The cost of consent: why healthcare providers must be compliant with the Montgomery principles.

The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of "failure to warn", i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on "failure to warn" and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA. Cite this article: Bone Joint J 2020;102-B(5):550-555.

Moral ambivalence towards the Cancer Drugs Fund.

The UK's Cancer Drugs Fund (CDF) was introduced in 2010 following the Conservative Party's promise to address the fact that numerous efficacious cancer drugs were not available because of their cost ineffectiveness, as deduced by the National Institute of Health and Care Excellence. While, at face value, this policy appears only to promote the UK's public welfare, a deeper analysis reveals the ethically unjustifiable inconsistencies that the CDF introduces; where is the analogous fund for other equally severe diseases? Have the patients without cancer been neglected simply due to the fear-inducing advertising and particularly ferocious speech which surrounds cancer? The CDF is unjustifiable when challenged by such questions. However, it is troubling to think that the CDF might be repealed in order to abolish these ethical concerns. Intuitively, one feels uncomfortable stripping the cancer patient of their benefits just so that they might be on an equally pessimistic footing with others. In the present essay, I argue that, although there are no ethically justifiable grounds for the CDF's introduction, its removal would be inappropriate. Following this realisation, I investigate whether the procedural steps of the CDF itself-theoretically removed from the context of resource distribution for all disease types-represent an ethically justifiable system. I believe that the answer is yes, given the CDF's conformity to accountability for reasonableness, a robust framework of procedural justice, which continuously improves the ethical and epistemological standards of the policies to which it is applied.

Conflicting demands on a modern healthcare service: Can Rawlsian justice provide a guiding philosophy for the NHS and other socialized health services?

We explore whether a Rawlsian approach might provide a guiding philosophy for the development of a healthcare system, in particular with regard to resolving tensions between different groups within it. We argue that an approach developed from some of Rawls' principles - using his 'veil of ignorance' and both the 'difference' and 'just savings' principles which it generates - provides a compelling basis for policy making around certain areas of conflict. We ask what policies might be made if those making them did not know if one was patient, doctor, nurse or manager - in this generation or the next. We first offer a brief summary of Rawls' approach and how we intend to extrapolate from it. We examine how this adapted Rawlsian framework could be applied to specific examples of conflict within healthcare; we demonstrate how this framework can be used to develop a healthcare service which is both sustainable (in its training and treatment of staff, and in encouraging research and innovation) and open (to protect the powers and opportunities of those using the health service). We conclude that while Rawls' approach has previously been rejected as a means to address specific healthcare decisions, an adapted veil of ignorance can be a useful tool for the consideration of how a just health service should be constructed and sustained. Turning the theoretical into the practical (and combining Rawls' thought experiment with Scanlonian contractarianism), managers, doctors, patients, carers and nurses could come together and debate conflicting issues behind a hypothetical veil.

Promoting Honesty and Truthfulness When Things Go Wrong During Care Delivery for Sick Children.

Emeritus Professor and Editor-in-Chief Edward Alan Glasper discusses why children's nurses must fully adopt the duty of candour in care delivery, which in some countries is a legal obligation, to ensure that consumers of healthcare and their families are apologized to, and communicated with, openly and honestly when things have gone wrong in their care.

Ethnic variations in the provision of biologic therapy for Crohn's disease: a Freedom of Information study.

In this study, we investigate whether the provision of biologic therapy for Crohn's disease is equitable across South Asian and English groups in NHS Trusts, which serve areas with significant ethnic variation. Data were requested from 10 NHS Trusts using a Freedom of Information (FOI) approach. Details of numbers of patients by ethnicity treated with infliximab or adalumimab for Crohn's disease between 2010 and 2012 were requested. Using population-based estimates of disease prevalence and Census data on population structure, observed and expected numbers who should have received treatment were calculated. In three Trusts, the number of South Asian patients who received such treatment was significantly less than British/White patients. These were: Pennine Acute Hospitals NHS Trust covering Oldham and North Manchester, Barking, Havering & Redbridge University Hospitals NHS Trust and University Hospitals of Leicester NHS Trust. The study is limited by several factors: 1. The only data available on prevalence in both English and South Asian communities comes from Leicester and was published in 1993. More recent data suggests that the prevalence of Crohn's disease now approaches 150/10(5) compared to the 76/10(5) for English patients which was recorded in Leicester. However, the two subsequent studies on prevalence which were published in 2000 from the North of England and 2010 from Scotland do not provide a breakdown by ethnicity. 2. The data were collected by administrative staff using a variety of approaches to their Trust's data bases and so the techniques used in each Trust are not comparable. In addition, studies from elsewhere suggest that the quality of FOI data is affected by the motivation of staff who collect the data. 3. With the exception of Leicester, there was no quality check on the accuracy of the data. In Leicester, 139 patients were on a register of biologic therapy and this compared with 343 patients reported by the FOI request. However, the proportions of patients by type of treatment and by ethnicity were comparable in the two data sets. This suggests that the data on ethnic differences reported by the FOI study reflects real differences. Clearly, there are South Asian communities where patients with Crohn's disease appear not to receive appropriate treatment in the form of biologics, and the reasons behind this need further consideration and investigation. We need to develop robust methods of monitoring the provision of biologic therapy across ethnic groups and communities. It is unacceptable for there to be a difference based on such grounds.

Medical responsibility.

These comments seek to take issue with the contention that society has a responsibility to provide its members with any needed health care. In order to deal with this claim we must first make clear exactly what it meant by the proposition. I take it that those who embrace this view mean considerably more than that each of us has a moral obligation to contribute to those in need of medical attention who are unable, for one reason or another, to afford the necessary care. This is a moral proposition and is traditionally dealt with under the heading of charity. But the contention, as here used, means considerably more since its main implications are not moral but primarily political.

Market-based reforms in health care are both practical and morally sound.

In this paper I argue that the free-market provision of health care is both practical and morally sound, and is superior in both respects to its provision by the State. The State provision of health care will be inefficient compared to its free-market alternative. It will thus provide less health care to persons for the same amount of expenditure, and so save fewer lives and alleviate less suffering for two reasons: state actors have no incentive to husband their resources effectively, and that in a non-market setting, special interest groups can capture resources through lobbying, perverting them away from their efficient allocation. Given these considerations of efficiency a utilitarian should morally prefer the free-market provision of health care to its State-based rival. Furthermore, even if one is not a utilitarian, the free-market provision of health care will be more morally sound than its State-based alternative because it will likely better respect the autonomy of persons, and will better refrain from imposing values upon persons. With these points in hand, I address two prominent objections to a free market system of health care.

Beyond the 'nanny state': stewardship and public health.

BACKGROUND: Some public health measures restrict personal freedom more than others, and deciding what type of measure will be appropriate and effective has long been a problem for policy makers. Existing bioethical frameworks are often not well suited to address the problems of public health. METHODS: The Nuffield Council on Bioethics set up an expert working party to examine the ethical issues surrounding public health in January 2006. Following evidence gathering and a public consultation exercise, the Council published its conclusions and recommendations in the report 'Public health: ethical issues' in November 2007. RESULTS: A spectrum of views exists on the relationship between the state's authority and the individual. The Council set out a proposal to capture the best of the libertarian and paternalistic approaches, in what it calls the 'stewardship model'. This model suggests guiding principles for making decisions about public health policies, and highlights some key principles including Mill's harm principle, caring for the vulnerable, autonomy and consent. An 'intervention ladder' is also proposed, which provides a way of thinking about the acceptability of different public health measures. The report then applies these principles to a number of case studies: infectious diseases, obesity, alcohol and tobacco, and fluoridation of water supplies. CONCLUSIONS: The idea of a 'nanny state' is often rejected, but the state has a duty to look after the health of everyone, and sometimes that means guiding or restricting people's choices. On the other hand, the state must consider a number of principles when designing public health programmes, and justification is required if any of these principles are to be infringed.

Social inequality in health: dichotomy or gradient? A comparative study of problematizations in national public health programmes.

Recent public health programmes from four countries: Denmark, England, Norway, and Sweden, are studied to analyse how social inequality in health is described, explained and suggested to be tackled, i.e., the problematization or the discursive process whereby the issue is framed and made accessible to political action. Social inequality in health is defined in these programmes both as a disadvantaged minority with major health problems, in contrast to the rest of the population, i.e., as a dichotomy; and as a gradient in which health problems are seen as increasing with lower social class or educational level. The causes of health inequality are identified as behaviour, social relations and underlying social structures. Policies aimed at reducing health inequality can be characterized as either in accordance with a residual welfare state model, targeting the disadvantaged, or a universal model, addressing the whole population. All countries have policies that are mixtures of these problematizations, but with some systematic differences between the countries. In this field England resembles the Scandinavian countries, as much as they resemble each other dispelling the idea of a Nordic or Scandinavian welfare state model.

Is the British National Health Service equitable? The evidence on socioeconomic differences in utilization.

Is the British National Health Service (NHS) equitable? This paper considers one part of the answer to this: the utilization of the NHS by different socioeconomic groups (SEGs). It reviews recent evidence from studies on NHS utilization as a whole based on household surveys (macro-studies) and from studies of the utilization of particular services in particular areas (micro-studies). The principal conclusion from the majority of these studies is that, while the distribution of use of general practitioners (GPs) is broadly equitable, that for specialist treatment is pro-rich. Recent micro-studies of cardiac surgery, elective surgery, cancer care, preventive care and chronic care support the findings of an earlier review that use of services was higher relative to need among higher SEGs.

Equity in waiting times for two surgical specialties: a case study at a hospital in the North West of England.

BACKGROUND: Reducing inequalities in access to the National Health Service is a key government priority. This study investigates the extent to which equitable access is achieved in one routinely administered hospital waiting list system. METHODS: Using hospital episode statistics for one hospital in the North West of England, a retrospective study of waiting times to surgery was undertaken for two surgical specialties (Orthopaedics and Ophthalmology). Participants were 4306 waiting list patients (elective, first episodes) living within Health Authority boundaries, treated within the two specialties between 1 April 2000 and 31 March 2001. Multiple logistic regression analysis of the relationship between waiting times and age, gender, ethnicity and deprivation status was undertaken. Main outcome measures were length of waiting time between being referred to the waiting list and treatment, and odds ratios for being associated with longer than median waiting times by age, gender, ethnicity and deprivation. RESULTS: For ophthalmology, the median waiting time was 140 days. After adjustment, older people had an odds ratio (OR) of 1.64 (95 per cent confidence interval (CI) 1.42-1.89), patients in deprived areas an OR of 1.29 (95 per cent CI 1.08-1.55) and men an OR of 0.79 (95 per cent CI 0.68-0.92) for having longer than median waiting times. No significant association was found between waiting times and ethnicity. For orthopaedics, the median waiting time was 129 days, and there were no significant differences in waiting times according to age, gender, ethnicity or deprivation. CONCLUSION: Routine waiting list systems are not always delivered equitably. For one specialty, female, older and deprived patients were significantly more likely to experience longer than average waits. Potential explanations and implications for policy-makers are considered.