Transradial catheterization

Transradial catheterization is an endovascular procedure or catheterization procedure performed to diagnose and treat arterial disease (e.g., coronary artery disease, peripheral artery disease, etc.). Endovascular procedure can be performed achieving access in to body’s arterial system from either femoral artery (in groin), brachial artery (in elbow) or radial artery in the wrist. The transfemoral (through groin) approach to perform cardiac catheterization has typically been more prevalent in invasive cardiology. But radial access has gained popularity due to technical advances with catheters and lower complication rates than transfemoral access. The European Society of Cardiology and the American Heart Association both support a radial-first approach in acute coronary syndrome.
History.
In 1948, Radner published one of the first descriptions of transradial central arterial catheterization and attempts at coronary artery imaging using radial artery cut-down. Transradial access to perform diagnostic cardiac catheterization procedures was introduced by Campeau and was later adapted for therapeutic procedures of coronary angioplasty by Kiemeneij and Laarman.
In past few years, transradial access for coronary intervention has become increasingly popular. The most advantageous aspect is very low access-site bleeding complications even with aggressive use of anticoagulation and antiplatelet therapies. During the angioplasty and stent procedures patients are given therapeutic (high) doses of anticoagulation (blood thinners) and platelet inhibiting medications.
Characteristics.
With transfemoral access, the rate of bleeding complications is 3% - 6%. Occasionally, patients can develop retroperitoneal bleeding (bleeding into the pelvic cavity), and up to 1% of patients require blood transfusion to treat the bleeding complication after transfemoral catheterizations. Patients may also develop painful hematoma, A-V fistula or pseudoaneurysms. In modern interventional cardiology the procedural success rates are high and ischemic complications are relatively rare. However the bleeding complications associated with transfemoral catheterization have not been significantly reduced even after the introduction of new pharmacological strategies. There is strong evidence suggesting that post-PCI bleeding is associated with an adverse prognosis. Postprocedural blood transfusion is also associated with poor prognosis. Bleeding complication, pseudoaneurysm, hematoma formation are less than 2% with transradial catheterization. Possibility of blood transfusion requirement is extremely rare after transradial catheterization.
The other reason for the increased use of radial access is the technological advances in the sheath and catheter design, and improved physician experience with this approach. With improvement in the physician's experience, radial artery access is now being used with equal efficacy to treat almost every complex coronary artery disease, including acute myocardial infarction, chronic total occlusion, bifurcation coronary artery disease and rotablation. Radial access has also been used
successfully to treat peripheral artery disease including bilateral iliac artery stenosis, renal artery stenosis and for carotid interventions.
Due to rapid ambulation post procedure the radial interventions became particularly attractive for patients with back pain, chronic obstructive lung disease, prostatic hypertrophy and elderly patients. As after catheterization through femoral approach patient is generally required to lay flat with immobilization of the leg for 4– 6 hours. Early ambulation and early discharge after transradial catheterization improves quality of life and reduces morbidity. Both patients and hospital staff typically strongly prefer the transradial approach as opposed to femoral access.
In era of cost control, the savings in closure devices (which are used to allow earlier ambulation after transfemoral catheterization), and early discharge had made this a cost-saving approach. Some of these savings are outweighed by a relatively long learning curve for physicians, which has likely slowed the adoption of the procedure in the U.S.
Although transradial procedures often have less complications than femoral procedures, they have some shortcomings. The procedure is technically more difficult and has a relatively long learning curve, which includes the potential for unsuccessful completion of procedure during said learning curve. In clinical trials before crossing the learning curve there is up to 5% failure in completing the catheterization successfully from radial approach. Technical difficulties are because of loops and tortuosity of the radial and the subclavian artery, anatomical variations in radial artery, and radial spasm.
Major complication associated with a transradial interventions include early and late radial artery occlusion. Most of the radial artery occlusions are asymptomatic. Post PCI radial artery occlusion can be reduced by using smaller diameter catheters and anticoagulation. Also by avoiding prolonged compression of the radial artery and applying just enough pressure to achieve hemostasis reduces this complication of asymptomatic radial occlusion significantly. Implying this approaches the radial artery occlusion rate has come down to 1.1-1.8%.
The transradial technique is an effective, minimally invasive approach to perform coronary and peripheral angiograms and interventions. Transradial catheterization is typically a safer, more cost-effective and patient friendly procedure. Studies show a lower rate of complications with transradial than with transfemoral catheterization in non-coronary interventions as well.. However, for women, the rate of complications may be about equal between transradial and transfemoral catheterization.


National Association of School Nurses

The National Association of School Nurses (NASN) is an American organization that releases guidance on the role of school nursing and recommends minimum standards for the profession. It develops education programs for its members, publishes position statements and issue briefs on relevant subjects, and uses advocacy to increase support for school nursing.
History.
In 1968, the National Education Association created the Department of School Nurses to advance the profession of school nursing. Through the 1970s, each US state created its own association of school nurses under the umbrella of the Department of School Nurses. In 1979, the program formally split from the National Education Association, incorporating to become the National Association of School Nurses.
Principles of school nursing.
In its 2016 Framework for 21st Century School Nursing Practice, the NASN established five principles of school nursing:
Publications.
NASN publishes a peer-reviewed journal, "NASN School Nurse", which releases six issues annually. It also publishes a weekly newsletter for its members.


David Daniel Davis

David Daniel Davis M.D. F.R.C.P. (15 June 1777 – 4 December 1841) was a British physician.
Born David Davies in Llandyfaelog in Wales, he received his M.D. from the University of Glasgow in 1801. He set up his practice as a physician in Sheffield, living in Paradise Square from 1803 to 1812. In 1806 he translated Philippe Pinel's influential book "Traité médico-philosophique sur l'aleniation mentale; ou la manie" with the English title "Treatise on Insanity". He then settled in London, and in 1813 was elected to the office of physician accoucher at the Queen Charlotte Lying-in Hospital. In this role, he was in attendance to the Duchess of Kent when she gave birth to the future Queen Victoria in 1819. In 1827, he was elected as the first professor in Midwifery at the University of London. In his study of obstetrics, Davis sought to improve the design of instruments used to assist childbirth and published widely on the subject, including his 1825 "Elements of operative Midwifery" and 1836 "The principles and practice of obstetric medicine in a series of systematic dissertations on the diseases of women and children".


Theodor Kaes

Theodor Joseph Martin Kaes (November 7, 1852 – December 22, 1913) was a German neurologist who was a native of Amberg.
Career.
He practiced medicine at the ("Staatskrankenanstalt Friedrichsberg") in Hamburg, where he was first prosector and head of the brain anatomy laboratory from 1899 until 1913. After his death, he was succeeded at Friedrichsberg by Alfons Maria Jakob (1884–1931).
Theodor Kaes was a pioneer in myeloarchitectonics, and is remembered for his morphological and myeloarchitectural research of the cerebral cortex, including the creation of cortical maps based on its fiber architecture. His name is lent to the eponymous "line of Kaes", which is a thin band of myelinated fibers located between the external granular layer and the external pyramidal layer of the cerebral cortex. This structure is sometimes called the "stria of molecular layer TA", or the "Kaes-Bekhterev layer", named in conjunction with Russian neurophysiologist Vladimir Bekhterev (1857–1927).
His principle written work was "Die Großhirnrinde des Menschen in ihren Maßen und in ihrem Fasergehalt – Ein gehirnanatomischer Atlas" (The cerebral cortex of humans in their dimensions and their fiber content. An anatomical brain atlas), 1907.


Opsoclonus

Opsoclonus refers to uncontrolled, irregular, and nonrhythmic eye movement. Opsoclonus consists of rapid, involuntary, multivectorial (horizontal and vertical), unpredictable, conjugate fast eye movements without inter-saccadic intervals. It is also referred to as saccadomania or reflexive saccade. The movements of opsoclonus may have a very small amplitude, appearing as tiny deviations from primary position.
Possible causes of opsoclonus include neuroblastoma and encephalitis in children, and breast, lung, or ovarian cancer in adults. Other considerations include multiple sclerosis, toxins, medication effects (e.g. Serotonin Syndrome), celiac disease, certain infections (West Nile virus, Lyme disease), non-Hodgkin lymphoma, and renal adenocarcinoma. It can also be caused by a lesion in the omnipause neurons which tonically inhibit initiation of saccadic eye movement (until signaled by the superior colliculus) by blocking paramedian pontine reticular formation (PPRF) burst neurons in the pons. It frequently occurs along with myoclonus in opsoclonus myoclonus syndrome.


Paul S. Appelbaum

Paul Stuart Appelbaum (born 1951) is an American psychiatrist and a leading expert on legal and ethical issues in medicine and psychiatry.
Appelbaum has been Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law, and Director, Division of Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons since 2006. Appelbaum was President of the American Psychiatric Association (2002-2003) and President of the American Academy of Psychiatry and the Law (1995-1996).
Appelbaum is a member of the Standing Committee on Ethics of the World Psychiatric Association, and Chair of the APA's DSM Steering Committee. He was the Fritz Redlich Fellow at the Center for Advanced Study in the Behavioral Sciences; he was given the Isaac Ray Award of the American Psychiatric Association for "outstanding contributions to forensic psychiatry and the psychiatric aspects of jurisprudence." Appelbaum has been elected to the Institute of Medicine of the National Academy of Sciences, and is a Hastings Center Fellow.
Appelbaum is credited with conceptualizing the idea of the therapeutic misconception in which subjects in medical research studies misunderstand the primary purpose of their contact with the research team as treatment.
Education and early career.
Appelbaum is a graduate of Stuyvesant High School, Columbia College and Harvard Medical School. He completed his residency at the Massachusetts Mental Health Center in Boston. During his medical residency, Appelbaum studied as a special student at Harvard Law School. He describes his legal training as of "critical importance to my later career development." He then became Assistant Professor of Psychiatry at the Western Psychiatric Institute, University of Pittsburgh Medical School. He credits the special student status he had at the Graduate School of Public Health, University of Pittsburgh while working as a young psychiatric research professor with helping him "move with greater assurance into empirical research on issues in law and psychiatry."
He returned to the Massachusetts Mental Health Center to serve as Executive Officer and as head of the Program in Psychiatry and Law for one year, before becoming the A. F. Zeleznik Distinguished Professor of Psychiatry, at the University of Massachusetts Medical School. He served for many years as Chairman of the Department of Psychiatry and Director of the Law and Psychiatry Program at the University of Massachusetts Medical School.
Research.
According to Appelbaum, his focus has always been on "trying to address the empirical questions that... inform and influence policy-related decisions."
His areas of particular expertise include the logic and practice of informed consent, the understanding of the influence of law on psychiatry, and the prediction of dangerousness so as to better guide psychiatric practice. His original work with Tom Grisso in the assessment of patient competency has had broad influence for research and better treatment of both civil and criminal patients.
He developed a theory of ethics for forensic psychiatry.
Since moving to Columbia College of Physicians & Surgeons in 2006, Appelbaum has focused on the medical, ethical and legal aspects of human genetic research. He leads the Center for Research on the Ethical, Legal and Social Implications of Psychiatric, Neurologic and Behavioral Genetics.
Appelbaum is a frequent media commentator on medical issues.
 The New York Times describes him as "a professor of psychiatry at Columbia who has published widely on medical ethics and the law."
Awards, honors, memberships.
Four of Appelbaum's books have received the Manfred Guttmacher Award from the American Psychiatric Association and the American Academy of Psychiatry and the Law. Appelbaum became President of the American Psychiatric Association in May 2002. He was President of the American Academy of Psychiatry and the Law, and of the Massachusetts Psychiatric Society. He has twice chaired the "Council on Psychiatry and Law," and the "Commission on Judicial Action" for the American Psychiatric Association, and served as a member of the MacArthur Foundation Research Networks on Mental Health and the Law and on Mandated Community Treatment. He has received the Isaac Ray Award of the American Psychiatric Association for ‘outstanding contributions to forensic psychiatry and the psychiatric aspects of jurisprudence’.
Personal life.
Appelbaum grew up in Brooklyn, New York, the son of a letter carrier and a school teacher. He is married to Diana Muir Appelbaum; they have three adult children, Binyamin Appelbaum; Yoni Appelbaum; and Avigail Appelbaum and belong to Congregation Ramath Orah in Manhattan.


Medical scoring

There are several scoring systems in intensive care units (ICUs) today.


Healthcare Resource Group

Within the English National Health Service (NHS), a Healthcare Resource Group (HRG) is a grouping consisting of patient events that have been judged to consume a similar level of resource. For example, there are a number of different knee-related procedures that all require similar levels of resource; they may all be assigned to one HRG.
The current revision of Healthcare Resource Groups in use is the fourth, and is known as HRG4. HRG4 is updated annually to enhance the system, reflect changes in clinical practice and to include changes to policy.
HRG4 is maintained by the National Casemix Office, part of the Health and Social Care Information Centre.
The HRG system is used by Payment by Results, an activity based payment system rolled out in the NHS in England (but not Wales) from 2004 and used to determine the income hospitals in England get for given hospital stays and procedures.
HRGs can be derived for the following areas:
Patient data are assigned HRG codes using a software application known as a Grouper.
An HRG code consists of five characters: two letters followed by two numbers and a final letter. The first letter refers the Chapter, the second being the Sub-Chapter; these correspond to body areas or body systems identifying the area of clinical care that the HRG falls within. The final letter is known as the 'split' and is used, for example, to indicate the level of complications and comorbidities associated with the HRG (e.g. Minor, Intermediate and Major), for different lengths of stay, ages or a combination of factors.
Admitted Patient Care.
In Admitted Patient Care, an HRG is derived for each Consultant Episode (a period of care under one consultant) and Provider Hospital Spell (a period of care from admission to discharge) using clinical coding (ICD-10 and OPCS-4) and administrative codes about patient events.
Non-Admitted Consultations.
Non-admitted consultations includes outpatients and ward attenders. An HRG is derived for each attendance record using clinical coding and the 'First Attendance' data item.
Emergency Medicine.
Emergency Medicine (A&E) data are grouped based on investigation and treatment codes.
Adult Critical Care.
Adult Critical Care HRGs are allocated per Critical Care Period using a count of organ systems supported.
Paediatric Critical Care.
Paediatric Critical Care HRGs are allocated on a per-day basis largely using Critical Care Activity Codes.
Neonatal Critical Care.
Neonatal Critical Care HRGs are allocated on a per-day basis largely using Critical Care Activity Codes.
Renal.
Renal HRGs are allocated based on the National Renal Dataset


National Black Nurses Association

The National Black Nurses Association (NBNA) was founded in 1971 in Cleveland, Ohio. It was incorporated in 1972. The organization is dedicated to promoting African American women in the profession of nursing.
History.
At the American Nurses Association (ANA) Convention in 1970, 200 African-American nurses proposed the formation of the National Black Nurses Association (NBNA). After the convention, several nurses met at Doctor Mary Harper's home in Cleveland, Ohio to discuss the formation of an organization. The group was organized in December of 1971. Betty Smith Williams was the nurse who proposed the formation of the group under its current name. The first president of NBNA was Doctor Lauranne Sams. In 1972, the organization was officially incorporated. By 1991, there were 51 chapters of the organization around the United States.
Williams served as president from 1995 to 1999.
About.
The goal of the NBNA is to improve the health status of black people in the United States and to open nursing education and leadership positions for African Americans. The official mission statement was to provide a forum for collective action by black nurses to investigate, define and advocate for the health care needs of African Americans and to implement strategies that ensure access to health care, equal to, or above health care standards of the larger society.
The NBNA has hosted "NBNA Day on Capitol Hill" since 1988. At the event, nursing professionals share ways to advocate for nursing and for their communities.
The official journal of the NBNA is the "Journal of the NBNA".
As of 2020, there are around 200,000 members of NBNA and 115 chapters.


Cancer Epidemiology Unit

The Cancer Epidemiology Unit (CEU) is a medical research institute within Oxford University's Nuffield Department of Population Health in the United Kingdom. It is located in the Richard Doll Building on the Old Road Campus, Headington, Oxford.
Major projects.
Major projects run by the CEU include the Million Women Study.
The unit is also involved with the UK Biobank project.


American Academy of Allergy, Asthma, and Immunology

Founded in 1943, the American Academy of Allergy, Asthma & Immunology (AAAAI) is a professional medical membership organization of nearly 6,800 allergist/immunologists and related professionals around the world with advanced training and experience in allergy, asthma and other immunologic diseases. The Academy is dedicated to the advancement of the knowledge and practice of allergy, asthma and immunology for optimal patient care.
Most members of the AAAAI are board-certified allergist/immunologists. A select group of the membership are elected as Fellows and carry the title FAAAAI.
The organization, headquartered in Milwaukee, Wisconsin, hosts a website for patients and healthcare professionals that includes a physician referral directory for patients.
History.
Founded in 1943, the organization was originally called the American Academy of Allergy (AAA). From 1982 to about 1991 it was called the American Academy of Allergy and Immunology (AAAI). Since then it has been called the American Academy of Allergy, Asthma, and Immunology (AAAAI).
Publications.
"The Journal of Allergy and Clinical Immunology" (JACI), published monthly, is the official scientific journal of the AAAAI. It is the most-cited journal in the field of allergy and clinical immunology.
In January, 2013, the AAAAI launched "The Journal of Allergy and Clinical Immunology: In Practice", a publication aimed at the practicing clinician treating allergies, asthma and immunologic disorders.
The organization also publishes educational materials for patients and consumers.
National Allergy Bureau.
The National Allergy Bureau (NAB) is an AAAAI-certified pollen and outdoor mold spore counting network. The NAB issues pollen and mold reports three times a week and provides information on common seasonal outdoor allergy triggers. The NAB is part of the AAAAI's Aeroallergen Network, and consists of pollen and spore counting stations staffed primarily by AAAAI member volunteers. They provide pollen and mold counts from approximately 80 counting stations throughout the United States, two counting stations in Canada, and two in Argentina.
Annual meeting.
Each year, academic and clinical leaders attend the AAAAI Annual Meeting, which showcases new research and discuss other developments in the areas of allergy, asthma and immunology. The meeting is attended by more than 7,000 allergist/immunologists, related physicians, allied health professionals and industry representatives.


John Edmundson

Captain John Edmundson USN was the chief doctor at the Guantanamo Bay detainment camps, in Cuba.
During a reporter's tour of the 48-bed facility in January 2005, Edmundson revealed, in an off-hand comment, that 23 detainees had tried to hang themselves in a simultaneous mass-suicide bid in late 2003.
Following the June 10, 2006 suicide bid Edmundson told reporters that the three men had all had routine Psychological tests administered because they were participating in the recent hunger strike.
Edmundson said that the men showed no sign of despair or suicidal tendencies.
Edmundson's boss, Admiral Harry Harris, stirred controversy by calling the suicides ""acts of asymmetrical warfare".
A June 28, 2006
"Los Angeles Times" article quotes Edmundson: "If you ask my opinion, I agree with the admiral that this was somewhat of a political statement.""


Medicaid Estate Recovery Program

The Medicaid Estate Recovery Program (MERP) is a process initiated by state governments in the United States for recovering payments made under the Medicaid program to program beneficiaries. The government recovers the sum of payments from the estate at the time of death of the program beneficiary.
The moral justification for Estate Recovery has been stated as “if you’re receiving a public benefit and the state is trying to support you, you should give back if you are able".
Details.
States are required to recover long-term-care-related (LTCR) Medicaid expenses from people who are 55 or older and have received Medicaid, from recipients' probate estates.
States also have the option to recover costs of all other Medicaid services for people who are 55 or older and have a separate option to extend the recovery beyond probate estates, which is known as "expanded estate recovery".
Recovered amounts may include capitation charges as to whether or not medical services were used, as well as expenses directly paid under Medicaid to the service provider for utilized services.
The scope of the recovery includes "traditional" Medicaid (referring to the versions of Medicaid that existed prior to the Affordable Care Act (ACA), as well as the expanded Medicaid introduced by the ACA.
States may not recover from the estate of a deceased Medicaid enrollee who is survived by a spouse, or a child that is under age 21, blind or disabled. States are also required to establish procedures for waiving estate recovery when recovery would cause an undue hardship.
States may impose a lien for Medicaid benefits incorrectly paid pursuant to a court judgment. States may also impose liens on real property during the lifetime of a Medicaid enrollee who is permanently institutionalized. The states must remove the lien when the Medicaid enrollee is discharged from the facility and returns home.
Historical origin.
The states have been authorized to implement estate recovery programs since 1965 when Medicaid first began. However, prior to 1990, only 12 of the states had established Medicaid estate recovery programs.
The federal government made it a requirement for every state to implement an estate recovery program for Medicaid in the Omnibus Budget Reconciliation Act of 1993. This was done with primary concern towards recipients who received long-term care services, which had required the applicant to have very low asset levels.
It allowed recipients and their spouses to retain a home and certain other modest assets, to avoid total impoverishment, while they are alive. The estate recovery collected the assets from the estate when both the recipient and their spouse were deceased. The Act also gave states the option of recovering other Medicaid expenses.
Non-LTCR estate recovery and the ACA.
View that the non-LTCR recovery is problematic.
The view that there were problematic aspects of the interaction of non-LTCR Medicaid estate recovery with the ACA was put forth in various places starting from the time the ACA was passed, and stemmed from the fact that much of the coverage made available under the ACA is Medicaid, which is subject to estate recovery for people 55 and older, in a number of states.
The ACA was designed to make available, and promoted as making available, affordable health insurance to all people without other forms of insurance.
It attempts to make the insurance available (for the case of U.S. citizens) by retaining existing Medicaid programs ("traditional Medicaid", which generally required both low incomes and very low asset levels), starting a new class of Medicaid for people whose Modified Adjusted Gross Incomes (MAGIs) are no more than 138% of the Federal Poverty Level (FPL) and with no maximum asset levels, and by offering people with all income levels access to on-exchange insurance plans from private insurers, and offering sliding-scale income-based subsidies for those with MAGIs above 100% of the FPL to 400% of the FPL, provided they are not eligible for either a traditional Medicaid or expanded Medicaid, a Children's Health Insurance Program (CHIP), or an employer's or a family member's employer's insurance program.
One aspect of this point of view that was raised is seen by noting that the goal of providing health insurance is interfered with if states exercise their option to recover costs of all medical care (not just LTCR) for people 55 or older. People getting Medicaid do not have the protections normally associated with health insurance.
People 55 or older getting Medicaid are not eligible to receive a subsidy on an ACA on-exchange plan, but do have an option of purchasing an ACA on-exchange plan without a subsidy. However, this option may be unaffordable, since the class of people involved often have a MAGI at or below 138% of the FPL.
An additional problematic aspect of the estate recovery of non-LTCR expenses that was brought up, was the unequal treatment of people below 138% of the FPL under the ACA, who get expanded Medicaid and are subject to estate recovery if they are 55 or older, and people just above 138% of the FPL, who get highly subsidized, very-low-net-cost, on-exchange insurance, which is not subject to estate recovery.
Another aspect raised was that people were obligated under the ACA to be covered under threat of a financial penalty if not covered, but for many people, the only affordable coverage available was Medicaid. Medicaid came often with capitation charges against the person's estate even if medical services were unused; it often came with a risk of large payments for medical services used if the person got sick having to be paid back by the estate. The Federal mandate has been removed since the start of 2019; this aspect continues to have relevance in states which have their own financial penalties for not carrying coverage, which include New Jersey, Massachusetts, and the District of Columbia among states that currently do estate recovery of non-LTCR Medicaid expenses.
In a Jan, 2014 Washington Post article, Matt Salo, executive director of the National Association of Medicaid Directors, responded to the issues by indicating "It wouldn’t make sense for a state to pursue a claim on the property of a new [expanded] Medicaid recipient under the health-care law", and added, “There’s no way any state is going to see it as cost-effective or politically sensible to do that.” (However, subsequently, state Medicaid spokespersons for both NJ and MN made contradictory assertions, indicating their states intended to continue the estate recovery of all medical expenses for all Medicaid recipients. As of Aug, 2019, at least 12 states that have expanded Medicaid: Massachusetts, New Jersey, Iowa, Nevada, New Hampshire, North Dakota, Ohio, Rhode Island, Indiana, Utah, Maryland, and the District of Columbia maintain the estate recovery of all medical expenses for expanded Medicaid recipients in their laws and regulations.)
In late February 2014 (two months after the main ACA provisions went into effect) the Obama administration's Center for Medicare and Medicaid Services (CMS) issued a letter stating “CMS intends to thoroughly explore options and to use any available authorities to eliminate recovery of Medicaid benefits consisting of items or services other than long term care and related services in the case of individuals who are determined eligible for Medicaid benefits using the MAGI methodology." "MAGI methodology" for Medicaid eligibility refers to roughly those people added to Medicaid in expanded Medicaid.
Argument for non-LTCR estate recovery post-ACA.
Medicaid estate recovery documents from the various states that do estate recovery of non-LTCR expenses often explain the purpose of their estate recovery program. For example, an NJ document has "DMAHS pursues recovery from estates to supplement funds available for medical assistance programs and limit the burden upon taxpayers caused by rising medical costs. Funds recovered help provide assistance to others in need."
It can be argued that the justifications were written before the ACA main provisions went into effect in 2014, and do not account for the changes in who is affected by the recovery post-ACA; as well, the ACA may reflect a changed attitude intended in the law, that affordable health insurance should be, post-ACA, available to all as an expected matter of national policy. Some may consider it important to examine justifications post-ACA, under the assumption of expanded Medicaid.
Post-ACA, the argument to continue non-LTCR estate recovery was expressed by an assistant commissioner for the Minnesota Department of Human Services (a state which had expanded Medicaid) as “The general idea here is that people with assets should help contribute to the cost of their coverage, Many have incurred thousands of dollars of medical expenses at taxpayer expense. That’s the reason for these recoveries. It’s not intended to be punitive.”
Post-ACA adjustments to recovery regulations.
State regulation adjustments stopping non-LTCR Estate Recovery.
Prior to the ACA main provisions going into effect on Jan 1, 2014, a number of Medicaid expansion states had had laws and regulations which did the non-LTCR estate recovery, and have stopped or limited the practice, though not necessarily permanently:
In addition, there are some Medicaid expansion states which did not do non-LTCR Medicaid estate recovery, and still do not (such as Pennsylvania).
States maintaining non-LTCR Estate Recovery.
In other Medicaid expansion states which did non-LTCR Medicaid estate recovery just prior to the ACA main provisions, (such as Massachusetts, New Jersey, Iowa, Nevada, New Hampshire, North Dakota, Ohio, Rhode Island, Indiana, Idaho, Utah, and Maryland, as well as in the District of Columbia) the recovery of non-LTCR persists.


American College of Physicians

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. With 154,000 members, ACP is the largest medical-specialty organization and second-largest physician group in the United States, after the American Medical Association. Its flagship journal, the "Annals of Internal Medicine", is considered one of the five top medical journals in the United States and Britain.
Mission and history.
Founded in 1915, ACP's stated mission is to "enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine." In 1998, it merged with the American Society of Internal Medicine (ASIM). ASIM's focus on the economic, political, and social aspects of medical care both enlarged and complemented its mission.
Known as ACP-ASIM from 1998 to 2003, the organization re-adopted "American College of Physicians" as its corporate name from 2003 on.
Structure.
The college is governed by a board of regents, the main policy-making body that oversees its business and affairs. The board of regents is made up of elected officers. The board of governors serves as an advisory board to the board of regents, along with a various councils and committees. The board of governors is composed of elected governors who implement projects and initiatives at a chapter level and represent member concerns at the national level. The board of governors is composed of elected governors in chapters and regions of the United States, Canada, Central and South America, Japan, and Saudi Arabia.
The organization is represented in the American Medical Association, the Council of Medical Specialty Societies, and other associations.
Membership and recognition.
Levels of membership are Medical Student, Associate, Member, Fellow (FACP), and Master (MACP). Fellowship and Mastership in ACP recognize outstanding achievement in internal medicine. Fellows are recommended by their peers, endorsed by their local chapter leadership, and reviewed by a national credentials subcommittee. Masters are nominated from among the Fellows of ACP for annual election to this group. Board certification in internal medicine is not required, though potential members must be "board eligible."
Non-Physician Affiliate membership is available to licensed non-physician health care professionals, or a physician holding an internationally equivalent degree and who maintain their professional credentials to practice.
Publications and products.
The American College of Physicians distributes numerous publications and products to members. They include:
Activities.
The Washington, D.C., office monitors and responds to public policy issues that affect public health and the practice of medicine. Activities include development of policy statements and communication with legislative and administrative sectors of government.
The Center for Ethics & Professionalism seeks to advance physician and public understanding of ethics and professionalism issues in the practice of medicine in order to enhance patient care by promoting the highest ethical standards. The sixth edition of the "ACP Ethics Manual" was published in 2012.
The High Value Care initiative aims to help patients receive the best possible care from physicians while reducing unnecessary costs to the healthcare system. The initiative includes clinical and public policy recommendations, curriculum, and resources for physicians. For patients, ACP offers resources about the benefits, harms, costs and treatments options for common clinical issues.
Education and information resources.
ACP develops several types of clinical recommendations, including Clinical Practice Guidelines, Guidance Statements, and Best Practice Advice papers. The different types of guidance are meant to be read differently. Guidelines are seen as the strongest recommendation, while guidance statements review existing guidance and best practice advice reviews available evidence.
In 2015, the ACP advocated for a public health approach to gun violence, supporting restrictions on automatic weapons, universal background checks, and legal mechanisms to keep guns out of the hands of the mentally ill.


Colin Bradley (physician)

Colin Bradley is a professor of general practice at University College Cork, best known for his 1995 paper on significant event audit, co-authored with Mike Pringle.


Rhona Goskirk

Rhona Goskirk is a fictional character from the British ITV soap opera, "Emmerdale", played by Zoe Henry. She made her first screen appearance during the episode broadcast on 17 September 2001. The character was introduced by series producer Steve Frost and appeared initially in 2001 and 2002. She returned to "Emmerdale" as a full-time character in March 2010, reintroduced by series producer Gavin Blyth. She has been through a diverse range of storylines, including a romantic bond with comedic chef Marlon Dingle (Mark Charnock); giving birth to their son Leo Goskirk, who has Down Syndrome; marrying Paddy Kirk (Dominic Brunt); becoming addicted to painkillers, discovering Paddy's affair with her friend Tess Harris (Nicola Stephenson) after Tess' death; pursuing a manipulative relationship with Tess's widower Pierce Harris (Jonathan Wrather), her near-death in the soap's biggest stunt known as "No Return Week", marital rape at the hands of Pierce; becoming infertile after a farming accident; and bringing Pierce to justice for killing her boyfriend Graham Foster (Andrew Scarborough) amid feuding with Graham's estranged boss and ex-wife Kim Tate (Claire King).
Development.
Casting.
Henry joined the cast of "Emmerdale" as Rhona Goskirk in 2001 for an initial seven episodes. The actress returned in 2002 for another brief stint, departing in December. On 13 February 2010, Kris Green of Digital Spy reported Henry had reprised her role and Rhona would be returning to "Emmerdale" later in the year.
Family and characterisation.
In an interview with "Inside Soap", Henry expressed her desire to see Rhona's mother be cast on "Emmerdale". She stated: "I'd love to see Rhona's mum, who lives in Kent and we hear about all the time, come to the Dales." Regarding who she would want to portray her mother Mary, Henry explained that she originally wanted Judith Barker, until she was cast as Agatha Finn. She then suggested that Susan George would be "great". When asked about her favourite qualities of Rhona, Henry said that she "admires her sense of fun and her inner strength", and described Rhona as a "lioness". Henry added that she has felt "exhausted" by some of the storylines that her character has been part of, but that she does not "wish any of them hadn't happened", and does not regret the effort she put into them. On the various relationships that her character has been part of, Henry stated that Rhona "could rekindle things with Marlon, which would be amazing for Leo, and for April, as Rhona is the closest she has to a mother", but stated that she enjoyed working with all of the actors Rhona has romances with.
Storylines.
2001–2002.
Rhona first appeared in the village in September 2001 as a locum, helping Paddy Kirk (Dominic Brunt) and covering for Zoe Tate (Leah Bracknell), whilst she was on holiday. She begins dating with local chef Marlon Dingle (Mark Charnock) in light of his ex-girlfriend, Tricia Fisher (Sheree Murphy), departing the village after their relationship had ended. However, Tricia soon reappeared and Rhona left not long after. Rhona returned in June 2002 to cover for Zoe as she was incapable of work, due to mental illness. She and Marlon soon resumed their relationship and realized they had several shared interests, including Laurel and Hardy films and design. When Tricia found out, she was very upset but Rhona left again in December.
2010–present.
Rhona returned in 2010, covering for Paddy after his foster son Aaron Livesy (Danny Miller) attacked him. Rhona stayed for a few weeks and clashed with receptionist Pearl Ladderbanks (Meg Johnson), as she wanted to protect Paddy. It was later revealed that in her absence, Rhona had married and divorced. Rhona completed her contract and left but returned when Paddy needed to care for Aaron, following his suicide attempt. As no one knew how long Aaron's recovery might take, Rhona stayed with Andy Sugden (Kelvin Fletcher) and Ryan Lamb (James Sutton) but moved in with Marlon, Bob Hope (Tony Audenshaw) and Lizzie Lakely (Kitty McGeever). She left when she realised she was in love with Paddy. She confided in Laurel Thomas (Charlotte Bellamy) that her relationship with Paddy had become difficult and was seriously considering leaving so Laurel told Paddy to sort things out with her before she left.
Rhona discovered she was expecting Marlon's baby. When she learns that the baby has Down's syndrome, she considers a termination but decides not to after talking to Hazel Rhodes (Pauline Quirke). On 1 February, she has a scan and discovers that the sonographer is an old school friend, Stephanie Ray, and she tells Paddy and Marlon that Rhona was very rebellious when she was at school. Rhona tries to set Marlon and Stephanie up but he wasn't keen. Marlon decided that they should try pregnancy yoga and Rhona agrees but decides to go alone, because Marlon is very irritating. She has another scan in March and is told everything is fine but is so worried that they visit a Downs Syndrome support group. In April, she and Paddy tell Aaron about the baby's condition and are touched by his reaction. She gets Braxton Hicks Contractions twice before giving birth to a boy they name Leo.
Rhona starts to make plans to propose. However, Paddy gets drunk and Rhona cannot go through with it. Paddy tells Rhona that he feels getting married is unnecessary but proposes when he feels guilty and she accepts. Paddy is offered a job in New Zealand and he and Rhona agree to go but Marlon refuses to let them take Leo. Consequently, Paddy and Rhona ask Marlon to go with them and he agrees but later changes his mind. Rhona tells Marlon that she is still taking Leo but Marlon tells them that he has taken legal action to stop them. After a lot of debate between Rhona and Laurel about taking Leo to New Zealand, Rhona and Leo leave but Paddy has to stay after being arrested for assaulting a police officer. Rhona and Leo return after Marlon tells Paddy to tell Rhona to come back voluntarily or be forced to return as they have another court date. Paddy's licence to practice as a vet is suspended because of his arrest so Rhona's old friend, Vanessa Woodfield (Michelle Hardwick), helps out but she annoys Paddy. However, Vanessa buys a share in the surgery and when Paddy is able to return, he, Rhona and Vanessa all have their names above the door.
Rhona's life takes a turn for the worse when she becomes addicted to the painkillers prescribed for a back injury. Like many addicts, her personality changes and she becomes aggressive. Vanessa sees Rhona raid the surgery's drugs cabinet, warning her of the penalties if she is caught. Rhona apologises and hides while Leo cries in his cot. Vanessa sees this and is shocked by Rhona's state. She tells her that Leo is fine before giving her a pill to make her feel better. This helps initially but Rhona's dependence worsens dramatically. Vanessa tries to help Rhona wean herself off the painkillers and confesses that she has fallen in love with Rhona. Rhona initially spurns her affection before giving in as Vanessa is now her dealer but also buys drugs from a dealer named Gary. Paddy and others are suspicious of Rhona's odd behaviour. Paddy checks her phone and sees that she is contacting Gary and lying about where she goes. When he confronts her and grabs her phone, Rhona screams and attacks Paddy before demanding that he leave. However, Rhona's addiction leads her to put herself and others in danger as when visiting different pharmacies to get painkillers, she and Laurel are carjacked by Ross Barton (Michael Parr). Rhona is also unaware of the damage that the drugs are doing to her body and only realises when she is rushed to hospital after collapsing. The doctor tells her that her kidneys are about to collapse so Marlon, feeling Paddy has to look after Rhona, removes Leo. Losing residency of her son and attending rehab help Rhona get and stay clean.
After Vanessa brings her son, Johnny, home from hospital, Rhona realises that she wants another baby. As she has not got pregnant again, she decides to adopt and discusses it with Paddy. He agrees and the references selected by Paddy and Rhona include Aaron, Pearl and Leo's teacher, Tess Harris (Nicola Stephenson). Tess befriends Rhona and tells her that she is in love with a married man. Rhona encourages Tess to go for it, saying life is too short but after Tess dies, Rhona learns that Paddy is Tess's married man. Initially Rhona insists on carrying on as normal but soon realises that she and Paddy cannot stay together, let alone adopt a child, as things are so bad between them that they didn't realise that Leo was hurting April.
In March 2016, Rhona tells Pierce Harris (Jonathan Wrather), Tess' widower, that Paddy was Tess' lover so Pierce punched Paddy. Later, Rhona discover Aaron and Chas knew that Paddy was having an affair. Not long afterwards, Rhona gets involved with Pierce who harbours a dark secret. Initially her friends and family think this a bad idea but come round when they see that Pierce and Rhona are happy together. In October, after Rhona and Pierce argue, she goes camping with Paddy, Marlon and Leo. However, Pierce arrives and they argue again. After Pierce leaves, Paddy and Rhona go after him and are involved in a pile up, caused by Emma Barton (Gillian Kearney) pushing her husband, James, from a bridge. Rhona and Paddy are badly injured but they all survive and Rhona continues her relationship with Pierce.
In January 2017, Rhona and Pierce's relationship takes a sinister turn when Pierce forces himself on Rhona. After this, Rhona is left in a state of confusion and probable shock, suggesting Rhona did not give her explicit consent. A month later, despite Pierce forcing himself on her for a second time, she agrees to marry him on Valentine's Day, although she has shared a kiss with Paddy. Pierce overhears Rhona and Paddy discussing the kiss, unaware that Pierce has overheard; On her wedding day, Paddy gives Rhona his mother's necklace and she and Pierce marry. Pierce shows Rhona information of a Lake District veterinary practice lease, but Rhona is surprised he acquired it without discussion and, when Pierce suggests Rhona is not over Paddy, Rhona admits she drunkenly kissed Paddy. He insults her so she attempts to flee the house, however, Pierce drags her back in the house and jealously rips the necklace off. Losing control, Pierce pushes Rhona to the floor and proceeds to rape her. He attempts to shift the blame onto Rhona but, under pretence of showering, a shocked Rhona escapes the house, goes to the police station and reports her rape. Rhona is taken to a Sexual Assault Referral Centre, where she is examined. Rhona leaves during the interview and orders Pierce to get out or she'll phone the police. Rhona almost confides in Marlon, later, after putting Leo to bed, she breaks down on the stairs. Pierce tells her things will be worse if she does tell the police.
Rhona meets Pierce's mother Martha after the truth comes out, and Martha gives insight into Pierce's troubled mindset due to his father's death when he was young. At Pierce's trial, his defense suggests Rhona is lying about the rape as the couple enjoyed "rough" sexual intercourse. As it appears the jury is swayed in Pierce's favour, he is ultimately found guilty of his crime and later sentenced to a period of jail time. Rhona is allowed to visit Pierce in prison, and he acknowledges his actions and apologises to Rhona, who rejects the apology and in return declares she is free of him at last.
It takes Rhona some time to get over her ordeal, but in early 2018, she falls for farmhand Pete Barton (Anthony Quinlan), whom Leo quickly becomes attached to. Pete even tries his hand at learning Makaton to communicate with Leo. Rhona and Pete get engaged and after Pete's brother, Ross (Michael Parr), leaves the village, he gives up their old house and moves into Smithy Cottage. In February 2019, while out on a call to Butler's Farm concerning the animals there, Rhona is run over by faulty farming machinery operated by Pete's cousin, Matty Barton (Ash Palmisciano). The accident leaves Rhona gravely injured, and an operation she needs in order to stand a chance of fully recovering would render her unlikely to have children again, which strains Rhona's relationship with Pete as she worries he will want more children after they marry. Rhona confides her worries in businesswoman Kim Tate (Claire King), with whom she becomes friends. However, Kim has an ulterior motive; her former stepdaughter Zoe (Leah Bracknell) used to be part-owner of the vets, in business with Paddy, and now Kim wants to buy into the vet's, which is in financial straits, so she can employ her son - Jamie (Alexander Lincoln). When Rhona thereafter realises Kim's plan, she rebuffs her - so Kim tries to seduce Pete. Though the pair never go beyond a kiss, Rhona feels betrayed and her relationship suffers further. On a night out with several other villagers in April 2019, Rhona kisses a stranger called Nate Robinson (Jurell Carter) after the pair get talking at the bar. The encounter leaves Rhona feeling guilty and she eventually tells Pete. After several months of difficulty, in June 2019, Rhona and Pete end their engagement and relationship. Pete moves in to Butler's Farm, but he and Rhona maintain a close friendship and Leo is still allowed to see Pete too.
In October 2019, Rhona starts seeing Kim's associate Graham Foster (Andrew Scarborough) - unaware that the pair have had a casual sexual relationship for several years. Kim's jealousy swells to the point that she tries sabotaging Rhona and Graham's relationship several times, until during a Halloween party in the Woolpack, Kim spills the beans on her and Graham's affair, insulting Rhona and warning her to stay away. In return, Graham angrily reveals that Jamie dobbed his mother in with the police for her criminal activities several years previously, which earned her a spell in prison. After the big reveal, Graham commits himself to Rhona and they make their relationship official - with Kim swearing revenge against them both.
In January 2020, Rhona is devastated to learn that Graham has been murdered and quickly suspects Kim to be the perpetrator - most notably after learning that Kim wanted Graham dead. She soon begins to doubt her theories on Kim, however, when Rhona learns that Pierce has been released from prison not long ago. Eventually, Rhona deduces that Pierce killed Graham upon learning that her ex-husband has been stalking her ever since he had been released from prison. Moreover, Pierce has kidnapped Vanessa and Johnny to force Rhona to meet him face-to-face - and she does so after finding out about the situation. When Rhona meets Pierce face-to-face for the first time since before he went to prison two years ago, she secretly records him admit to killing Graham - all the while the recording is being streamed live in front of Paddy and the other punters in The Woolpack. Paddy instantly phones the police just as Pierce knocks out Kim, after the latter arrived to help Rhona extract proof about the culprit behind Graham's murder. When the police arrive moments later, Pierce prevents Rhona from escaping and attempts to rape her again; however, she fights back by injecting an animal needle on Pierce to subdue him. As Pierce lies helpless and injured, Rhona lectures him for what he put her through by raping her and killing Graham. The police then besiege the building and Pierce, after being identified by his ex-wife as Graham's killer, is arrested for murder and kidnap; he is later charged for his crimes and consequently jailed once more, thus allowing Rhona to finally lay Pierce to rest from her life. Her efforts to move on from Graham become troubled when Kim arranges for his funeral to proceed without Rhona's knowledge, which restarts their conflict in the process. Rhona then learns that Graham left her a lot of money in his will and not Kim. She decides to keep it and use it to help Moira with her farming troubles, much to Kim's frustration.
Reception.
In August 2017, Henry was longlisted for Best Actress at the Inside Soap Awards. The nomination made the viewer-voted shortlist, although Henry lost out to Lucy Fallon, who portrays Bethany Platt in "Coronation Street".


Immunotransplant

Immunotransplant is a maneuver used to make vaccines more powerful. It refers to the process of infusing vaccine-primed T lymphocytes into lymphodepleted recipients for the purpose of enhancing the proliferation and function of those T cells and increasing immune protection induced by that vaccine.
The concept takes advantage of data from animal and studies in vaccinology and the homeostasis of T cells and has applications in the treatment of infectious disease, immunodeficiency syndromes, and cancer.
Basic Immunology.
Vaccines.
Historically, the effect of vaccines -particularly against pathogens- has been assessed by measurement of their induction of a B-cell-mediated -or humoral- immune response, i.e. the production of pathogen-specific antibodies. In the study of both infectious diseases and cancer, a majority of potential immune targets are only expressed intra-cellularly, and are thus inaccessible to antibody-mediated elimination. T-cell mediated immunity, by contrast, has the potential to recognize targets expressed either extra- or intra-cellularly and has therefore been studied extensively for treatment of these diseases.
A number of pre-clinical and clinical studies have demonstrated that vaccines against pathogens, bystander (non-pathogenic) proteins, tumor-associated antigens, or whole tumor cells, can induce specific T-cell mediated immune responses. A number of approaches have been considered to amplify T cell mediated immune responses(e.g. IL-2, CTLA-4, IL-7, CD137), and some of these have shown clinical efficacy in eliminating particular types of cancer, most notably melanoma and renal cell carcinoma.
T-Cell Homeostasis and Homeostatic Proliferation.
The use of immunotransplant to enhance T cell-mediated immune responses, derive from studies of T cell homeostasis. The total cohort of T cells in an organism maintain homeostasis – a consistent total number of T cells in the peripheral blood. Transient elevations in peripheral blood T cell counts cause the whole population to diminish, transient depletions cause the whole population to proliferate, generally maintaining a roughly total T cell count. The latter situation –lymphodepletion– has been studied extensively and the proliferation of mature T cells upon transfer into the lymphopenic host is referred to as “lymphodepletion-induced” or “homeostatic” proliferation. It has been shown that homeostatic proliferation induces not only quantitative changes in T cell cohorts, but qualitative changes as well, such as increased function and the development of a memory-cell phenotype. The mechanism of these changes has been shown to be primarily due to upregulation of a group of cytokines including IL-7 and IL-15 induced by lymphodepletion. Additionally, lymphodepletion is a non-selective method of eliminating several known regulatory, or immunosuppressive, subsets of immune cells, such as regulatory T cells.
Clinical Trials Of T-Cell Adoptive Transfer.
These observations have prompted several clinical studies of infusing pathogen- or tumor-specific T cells into lymphodepleted patients. A group at the National Cancer Institute demonstrated remarkable efficacy by infusing melanoma-specific T cells (obtained by growing tumor-infiltrating T cells ex vivo) into melanoma patients treated with lymphodepleting chemotherapy. In a series of studies (to 2005) of this approach, up to 70% of treated patients were shown to have regressions of their tumors, many of which had been considerable in size and refractory to other therapies. These findings compare favorably with standard-of-care therapies for melanoma which generally lead to tumor regressions in only ~10-12% of patients.
Pre-Clinical Studies And Clinical Trials Of Vaccine-Primed T-Cell Adoptive Transfer (I.E. Immunotransplant).
Because of the logistic difficulty of obtaining tumor-specific T cells via the ex vivo expansion of tumor-infiltrating cells, a number of studies have examined inducing these cells in vivo by vaccination. Levitsky et al., at Johns Hopkins, in a series of pre-clinical studies demonstrated that vaccine-induced T cells could be considerably more effective when re-infused into lymphodepleted recipients. Subsequently, a clinical study in patients with multiple myeloma conducted by June et al., demonstrated that a standard vaccination against pneumonia could induce a T-cell-mediated response to the vaccine and that re-infusing these T cells after an extremely lymphodepletive therapy –autologous stem cell transplant – could significantly enhance that response.
To expand this immunotransplant concept to the amplification of anti-cancer immunity, researchers at Stanford University developed a pre-clinical lymphoma model using a in situ, CpG-base vaccine to induce anti-tumor immunity and demonstrated that this immunity was enhanced 10-40 fold by immunotransplant. The above studies by Levitsky et al., were an important precedent for this work. In fact the Hopkins published preliminary results of a clinical study testing the basic immunotransplant concept in acute myeloid leukemia demonstrating encouraging signals of enhanced anti-tumor immunity. To continue the clinical translation of this approach, in August 2009 the Stanford group initiated a phase I/II clinical trial for patients with newly diagnosed mantle cell lymphoma. That study uses a whole-cell, CpG-activated, autologous tumor vaccine to induce anti-tumor immunity followed by leukapheresis and re-infusion of the vaccine-primed cells immediately after standard autologous transplant. Initial results of this study were presented at the ASCO 2011 Annual Meeting showing successful data towards the primary endpoint: amplification of anti-tumor T-cell responses.


Exupere Joseph Bertin

Exupere Joseph Bertin (25 June 1712 – 21 February 1781) was a French anatomist born in Tremblay (Ille-et-Vilaine), Brittany. He was the father of cardiologist René-Joseph-Hyacinthe Bertin (1757-1828).
He served as regent of the "Académie Nationale de Médecine" in Paris and was "first physician" to the royal army. He is remembered for his research on the renal system. His best known written work is in the field of osteology, "Traité D'ostéologie" (1754, 4 volumes).
The columns of Bertin are named after him, as are "Bertin's ossicles" (sphenoidal conchae) and "Bertin's ligament" (iliofemoral ligament).
References.
"Biographical information based on an equivalent article at the French Wikipedia"


Group medical practice in the United States

Group medical practices practice medicine by physicians who share resources.
There are approximately 230,187 physician practices in the United States. Among the physician practices, 16.5% had only one office-based physician in 2016. Physician group practices with 2-4 physicians make up 22.3% of physician offices in the United States, 19.8% have 5-10 physicians, 12.1% have 11-24 physicians, 6.3% have 25–49, and the remaining 13.5% have 50 or more physicians.
In recent years, many small or solo practitioners have come together to form larger specialty groups because of managed care.
Formal definition.
The Centers for Medicare and Medicaid Services (CMS) changed the definition of "group practice" in its 2012 physician fee schedule to mean 25 or more eligible professionals in the same practice.


Richard Starke

Richard Karl Alfred Starke, (born June 18, 1960) is a Canadian politician who represented the electoral district of Vermilion-Lloydminster in the Alberta Legislature. Starke was elected to his first term as MLA for Vermilion-Lloydminster on April 23, 2012. Starke was appointed the minister for Tourism, Parks, and Recreation on February 4, 2013. He was not included in the Cabinet sworn in on September 15, 2014, but was appointed Chair of the Rural Health Services Review Committee on September 23, 2014. He is one of only two PC MLAs to be elected outside the city of Calgary in the 2015 provincial election.
Starke ran for the leadership of the Progressive Conservatives in 2017 but was decisively beaten by Jason Kenney who campaigned on a merger with the Wildrose Party. When the merger was approved by both party memberships, Starke was the only MLA from either party to not join the United Conservative Party caucus. Richard Starke is permitted to maintain his PC status in the legislature even though the party is no longer functioning.
Personal life.
Starke was born and raised in Edmonton. He and his wife, Alison, have two adult sons. They reside near Lloydminster, Alberta.
He coached speed skating.
Education and work.
Richard graduated from Queen Elizabeth High School in Edmonton and attended the University of Alberta Faculty of Agriculture and Forestry for his pre-vet studies. In 1979, he was accepted to the Western College of Veterinary Medicine at the University of Saskatchewan. He attained the degree of Doctor of Veterinary Medicine (with Distinction) in 1983.
He joined the Lloydminster Animal Hospital in 1983 and became an owner in 1985. He was also elected to the Lloydminster city council in 1985 and served two terms as alderman. While Richard was Senior Partner at the Lloydminster Animal Hospital, the practice received several awards:
A second practice, Companion Animal Care Centre, was opened in 2008 and received 2010 Lloydminster Chamber of Commerce Rookie Business of the Year Award winner. He sold both practices before running for politics in 2011.
Volunteer service.
Starke has served on a wide variety of professional, national, provincial, municipal, cultural, community service and sport committees. While he was on Lloydminster City Council he served on the Lloydminster Leisure Centre Building Committee and chaired the Barr Colony Heritage Cultural Centre Building Committee. He served on the Communications Committee of the Canadian Veterinary Medical Association, as well as the Public Relations, Economic, and Professional Review Committees of the Alberta Veterinary Medical Association. In 1992, he was a founding member of the Lloydminster German Heritage Society. He joined the Lloydminster Rotary Club in 1988 and was a Charter Member of the Border City Rotary Club, serving as President of that club in 2005. He served on the Lloydminster Region Health Foundation Board from 2002–11, the last two years as Board Chair. He served as Director of Coaching & Programs at the Lloydminster Border Blades Speed Skating Club, and on the Coaching Development Committee at Speed Skating Canada.


Tg-PVR mouse

Tg-PVR mouse is a transgenic mouse, developed at the Central Institute for Experimental Animals (CIEA), carrying the human poliovirus receptor (PVR) gene, to be used in testing the neurovirulence of oral polio vaccine (OPV). The neurovirulent safety and consistency of OPV had been traditionally assayed in the monkey neurovirulence test (MNVT), as only primates, including humans and monkeys, are susceptible to polioviruses. After the development of the Tg-PVR mouse, the suitability of the mouse to replace monkeys for OPV testing was evaluated and confirmed.


National Health Service

The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948 they have been funded out of general taxation. There are three systems which make up the "NHS" (NHS England, NHS Scotland and NHS Wales). Health and Social Care in Northern Ireland was created separately and although it does not use the name "NHS" it is still often to referred to as such, particularly in reference to the overall health system in the UK. The four systems (representing each national region) were established in 1948 as part of major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery—a health service based on clinical need, not ability to pay. Each service provides a comprehensive range of health services, free at the point of use for people ordinarily resident in the United Kingdom apart from dental treatment and optical care. In England, NHS patients have to pay prescription charges; some, such as those aged over 60 and certain state benefit recipients, are exempt.
Each of the United Kingdom’s health service systems operates independently and is politically accountable to the relevant government: the Scottish Government, Welsh Government, Northern Ireland Executive, and the UK Government, responsible for England's NHS. Since 2013 operational responsibility for the NHS in England has been passed to NHS England. NHS Wales was originally part of the same structure as that of England until powers over the NHS in Wales were first transferred to the Secretary of State for Wales in 1969 and thereafter, in 1999, to the Welsh Assembly as part of Welsh devolution. Some functions may be routinely performed by one health service on behalf of another. For example, Northern Ireland has no high-security psychiatric hospitals and depends on hospitals in Great Britain, routinely at Carstairs hospital in Scotland for male patients and Rampton Secure Hospital in England for female patients. Similarly, patients in north Wales use specialist facilities in Manchester and Liverpool which are much closer than facilities in Cardiff, and more routine services at the Countess of Chester Hospital. There have been issues about cross-border payments.
Taken together, the four National Health Services in 2015–2016 employed around 1.6 million people with a combined budget of £136.7 billion. In 2014, the total health sector workforce across the United Kingdom was 2,165,043. This broke down into 1,789,586 in England, 198,368 in Scotland, 110,292 in Wales and 66,797 in Northern Ireland. In 2017, there were 691,000 nurses registered in the United Kingdom, down 1,783 from the previous year. However, this is the first time nursing numbers have fallen since 2008. Every 24 hours it sees one million patients, and with 1.7 million staff it is the fifth biggest employer in the world, as well as the largest non-military public organisation in the world.
Although there has been increasing policy divergence between the four National Health Services in the United Kingdom, it can be difficult to find evidence of the effect of this on performance since, as Nick Timmins says: "Some of the key data needed to compare performance – including data on waiting times – is defined and collected differently in the four countries." Statistics released in December 2017 showed that, compared with 2012–2013, the number of patients in Scotland waiting more than four hours in accident and emergency dropped by 9% (from about 8% of all A&E patients to about 6%), whereas in England that proportion had increased by 155% (from less than 5% of all A&E patients to about 11%). However, since then, Scotland in common with the other three UK nations has experienced increasing pressure in Accident and Emergency departments with lengthening waiting times.
When purchasing drugs, the NHS has significant market power that, based on its own assessment of the fair value of the drugs, influences the global price, typically keeping prices lower. Several other countries either copy the United Kingdom’s model or directly rely on Britain’s assessments for their own decisions on state-financed drug reimbursements.
History.
Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909.
Somerville Hastings, President of the Socialist Medical Association, successfully proposed a resolution at the 1934 Labour Party Conference that the party should be committed to the establishment of a State Health Service.
Following the 1942 Beveridge Report's recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease", cross-party consensus emerged on introducing a National Health Service of some description. Conservative MP and Health Minister, Henry Willink later advanced this notion of a National Health Service in 1944 with his consultative White Paper "A National Health Service" which was circulated in full and short versions to colleagues, as well as in newsreel.
When Clement Attlee's Labour Party won the 1945 election he appointed Aneurin Bevan as Health Minister. Bevan then embarked upon what the official historian of the NHS, Charles Webster, called an "audacious campaign" to take charge of the form the NHS finally took. Bevan's National Health Service was proposed in Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's Public Health Services Act 1947. Charles Webster, official historian of the NHS, wrote in 2002 that "the Luftwaffe achieved in months what had defeated politicians and planners for at least two decades.
NHS Wales was split from NHS (England) in 1969 when control was passed to the Secretary of State for Wales before transferring to the Welsh Executive and Assembly under devolution in 1999.
The NHS was born out of the ideal that good healthcare should be available to all, regardless of wealth. Although being freely accessible regardless of wealth maintained Henry Willink's principle of free healthcare for all, Conservative MPs were in favour of maintaining local administration of the NHS through existing arrangements with local authorities fearing that an NHS which owned hospitals on a national scale would lose the personal relationship between doctor and patient.
Conservative MPs voted in favour of their amendment to Bevan's Bill to maintain local control and ownership of hospitals and against Bevan's plan for national ownership of all hospitals. The Labour government defeated Conservative amendments and went ahead with the NHS as it remains today; a single large national organisation (with devolved equivalents) which forced the transfer of ownership of hospitals from local authorities and charities to the new NHS. Bevan's principle of ownership with no private sector involvement has since been diluted, with later Labour governments implementing large scale financing arrangements with private builders in private finance initiatives and joint ventures.
At its launch by Bevan on 5 July 1948 it had at its heart three core principles: That it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay.
Three years after the founding of the NHS, Bevan resigned from the Labour government in opposition to the introduction of charges for the provision of dentures, dentists, and glasses. The following year, Winston Churchill's Conservative government introduced prescription fees. These charges were the first of many controversies over reforms to the NHS throughout its history.
From its earliest days, the cultural history of the NHS has shown its place in British society reflected and debated in film, TV, cartoons and literature. The NHS had a prominent slot during the directed by Danny Boyle, being described as "the institution which more than any other unites our nation".
Eligibility for treatment.
UK residents are not charged for most medical treatment, though NHS dentistry does have standard charges in each of the four national health services in the UK. In addition, most patients in England have to pay charges for prescriptions though some are exempted.
Aneurin Bevan, in considering the provision of NHS services to overseas visitors wrote, in 1952, that it would be "unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody."
The provision of free treatment to non-UK-residents, formerly interpreted liberally, has been increasingly restricted, with new overseas visitor hospital charging regulations introduced in 2015.
Citizens of the EU holding a valid European Health Insurance Card and persons from certain other countries with which the UK has reciprocal arrangements concerning health care can get emergency treatment without charge.
The NHS is free at the point of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents. People with the right to medical care in European Economic Area (EEA) nations are also entitled to free treatment by using the European Health Insurance Card. Those from other countries with which the UK has reciprocal arrangements also qualify for free treatment. Since 6 April 2015, non-EEA nationals who are subject to immigration control must have the immigration status of indefinite leave to remain at the time of treatment and be properly settled, to be considered ordinarily resident. People not ordinarily resident in the UK are in general not entitled to free hospital treatment, with some exceptions such as refugees.
People not ordinarily resident may be subject to an interview to establish their eligibility, which must be resolved before non-emergency treatment can commence. Patients who do not qualify for free treatment are asked to pay in advance or to sign a written undertaking to pay, except for emergency treatment.
People from outside the EEA coming to the UK for a temporary stay of more than six months are required to pay an immigration health surcharge at the time of visa application, and will then be entitled to NHS treatment on the same basis as a resident. This includes overseas students with a visa to study at a recognised institution for 6 months or more, but not visitors on a tourist visa. In 2016 the surcharge was £200 per year, with exemptions and reductions in some cases. This was increased to £400 in 2018. The discounted rate for students and those on the Youth Mobility Scheme will increase from £150 to £300.
From 15 January 2007, anyone who is working outside the UK as a missionary for an organisation with its principal place of business in the UK is fully exempt from NHS charges for services that would normally be provided free of charge to those resident in the UK. This is regardless of whether they derive a salary or wage from the organisation, or receive any type of funding or assistance from the organisation for the purposes of working overseas. This is in recognition of the fact that most missionaries would be unable to afford private health care and those working in developing countries should not effectively be penalised for their contribution to development and other work.
Those who are not ordinarily resident (including British citizens who may have paid National Insurance contributions in the past) are liable to charges for services.
There are some other categories of people who are exempt from the residence requirements such as specific government workers and those in the armed forces stationed overseas.
Historic issues.
The trade union, Unite, said back in early 2019 that the NHS had been under pressure as a result of economic austerity. A 2018 public survey reported that public satisfaction with the NHS has fallen from 70% in 2010 to 53% in 2018. The NHS is consistently ranked as the institution that makes people proudest to be British, beating the Royal family, Armed Forces and the BBC. NHS staff – particularly pharmacists, nurses and doctors – are the most trusted professions in Britain.
Funding.
The systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services. About 10% of GDP is spent on health and most is spent in the public sector. The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 per person in the UK.
When the NHS was launched in 1948 it had a budget of £437 million (equivalent to £ billion in ). In 2016–2017, the budget was £122.5 billion. In 1955/6 health spending was 11.2% of the public services budget. In 2015/16 it was 29.7%. This equates to an average rise in spending over the full 60-year period of about 4% a year once inflation has been taken into account. Under the Blair government spending levels increased by around 6% a year on average. Since 2010 spending growth has been constrained to just over 1% a year.
Some 60% of the NHS budget is used to pay staff. A further 20% pays for drugs and other supplies, with the remaining 20% split between buildings, equipment, training costs, medical equipment, catering and cleaning. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas. Since 2010, there has been a cap of 1% on pay rises for staff continuing in the same role. Unions representing doctors, dentists, nurses and other health professionals have called on the government to end the cap on health service pay, claiming the cap is damaging the health service and damaging patient care. The pay rise is likely to be below the level of inflation and to mean a real-terms pay cut.
The House of Commons Library did research showing that real-terms NHS funding per head will fall in 2018–19, and stay the same for two years afterwards.
There appears to be support for higher taxation to pay for extra spending on the NHS as an opinion poll in 2016 showed that 70% of people were willing to pay an extra penny in the pound in income tax if the money were ringfenced and guaranteed for the NHS. Two thirds of respondents to a King's Fund poll favour increased taxation to help finance the NHS.
"The Guardian" has said that GPs face excessive workloads throughout Britain and that this puts the GP's health and that of their patients at risk. The Royal College of Physicians surveyed doctors across the UK, with two-thirds maintaining patient safety had deteriorated during the year to 2018: 80% feared they would be unable to provide safe patient care in the coming year while 84% felt increased pressure on the NHS was demoralising the workforce. Jane Dacre said, “We simply cannot go through this [a winter when the NHS is badly overstretched] again. It is not as if the situation was either new or unexpected. As the NHS reaches 70, our patients deserve better. Somehow, we need to move faster towards a better resourced, adequately staffed NHS during 2018 or it will happen again.” At a time when the NHS is short of doctors foreign doctors are forced to leave the UK due to visa restrictions. A study found that a fifth of doctors had faced bullying from seniors in the previous year due to pressure at work.
The NHS is under-resourced compared to health provisions in other developed nations. A King’s Fund study of OECD data from 21 nations, revealed that the NHS has among the lowest numbers of doctors, nurses and hospital beds per capita in the western world. Nurses within the NHS maintain that patient care is compromised by the shortage of nurses and the lack of experienced nurses with the necessary qualifications. According to a YouGov poll, 74 percent of the UK public believes there are too few nurses. The NHS performs below average in preventing deaths from cancer, strokes and heart disease. Staff shortages at histology departments are delaying diagnosis and start of treatment for cancer patients. In England and Scotland cancer wards and children's wards have to close because the hospital cannot attract sufficient qualified doctors and nurses to run the wards safely. Cancer patients and child patients are having to travel very long distances to get treatment and their relatives must travel far to visit the patients. In wards which have not closed staff sometimes work under stress due to staff shortages. Brexit is likely to aggravate these problems. Due to the shortage of nurses the NHS is relying on less qualified staff like healthcare assistants and nursing associates.
Cancer survival rates in the UK have been rising fast but probably still lag behind the best results internationally, mainly because of late diagnosis. However death rates from breast cancer are falling faster in Britain than in any other of the six largest countries in Europe, and are estimated now to have improved beyond the European average. According to Breast Cancer Care 72% of NHS trusts across the UK do not provide dedicated specialist nurses for patients with incurable breast cancer." Cancer Research UK maintains more NHS cancer personnel are needed to enable the UK to catch up The NHS in England is expanding early diagnosis services with the goal of increasing the proportion of cancers diagnosed early (at stages 1 and 2) from 53% to 75% in the decade to 2028. The NHS was the first health service in Europe to negotiate coverage for novel CAR-T cancer therapy, with agreement reached within 10 days of its European marketing authorisation.
In 2018, British Prime Minister Theresa May announced that NHS in England would receive a 3.4% increase in funding every year to 2024, which would allow it to receive an extra £20bn a year in real terms funding. There is concern that a high proportion of this money will go to service NHS debts rather than for improved patient care. There are calls for the government to write off the NHS debt. Saffron Cordery of NHS Providers said that hospitals needed help to do their work without being up in deficit, as two-thirds were in the year to 2018. Some expressed doubt over whether May could carry out this proposed increase in funding. The next day, Health Secretary Jeremy Hunt backed the extra £20bn annual increase in NHS funding and responded to criticism by stating that taxation would be used to carry out the funding and that details would be revealed when the next budget is unveiled in November.
The Institute for Fiscal Studies has stated a 5% real-terms increase was needed for real change. Paul Johnson of the IFS said the 3.4% was greater than recent increases, but less than the long-term average. Health experts maintain the money will "help stem further decline in the health service, but it's simply not enough to address the fundamental challenges facing the NHS, or fund essential improvements to services that are flagging." Inflation may erode the real value of this funding increase.
As part of the 2018 funding increase the government asked the NHS to produce a 10-year plan as to how this funding would be used. On 7 January 2019, the NHS England published the NHS Long Term Plan.
Staffing.
The United Kingdom's exit from the European Union will affect physicians from EU countries, about 11% of the physician workforce. Many of these physicians are considering leaving the UK if Brexit happens, as they have doubts that they and their families can live in the country. A survey suggests 60% are considering leaving. Record numbers of EU nationals (17,197 EU staff working in the NHS which include nurses and doctors) left in 2016. The figures, put together by NHS Digital, led to calls to reassure European workers over their future in the UK.
In June 2018, the Royal College of Physicians calculated that medical training places need to be increased from 7,500 to 15,000 by 2030 to take account of part-time working among other factors. At that time there were 47,800 consultants working in the UK of which 15,700 were physicians. About 20% of consultants work less than full-time.
A study by the Centre for Progressive Policy called for NHS trusts to become “exemplar employers” by improving social mobility and pay especially for those "trusts in poorer places where they can play a particularly large role in determining the economic wellbeing of the local population.” They found the NHS to be " a middle ranking employer in comparison to other large organisations and falls short on social mobility and the real Living Wage", and ranked trusts using a ‘good employer index’. Ambulance trusts were ranked worst.
Performance.
A 2018 study by the King's Fund, Health Foundation, Nuffield Trust, and the Institute for Fiscal Studies to mark the NHS 70th anniversary concluded that the main weakness of the NHS was healthcare outcomes. Mortality for cancer, heart attacks and stroke, was higher than average among comparable countries. The NHS was doing well at protecting people from heavy financial costs when ill. Waiting times were about the same, and the management of longterm illness was better than in other comparable countries. Efficiency was good, with low administrative costs and high use of cheaper generic medicines. Twenty-nine hospital trusts and boards out of 157 had not met any waiting-time target in the year 2017–2018. The Office for National Statistics reported in January 2019 that productivity in the English NHS had been growing at 3%, considerably faster than across the rest of the UK economy.
Over 130,000 deaths since 2012 in the UK could have been prevented if progress in public health policy had not stopped due to austerity, analysis by the Institute for Public Policy Research found. Dean Hochlaf of the IPPR said, "We have seen progress in reducing preventable disease flatline since 2012.""
British exit from the European Union.
There is concern that a disorderly Brexit may compromise patients' access to vital medicines. In February 2018 many medical organisations were planning for a worst-case Brexit scenario because "time is running out" for a transition deal to follow the UK’s formal exit, scheduled for March 2019. Pharmaceutical organisations working with the Civil Service to keep medicine supplies available in the case of a no-deal Brexit had to sign 26 Non-Disclosure Agreements (NDAs) to prevent them from giving the public information. The figures were given on 21 December 2018 after Rushanara Ali asked a parliamentary question. Ali said, "It is utterly unacceptable for the government to use non-disclosure agreements with pharmaceutical businesses and trade associations. By effectively ‘gagging’ these organisations, these secretive agreements are preventing essential information from being shared, are undermining transparency and are hampering businesses’ ability to speak out." As negotiations continue between the UK and the EU as of 1 January 2021, vulnerable people needing treatment when working, living or travelling to the UK may lose out by not having access to NHS Care.
Rising social care costs.
Social care will cost more in future according to research by Liverpool University, University College London, and others and higher investment are needed. Professor Helen Stokes-Lampard of the Royal College of GPs said, “It’s a great testament to medical research, and the NHS, that we are living longer – but we need to ensure that our patients are living longer with a good quality of life. For this to happen we need a properly funded, properly staffed health and social care sector with general practice, hospitals and social care all working together – and all communicating well with each other, in the best interests of delivering safe care to all our patients.”
Mental health.
Some patients have to wait excessively long for mental health care. The Royal College of Psychiatrists found some must wait up to thirteen months for the right care. Wendy Burn of the Royal College of Psychiatrists said, “It is a scandal that patients are waiting so long for treatment. The failure to give people with mental illnesses the prompt help they need is ruining their lives.” Even patients who are suicidal or who have attempted suicide are sometimes denied treatment; patients are told they are not ill enough or waiting lists are too long. During very long waits for treatment, one in three patients deteriorate, and they may become unemployed or get divorced. One in four patients throughout the UK wait over three months to see an NHS mental health professional, with 6% waiting at least a year.
The National Audit Office found mental health provisions for children and young people will not meet growing demand, despite promises of increased funding. Even if promises to provide £1.4bn more for the sector are kept, there will be “significant unmet need” due to staff shortages, inadequate data and failure to control spending by NHS clinical commissioning groups. Currently one-quarter of young people needing mental health services can get NHS help. The Department of Health and Social Care hopes to raise the ratio to 35%. Efforts to improve mental health provisions could reveal previously unmet demand.
Meg Hillier of the select committee on public accounts said, “The government currently estimates that less than a third of children and young people with a diagnosable mental health condition are receiving treatment. But the government doesn’t understand how many children and young people are in need of treatment or how funding is being spent locally. The government urgently needs to set out how departments, and national and local bodies, are going to work together to achieve its long-term ambition.” Amyas Morse said, “Current targets to improve care are modest and even if met would still mean two-thirds of those who need help are not seen. Rising estimates of demand may indicate that the government is even further away than it thought.”
In response, NHS England has embarked on a major programme to expand mental health services, whose budgets are now growing faster than the NHS overall. MIND the mental health charity responded saying: "We are pleased that the plan includes a commitment of £2.3bn a year towards mental health, to help redress the balance. The plan promises that this money will see around two million more people with anxiety, depression and other mental health problems receive help, including new parents, and 24 hour access to crisis care. The plan also includes a guarantee that investment in primary, community and mental health care will grow faster than the growing overall NHS budget so that different parts of the NHS come together to provide better, joined-up care in partnership with local government. Since the funding announcement in the summer, Mind has been working with the NHS, Government and voluntary sector to help shape the long term plan. This longer-term strategy was developed in consultation with people with mental health problems to ensure their views are reflected."
Surgery.
Waiting times for routine surgery have fallen substantially since 2000. As of July 2019, the median wait for planned care in England is under 8 weeks. The number of people waiting over 12 months has fallen from over 200,000 in the 1980s to under 2000 in 2019. However the number of patients on the waiting list has risen recently as constrained funding, hospital beds and staffing growth has not kept up with increasing patient need.
Electronic systems.
Twenty-one different electronic systems are used in the NHS to record data on patients. These systems do not communicate well with each other so there is a risk doctors treating a patient will not know everything they need to know to treat the patient effectively. There were 11 million patient interactions out of 121 million where information from a previous visit could not be accessed. Half the Trusts using Electronic Medical Records used one of three systems and at least those three should be able to share information. A tenth of Trusts used multiple systems in the same hospital. Leigh Warren who participated in the research said, "Hospitals and GPs often don't have the right information about the right patient in the right place at the right time. This can lead to errors and accidents that can threaten patients' lives."
Sale of data.
Information on millions of NHS patients was sold to international pharmaceutical companies, in the US and other nations for research, adding to concerns over USA ambitions to access remunerative parts of the NHS after Brexit. There is concern over lack of transparency and clarity over the data and how it is used. Phil Booth of medConfidential , campaigning for privacy of health data said, “Patients should know how their data is used. There should be no surprises. While legitimate research for public health benefit is to be encouraged, it must always be consensual, safe and properly transparent. Do patients know – have they even been told by the one in seven GP practices across England that pass on their clinical details – that their medical histories are being sold to multinational pharma companies in the US and around the world?”
Medicines.
In November 2019 unprecedented shortages of medicines patients need developed. Drugs to treat cancer, heart disease, Parkinson's disease, mental health conditions, some eye conditions, antibiotics for tuberculosis and drugs to control epilepsy are among those in short supply. Life saving drugs will have to be rationed and not all patients who need them will get them. Some patients can be switched onto other drugs, though this may increase the workload of hard-pressed medical staff; other patients cannot be switched to alternative drugs. Many problems can impact the supply chain, like IT failure, speculators stockpiling drugs, alterations in regulation and sudden disease outbreaks. Tony O’Sullivan of Keep Our NHS Public said, “The Health Department’s guidance includes an unprecedented list of drugs unavailable or in short supply. Patients and clinicians alike should be on high alert when the advice includes how to ‘share stocks’ to make them last, to ‘prioritise’ patients already on specific treatments including cancer rather than a new patient and effectively how to ration so many vital drugs. Drug companies’ behaviour must be controlled. We must urgently protect the NHS from further risks of loss of control of drug prices and supplies from trade deals with the US and that requires returning it to a wholly public service.”
Whistleblowing.
In an independent review in 2016 by Robert Francis, it was concluded that some staff felt unable or unwilling to raise concerns about standards of care due to fear or low expectations, and that some staff who raised concerns had bad experiences and suffered unjustifiable consequences which the report described as "shocking". There is a culture of bullying towards those who raise concerns. This response may consist of placing the whistleblower on performance review, providing no assistance to them, starting a review process that can take months or years, possibly leading to mental health problems, and bullying and victimisation by other staff. This process rarely ended with being redeployed in an organisation, instead resulting in retirement, dismissal, or alternative employment.
An issue identified by the report was the use of "gagging clauses" involved in settlements surrounding the termination of employment of those who whistleblow. While the report found that all the contracts were legal, it noted that the language used was often complicated and legalistic, a culture of fear deterred public interest disclosures even when they were not in breach of contract, and that the terms were often unnecessarily restrictive, for examle by making the existence of the agreement confidential.
Surgeon Peter Duffy wrote about his experiences of whistleblowing following an avoidable death in an independently published book, "Whistle In the Wind".
Role in combating coronavirus pandemic.
In 2020, the NHS issued medical advice in combating COVID-19 and partnered with tech companies to create computer dashboards to help combat the nation's coronavirus pandemic. During the pandemic, the NHS also established integrated COVID into its 1-1-1 service line as well. Following his discharge from the St. Thomas' Hospital in London on 13 April 2020 after being diagnosed with COVID-19, British Prime Minister Boris Johnson described NHS medical care as "astonishing" and that "NHS saved my life. No question." In this time, the NHS underwent major re-organisation to prepare for the COVID-19 pandemic
Hospital beds.
In 2015, the UK had 2.6 hospital beds per 1,000 people. In September 2017, the King's Fund documented the number of NHS hospital beds in England as 142,000, describing this as less than 50% of the number 30 years previously. In 2019 one tenth of the beds in the UK were occupied by a patient who was alcohol-dependent.
NHS Music releases.
NHS charity songs under various choir names have become a tradition (usually at Christmas time but not necessarily) and various formation carrying the name of NHS have released singles including:
See also.
General: