (CGRD), the largest multi-institutional electronic medical records (EMR) collection in Taiwan, provides good access for researchers to efficiently use the standardized patient-level data. This study evaluates the capacity and representativeness of the CGRD to promote secondary use of EMR data for clinical research with more accurate estimates. METHODS: The National Health Insurance Research Database (NHIRD) which covers over 99.9% of the Taiwanese population served as the comparator in this study. We compare the data components of the CGRD with the NHIRD, including records for health care facilities, patients, diagnoses, drugs, and procedures. Using the chi-square test, we compared the distributions of age categories and sex of patients, and the rates of their health conditions between NHIRD and CGRD based on the year 2015. RESULTS: The CGRD contains more clinical information such as pathological and laboratory results than the NHIRD. The CGRD includes 6.1% of outpatients and 10.2% of hospitalized patients from the NHIRD. We found the CGRD includes more elderly outpatients (23.5% vs 12.5%) and pediatric inpatients (19.7% vs 14.4%) compared with the NHIRD. We found patients' sex distributions were similar between CGRD and NHIRD, but coverage rates of severe conditions, such as cancer, were higher than other health conditions in CGRD. CONCLUSIONS: The CGRD could serve as the basis for accurate estimates in medical studies. However, researchers should pay special attention to selection biases since patients' characteristics from CGRD differ from those of the national database.

Adherence to anti-osteoporosis medication associated with lower mortality following hip fracture in older adults: a nationwide propensity score-matched cohort study.

BACKGROUND: We investigated the association of anti-osteoporosis medication with mortality risk in older adults with hip fractures and evaluated the influence of medication adherence on mortality. METHODS: We conducted a population-based cohort study and identified a total of 13,123 patients aged 65 years or older with hip fracture from the Taiwan National Health Insurance Database during the period 2001-2010. Individuals with (n = 2092) and without (n = 2092) receiving anti-osteoporosis medication were matched using propensity score matching (1:1 ratio). The 1-, 3- and 5-year survival rates after the index fracture were compared between patients with and without treatment. In the treated group, survival rate was compared between those with good and non-adherence. Good adherence was defined as the medication possession ratio of ≥80% and non-adherence as a ratio < 80%. RESULTS: The 1-, 3- and 5-year mortality rates were significantly lower in the treated vs. the non-treated group (all p < 0.0001). In the treated group, the estimated 1-, 3- and 5-year survival rates were higher in those with good adherence than in those with non-adherence (all p < 0.0001). Regarding all-cause mortality, the adjusted hazard ratio in the treated vs. the non-treated group was 0.63 (95% confidence interval 0.58-0.68, p < 0.0001). The good adherence subgroup showed a significantly lower mortality risk than that in the non-adherence subgroup (hazard ratio 0.41, 95% confidence interval 0.32-0.51, p < 0.0001). CONCLUSIONS: The 1-, 3- and 5-year survival rates were significantly higher in patients receiving anti-osteoporosis medication than in the untreated group. All-cause mortality rates were lower in patients with good adherence to anti-osteoporosis medication.

Social Health Insurance in Europe: Basic Concepts and New Principles.

This article discusses recent developments in and new principles of European social health insurance (SHI). It analyses how privatization policies and competition have altered social insurance and whether financial difficulties are caused by social insurance features not evident in other types of health care systems. There is little if any evidence that SHI causes higher cost increases than other types of systems. The comparison of five European SHI systems demonstrates that despite cost containment policies these countries do not experience a trust crisis in health care or loss in support among the public. The author shows that SHI has moved toward universal health care and that the traditional values of solidarity and social security have even been strengthened over the past decades.

Waiting for common-law solutions for the most vulnerable populations' healthcare access.

BACKGROUND: The state of populations' health is linked to their access to quality healthcare. Best achieving this primary condition - a health, social and humanitarian condition - is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited. METHOD: The study of this example is based on monitoring of the framework's general implementation. This task was entrusted to the research team co-founded by the author, ODENORE (Observatory for the Non-take-up of Social Rights and Public Services). It is organized in four parts: quantitative monitoring of the detection and addressing of non-take-up situations (n=160,000 questionnaires); analysis of the results through qualitative interviews with beneficiaries and individuals who rejected the framework (n=365 interviews); analysis of the framework's implementation, using qualitative interviews and participant observations at the services in charge of the framework's implementation (n=18 collective interviews across three sites), and an analysis of the partnership through collective interviews with all the actors in the areas involved in the framework (three sites). RESULTS: The analysis shows that the integration of the most vulnerable populations' state of health into a common-law framework for intervention is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations. CONCLUSION: The difficulties of integrating the most vulnerable populations into a common-law framework such as the one proposed by the national health insurance do not seem insurmountable-provided, that is, that the regulatory authority (the regional health agencies) are willing and able to make it a strategic organizational objective at local level.

An NHS Trust and others v Y and another [2018] UKSC 46: Reducing the Role of the Courts in Treatment Withdrawal.

In An NHS Trust and others v Y and another, the Supreme Court was asked to address the question of whether a court order must always be obtained before clinically assisted nutrition and hydration (CANH), which is keeping alive a person with a prolonged disorder of consciousness (PDOC). This case note explores the Court's decision to dispense with the need for such a court order and analyses that important change in approach from the perspective of the right to life protected in Article 2 European Convention on Human Rights (ECHR) as well as in the broader context of end of life decision-making.

Obligation and the Changing Nature of Publicly Funded Healthcare.

This article explores the relationship between obligation and publicly funded healthcare. Taking the National Health Service (NHS) as the focal point of discussion, the article presents a historical analysis of the shifting nature and function of obligation as it relates to this institution. Specifically, and drawing inspiration from recent literature that takes seriously the notion of the tie or bond at the core of obligation, the article explores how the forms of social relation and bonds underpinning a system like the NHS have shifted across time. This is undertaken via an analysis of Aneurin Bevan's vision of the NHS at its foundation, the importance today of the patient (and the individual generally) within publicly funded healthcare, and the role of contract as a contemporary governance mechanism within the NHS. A core feature of the article is its emphasis on the impact that a variety of economic factors-including privatisation, marketisation, and the role of debt and finance capital-are having on previously settled understandings of obligation and the forms of social relation underpinning them associated with the NHS. It is therefore argued that an adequate analysis of obligation in healthcare law and related fields must extend beyond the doctor-patient relationship and that of state-citizen of the classical welfare state in order to incorporate new forms of relation, such as that between creditor and debtor, and new actors, including private healthcare providers and financial institutions.