Going onto European Time - a public good

It is encouraging that another attempt is being made to change the British time zone so as to increase our use of daylight. It will save energy and reduce road accidents at virtually no cost.

When this was last considered in 2007 I wrote to Sir David King the Scientific Adviser to the Lbour Government as follows:
Dear David
It was good to talk to you - albeit briefly.
You asked for more information on the use of Double Summer Time,  particularly as a virtually cost-free method of saving energy. It was used for this purpose in the Second World War (when we were effectively what is now European time) and a trial of just keeping single summer time throughout the year was performed in the UK in 1968 - 1971. The extent of energy saving seems not to be exactly known (at least to me) but the figure of 1% of electricity use is bandied about. That is not an entirely trivial amount. Just think how many wind turbines would be needed to do that - and how much they would cost (in energy as well as money) to build.

It is beyond question that at most times of year except in the two months round the winter solstice, hours of daylight in the early morning are exploited by fewer people than hours of daylight in the evening because we rise and go to sleep according to clock time and not according to sunlight hours. Therefore putting the clocks forward must - and does - reduce energy use. Some people dislike the idea of changing the clocks at all but we are, in any event, committed to this by European directive. So it is only the "time zone" that is in question.

There is also substantial evidence that road accidents are reduced by the change in spite of the fact that some newspapers campaigned shamelessly in 1968-71 by showing pictures of children involved in morning road accidents. Those not involved in the evenings cannot of course be pictured. ROSPA is convinced that the net effect is accident reduction.

I append for you a link to a debate in the House of Lords this spring where Lord Tanlaw proposed to reintroduce "Double summer time".  To its shame our (your!) government failed to support the bill and to provide the time for it to be enacted. The Scots are apparently hostile to the idea but now there is devolution they could keep their own time zone and there could then be a proper, controlled trial measuring both energy use and accidents.

I also append some extracts from a web-site giving some US data and an article which gives both sides of the arguments from the student British Medical Journal which is referenced.

I hope you can persuade Ministers that this is really will save some energy and cost nothing - and that you will persuade them to get the Tanlaw bill through parliament this session!

Best wishes

Yours ever

Peter










This year's debate in the House of Lords

http://www.theyworkforyou.com/lords/?id=2006-03-24b.459.0

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However, Daylight Saving Time does save energy. Studies done by the U.S. Department of Transportation show that Daylight Saving Time trims the entire country's electricity usage by a small but significant amount, about one percent each day, because less electricity is used for lighting and appliances. Similarly, in New Zealand, power companies have found that power usage decreases 3.5 percent when daylight saving starts. In the first week, peak evening consumption commonly drops around five percent.

Energy use and the demand for electricity for lighting homes is directly related to the times when people go to bed at night and rise in the morning. In the average home, 25 percent of electricity is used for lighting and small appliances, such as TVs, VCRs, and stereos. A good percentage of energy consumed by lighting and appliances occurs in the evening when families are home. By moving the clock ahead one hour, the amount of electricity consumed each day decreases.

In the summer, people who rise before the sun rises use more energy in the morning than if DST was not in effect. However, although 70 percent of Americans rise before 7:00 a.m., this waste of energy from having less sunlight in the morning is more than offset by the savings of energy that results from more sunlight in the evening.

In the winter, the afternoon Daylight Saving Time advantage is offset for many people and businesses by the morning's need for more lighting. In spring and fall, the advantage is generally less than one hour. So, Daylight Saving Time saves energy for lighting in all seasons of the year, but it saves least during the four darkest months of winter (November, December, January, and February), when the afternoon advantage is offset by the need for lighting because of late sunrise.

In addition, less electricity is used because people are home fewer hours during the "longer" days of spring and summer. Most people plan outdoor activities in the extra daylight hours. When people are not at home, they don't turn on the appliances and lights.

There is a public health benefit to Daylight Saving Time, as it decreases traffic accidents. Several studies in the U.S. and Great Britain have found that the DST daylight shift reduces net traffic accidents and fatalities by close to one percent. An increase in accidents in the dark mornings is more than offset by the evening decrease in accidents.

Oil Conservation
Following the 1973 oil embargo, the U.S. Congress extended Daylight Saving Time to 8 months, rather than the normal six months. During that time, the U.S. Department of Transportation found that observing Daylight Saving Time in March and April saved the equivalent in energy of 10,000 barrels of oil each day - a total of 600,000 barrels in each of those two years.
Likewise, in 1986, Daylight Saving Time moved from the last Sunday in April to the first Sunday in April. No change was made to the ending date of the last Sunday in October. Adding the entire month of April to Daylight Saving Time is estimated to save the U.S. about 300,000 barrels of oil each year.

from:http://webexhibits.org/daylightsaving/c.html
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Clockwatching

Impress your mates at the pub with your startling repertoire of esoteric medical knowledge


What happens this year on 26 March in Europe, is delayed until 2 April in America, but doesn't occur in Japan at all? Well, in those countries taking part, it's time to turn the clocks forward one hour, marking the start of daylight saving time (DST), or summer time as it's also known. Now you might groan about losing valuable minutes for partying, studying, or sleeping (your priorities changing as you progress through the course), but are there any tangible benefits to this annual ritual? And what about the health implications of daylight saving that don't often get a mention?

Origins

Benjamin Franklin came up with the bright idea in 1784, to make better use of daylight and so reduce the amount of money wasted on candles in 18th century Paris.^w1 By having the population rise at dawn and go to bed at sunset, as well as rationing candle sales and putting a tax on houses with shutters, he estimated (not entirely seriously) that anywhere between �150m and �400m in today's money could be saved.

The idea didn't resurface until 1907 when a London builder, William Willett, advocated advancing the clocks by 20 minutes on each Sunday in April and reversing the process in September.^w2 It found limited support until the first world war, when Britain, Germany, and other countries adopted daylight saving in 1916 to boost wartime production and save coal. The US followed suit for seven months in 1918, but public opposition led to Congress overriding the measure against the wishes of President Woodrow Wilson�it wasn't until the second world war that Franklin Roosevelt introduced it again across America. At the same time in the UK, political enthusiasm for the energy savings associated with DST led to the introduction of double summer time for the duration of the war, whereby the clocks were advanced two hours ahead of Greenwich Mean Time (GMT) in the summer and stayed an hour ahead of GMT for the rest of the year.

Fast-forward to today, and roughly 70 countries have daylight saving time, although when it starts, how long it lasts and how much of each country is affected varies widely.

Benefits
Accident reduction
A reduction in fatal road traffic accidents is often cited as the major public health benefit of daylight saving time. When Great Britain experimented with maintaining DST all year round between 1968 and 1971, it's thought about 2,500 fewer people were killed or seriously injured during the first two winters of the trial�the equivalent of an 11.7% reduction in casualties for the whole country. Although morning casualties increased, the number was far outweighed by the drop in casualties in the longer evenings.^w3 Smaller studies in the UK have confirmed this trend, with improvements in safety primarily for pedestrians, cyclists, and school children.^{w4 w5} More recently, the Royal Society for the Prevention of Accidents has estimated that 450 deaths and serious injuries occur during the five months of the year when DST is not in operation in the UK.^w6 In the US, the Insurance Institute for Highway Safety estimated that 901 fatal crashes could have been prevented over the years 1987-91 if DST had been retained year round due to the availability of an extra hour of daylight for the busier evening traffic rush.^w7
Unfortunately �unambiguous� and �evidence� rarely go together. The three year British trial of DST coincided with the introduction of random breath testing and new speed limits�powerful incentives for drivers to improve their behaviour regardless of how bright the evening is. Studies have shown an increase in road accidents during the first few days of DST (by as much as 8%)^w8 and unexpectedly following the end of DST^w9 which are attributed diversely to loss of an hour's sleep, alcohol, fatigue, and the fact that the early morning period is intrinsically risky.

Energy savings
Just as importantly for the planet, using daylight more efficiently could mean modest but significant energy savings and reduced pollution. As a result of the Arab oil embargo in the 1970s, the US Congress experimented with extended DST for two years (18 months over that period instead of the normal 12).

When the US Department of Transport evaluated the effectiveness of the trial, it found that roughly 100000 barrels of oil were saved daily in March and April of 1974 and 1975 by having DST.^w10 Extending this finding, energy stricken California estimates that an extension of DST for the winter months could reduce electricity use by 0.5%.^w11 These savings are mainly due to reduced domestic consumption thanks to the extra hour of daylight in the evenings.

However, before we rush to adjust our clocks, a senior official in the US Department of Transport recently
sounded a note of caution: �There have been dramatic changes in lifestyle and commerce since we completed our studies that raise serious questions about extrapolating conclusions from our studies into today's world.�^w10
She emphasised that their work is over 25 years old, was limited in scope, and has had its methods questioned (for example, failing to consider that reduced electricity use could be offset by increased petrol consumption owing to extra evening travel)^w12�so we haven't found an alternative to Kyoto just yet.

General wellbeing
Claims have been made that brighter evenings would increase our exposure to daylight and encourage outdoor activity, fitness and health. Supporters of extended DST also maintain that more time spent in the sunlight would reduce vitamin D deficiencies, especially in children and elderly people, and help people with depression^w13 and seasonal affective disorder (SAD)�a specific type of depression believed to be related to reduced exposure to sunlight.^w14 As low vitamin D levels are a problem for 6-18% of the elderly US population,^w15 rocketing to 57% of the general inpatient population,^w16 and with anywhere up to 500000 suffering from SAD in the UK alone,^w17 the public health benefits of DST could be far-reaching but have not been proved.

Exceptions to benefits

Nevertheless, although we might agree that all these �benefits are worth while, our bodies beg to differ when actually faced with the change. Circadian rhythms, our own biological clocks, regulate behavioural and physiological processes and are synchronised by the daily light-dark cycle. Changing over to DST in the spring is thought to upset this cycle in healthy adults who get less than eight hours sleep (most medics) or are more active in the evenings,^w18 and disruption is also seen for five days after DST ends.^w19 Those few transition days are particularly difficult for anyone with depression20 as well as teenagers and adolescents, whose body clocks are already poorly synchronised to daylight thanks to delayed secretion of melatonin, the body's �sleepiness� hormone.^w21 All in all, the only ones enjoying changeover day itself will probably be those irritating individuals who have never missed a night's sleep and finish a day's work before the rest of us are even out of bed, but, to quote Oscar Wilde, �Only dull people are brilliant at breakfast.�

Conclusion

Despite mixed reports, governments look set to continue tinkering with the issue. George Bush, mindful of his country's addiction to oil, has extended DST in the US by a month, starting in 2007. In the UK, frustrated by a decade of government dithering, the Royal Society for the Prevention of Accidents has called for DST to be in place throughout the winter, with double summer time from March to October (two hours ahead of GMT); a throwback to the war years, this would have the effect of abolishing GMT, putting the UK in the same time zone as western Europe.^w14 While some will be quick to criticise any possibility of change, a chance that hundreds of road traffic accidents could be prevented means that the plans deserve a fair hearing at the very least; whether they will be implemented is a different matter.

Thomas Mac Mahon , intercalating medical student, University College Dublin, IrelandEmail: tmacmahon@gmail.com


studentBMJ 2006;14:133 - 176 April ISSN 0966-6494

1. Franklin, B., "An Economical Project: Daylight Saving." A letter to the editor of the Journal de Paris April 26, 1784 http://webexhibits.org/daylightsaving/franklin3.html (accessed February 10, 2006)
2. Franklin, B., "An Economical Project: Daylight Saving." A letter to the editor of the Journal de Paris April 26, 1784 http://webexhibits.org/daylightsaving/franklin3.html (accessed February 10, 2006)
3. Home Office, "Review of British Standard Time," Cmnd 4512: HMSO, 1970
4. Whittaker, J.D., "An investigation into the effects of British Summer Time on road traffic accident casualties in Cheshire," J Accid Emerg Med 13 (1996): 189-92
5. Adams, J., White, M., Heywood, P., "Year-round daylight saving and serious or fatal road traffic injuries in children in the north-east of England," J Public Health (Oxf) 27 (2005): 316-7
6. Royal Society for the Prevention of Accidents. Lighter Evenings: RoSPA summertime briefing. Birmingham, 2005 http://www.rospa.com/roadsafety/info/summertime_briefing.pdf (accessed February 10, 2006)
7. Ferguson, S.A., et al., "Daylight saving time and motor vehicle crashes: the reduction in pedestrian and vehicle occupant fatalities," Am J Public Health 85 (1995): 92-5
8. Coren, S., "Accidental death and the shift to daylight savings time," Percept Motor Skills 83 (1996): 921-2
9. Varughese, J., Allen, R.P., "Fatal accidents following changes in daylight savings time: the American experience," Sleep Med 2 (2001): 31-6
10. U.S. Department of Transportation. The Daylight Saving Time study. A report to Congress. Washington, GPO, 1975. Cited by: L.L. Lawson, Acting Deputy Assistant Secretary for Transportation Policy, appearing before the House Science Committee, Energy Subcommittee, concerning daylight saving time and energy conservation, May 24, 2001 http://www.house.gov/science/energy/may24/lawson.htm (accessed February 10, 2006)
11. Kandel, A., Metz, D., "Effects of Daylight Saving Time on California Electricity Use," California Energy Commission, May 2001 http://www.energy.ca.gov/reports/2001-05-23_400-01-013.PDF (accessed February 10, 2006)
12. Tellier-Beauregard, F., "PRB 05-18E Daylight saving time and energy conservation," Parliamentary Research and Information Service, Parliament of Canada. July 29, 2005 http://www.parl.gc.ca/information/library/PRBpubs/prb0518-e.htm#2txt (accessed February 10, 2006)
13. Olders, H., "Average sunrise time predicts depression prevalence," J Psychosom Res 55 (2003): 99-105
14. Royal Society for the Prevention of Accidents. Single/Double Summer Time: Position Paper. Birmingham, 2003 (updated 2005). http://www.rospa.com/roadsafety/info/summertime_paper.pdf (accessed February 10, 2006)
15. http://whqlibdoc.who.int/publications/2004/9241546123_chap3.pdf (accessed February 10, 2006)
16. Thomas, M.K., et al., "Hypovitaminosis D in medical inpatients," N Engl J Med 338 (1998): 777-83
17. Seasonal Affective Disorder Association http://www.sada.org.uk/ (accessed February 10, 2006)
18. Lahti, T.A., et al., "Transition into daylight saving time influences the fragmentation of the rest-activity cycle," J Circadian Rhythms 19 (2006): 1 [Epub ahead of print]
19. Monk, T.H., Folkard, S., "Adjusting to the changes to and from Daylight Saving Time," Nature 261 (1976): 688-9
20. Bunney, W.E., Bunney, B.G., "Molecular clock genes in man and lower animals: possible implications for circadian abnormalities in depression," Neuropsychopharmacology 22 (2000): 335-45
21. Carskadon, M.A., et al., "Regulation of adolescent sleep: implications for behaviour," Ann N Y Acad Sci 1021 (2004): 276-91

from: http://www.studentbmj.com/issues/06/04/education/144.php

Further letter to Mr Lansley

	UNIVERSITY OF CAMBRIDGE Sir Peter J Lachmann FRS FMedSci Emeritus Sheila Joan Smith Professor of Immunology	Department of Veterinary Medicine Madingley Road Cambridge CB3 0ES Telephone:  01223 766242
		Secretary:   01223 766242 Fax:            01223 766244 e-mail:        pjl1000@cam.ac.uk

8  November 2010

Rt  Hon  Andrew Lansley CBE MP,

Department of Health

Richmond House

79 Whitehall

London SW1A 2NS

Dear Andrew (if I may),

Thank you very much for your detailed and constructive response to my letter to you.  I have read the various points you raised with considerable interest and I am delighted to see that the Department is taking the issues raised seriously.

 I fully appreciate that if drugs are to be introduced at the end of Phase 2 - as I suggested, initially on a voluntary basis and subject to the patients giving indemnity -  this  may well require Phase 2 trials to be modified in order to provide  satisfactory evidence of efficacy and lack of common adverse effects.  However most clinical trials on the optimal use of drugs already take place after drugs have been licensed and the ethical problems of using a placebo when a drug with some efficacy is already available applies equally to pre-registration and post-registration trials. 

I am much encouraged by your telling me that MHRA is developing a scheme to make some promising new drugs available earlier. I was also pleased to see a report that MHRA are to propose changes to the regulation of Biosimilars. The requirement that a new therapeutic antibody of the same class and subclass and with the identical specificity as an existing licensed antibody still has to go through a full programme of clinical trials before registration has always seemed quite excessive and certainly contributes to the high cost that even antibodies that have been used on many tens of thousands of patients (such as anti-TNF antibodies) still command. A third encouraging development is the issue by the FDA of a call for robust surrogate markers for use in place of outcome measures in pre-licensing trials.

However I would like to remind your colleagues in the Department of Health of Francis Cornford’s famous aphorism from the Microcosmographia Academica:  “there is only one reason for doing something the others are all reasons for doing nothing”.  

Getting drugs into use much more rapidly and much more cheaply is a categorical imperative if health services for the whole population are to survive at all.  Among the responses I have received to the letter I wrote to you is one from a colleague with a close connection to a large pharmaceutical company who tells me that the most recent estimate of the cost of taking a new drug to market is around $1.5 billion. It is also vitally important that drugs can be brought into use by companies other than big pharma and that drugs can profitably be developed for diseases that are neither rare enough to come under the orphan drug regulations or common enough for the drugs to be blockbusters.  The reasons for doing nothing all pale into insignificance by comparison.

 Closely associated problems arise from the litigation culture - suing drug companies and, for that matter, hospitals and primary care trusts, when any adverse effect occurs, whether or not there has been negligence or malfeasance;  and I will copy, as you suggest, this correspondence to the Ministry of Justice in the hope that Kenneth Clarke, whom I still remember as Health Secretary many years ago, will be sympathetic to the arguments that something really does need to be done about it if drug development, and indeed the running of the Health Service as a whole, is to work in the real interest of patients.  There is no doubt that to an increasing degree medical practice is dominated by the fear of litigation and the resulting defensive practices are clearly enough not usually in the best interests of the patient. This also applies strongly to the issues surrounding invasive therapies at the end of life.

I imagine that it would be extremely difficult for any individual NHS organisation to decide to go over to providing far more services on a 24 hours a day, seven day a week basis.  This would require the consent of the Health Service unions to work more unsocial hours. It would involve changing the British implementation of the European Working Time Directive by applying derogation for health staff. There would be longer term implications for the number of doctors required to be trained in the acute specialities.   I would agree that it would be an excellent idea to trial such a project in one region; and to measure quality of care outcomes to see what effects such a change would have on survival rates in various diseases or following various operations.  I would predict that if such an experiment were done, the attractions for doing this on a national scale would rapidly become apparent. 

I am most interested in what you have to say about end of life care and what you say is unexceptionable.  It does not, however, address one of the main problems I was trying to raise which is that large amounts of undignified, painful, and probably useless, intervention is carried out in the last months or weeks of life, not because it is in the best interests of the patient or the patient’s wish, but for a variety of complex reasons in which fear of prosecution by the GMC and fear of litigation play a role.  

 Allowing doctors to take an active role in assisting patients at the end of life is a criminal offence while withholding treatment and/or nutrition is allowed. The categorical distinction that the law makes between these two courses of action is not shared by many of the medical profession to whom inaction is just one option among many.  What can be done to improve this situation is highly controversial, but things should not be allowed to continue just as they are at the moment. 

Yours sincerely,

Peter

Reply from Andrew Lansley

This open letter to Mr Lansley will  be published as a Personal View in the BMJ on 16 October and may be cited as: BMJ 2010;341:c5618

An open letter to the health secretary: how to really save money on the NHS

Peter Lachmann

emeritus Sheila Joan Smith professor of immunology, University of Cambridge

pjl1000@cam.ac.uk

Dear Mr Lansley

Your proposals to transfer the role of purchasing NHS services for patients from primary care trusts to general practitioners is appealing in as much as it promises some reduction in the excessive bureaucracy that resulted from the “low trust” culture introduced by the Thatcher reorganisation of the NHS in the 1980s and never reversed. However, as was so eloquently pointed out by the late Douglas Black—an eminent physician and someone who had much experience in government as well—none of the reorganisations since (and including) those of 1973 have succeeded in improving function by tampering with structure.[1] Indeed they have all done the reverse, essentially, as Sir Douglas also pointed out, because they fail to appreciate that health care should be treated as a service rather than as a business. Business based models have not fared well when it is a service that is required.

However, I imagine that the main aim underlying your proposals is to save money and to provide better healthcare delivery at lower cost. There are, indeed, at least three ways in which very large sums of money could be saved in the delivery of health care, with improvement rather than detriment to the quality of service. However, none of these changes would be universally popular, and they would require time, tenacity, and political courage to bring them about. Nevertheless, without them the future of health care, not just in the United Kingdom but elsewhere, will be imperilled by ever rising costs.

Reducing the cost of drugs

Drugs are a large component of health expenditure. We now live in an environment where the population has been persuaded that medicines have to be absolutely safe and that if anybody comes to harm from taking a drug they should have the ability to seek compensation through the courts. This state of affairs has led to drugs becoming hugely expensive and very slow to bring into use. It is now estimated that to bring a novel drug into use costs several hundred millions of dollars and takes 10 years.

About 60% of drug development is taken up by the late stage, phase III, trials. Phase I trials to ensure safety and phase II trials to demonstrate efficacy require relatively small numbers. Phase III trials involve large numbers and aim both to get more precise information on clinical usefulness and, more importantly, to detect rare side effects. However, even very large phase III trials cannot detect side effects that occur in less than about one in 1000 people.

The details of clinical utility and of rare adverse reactions are detected just as well, or better, by post-marketing surveillance. This is an extremely important aspect of the use of drugs and can be particularly effective in the context of the NHS. There is a strong case for making drugs available after phase II trials and to rely on post-marketing surveillance for detecting uncommon side effects. This would have two big advantages: it would make drugs much cheaper; and it would make drugs available much earlier. Although accurate figures are hard to obtain, it seems likely that phase III trials probably save fewer lives from avoided side effects than they cause deaths from patients having been denied a valuable drug. Certainly the cost per extra life saved will be much in excess of the sums that are allowed in the road traffic industry, which was about £2m per life saved per year, or on the railways, where it was about £3m. Initially, the change to making drugs available at the end of phase II should probably be done on a voluntary basis so that those patients who wish to avail themselves of drugs at this stage would be given them, subject to their signing a legally binding indemnity that they would not look for compensation if they suffered any adverse effects.

The practice of suing drug companies for adverse effects is generally to be deplored. It has become much commoner, and the practice of doing so on a contingency fee basis, imported from the United States, has greatly increased its frequency. It is not sufficiently realised that suing drug companies does not do them any financial harm. The expense is passed on to the consumer and further increases the cost of drugs. The only group that really profits from the process is the lawyers. While those patients who win compensation are better off, the rest of the patient population does badly by paying more for drugs.

Legal redress should really be reserved for cases where there has been negligence or other malfeasance. In many cases this is clearly not the case. Quite recently two examples have been reported. GlaxoSmithKline has settled a large number of claims from people who believe that they had cardiovascular side effects from taking rosiglitazone for diabetes. While rosiglitazone produces such effects slightly more commonly than its competitor pioglitazone,[2] it has nevertheless been a useful treatment for diabetes, and there was no negligence involved in making it available. AstraZeneca has similarly settled claims for $198m from 17,500 patients who developed diabetes after taking quetiapine for mental illness[3]—despite there being no evidence accepted by a court that there is a causal association.

To reverse the litigious compensation culture that has now grown up would obviously not be easy, but it is necessary if drugs are to be available at affordable prices and on a reasonable time scale.

It is also likely that many drugs are never developed because the potential market is regarded as too small for all the risks currently involved in taking a drug to market. There is a less rigorous regime in place for what are known as “orphan drugs” for well characterised rare diseases, but there are many potential drugs that fall between having a sufficient market for commercial development and being for sufficiently rare and well characterised diseases to fall under the orphan drug regulations.

Reforms in this area could save many hundreds of millions of pounds a year and are urgently required. They are rarely even discussed, and the part of the Cooksey report dealing with this problem was simply ignored by the last government.[4]

Making better use of medical facilities

The maintenance of hospitals and their facilities—including operating theatres, radiology departments, with their expensive imaging equipment, and pathology laboratories, with their expensive machines—is all very consuming of capital. It would make much better economic sense to use these facilities much more intensively than they are at the moment. In general, hospital facilities, and indeed most general practices, operate on a five day week, eight hour day basis. This makes neither economic nor medical sense, and it would be much better if many more facilities were used seven days a week, 24 hours a day. This would reduce capital expenditure and, in the longer term, the number of hospitals that need to be built. There are, moreover, other advantages that may be even more important. There has long been convincing evidence that being taken acutely ill on a Friday night carries a worse prognosis than being taken ill on a Monday night, and a recent new report pointed out that babies born “out of hours” face higher risks.[5] The efficiency and quality of the clinical service will therefore benefit, as well as its economics. These changes would involve employing more staff per hospital and getting agreement to rather more unsocial hours of work. Until fairly recently most doctors, particularly in their younger years, did quite a lot of work in antisocial hours; and providing that this was properly remunerated, it should probably not cause huge problems. It would certainly be of great benefit to the NHS.

And perhaps the most important and the most difficult: end of life care

A forbidding statistic produced by the RAND Corporation[6] is that on average between one third and one half of a person’s lifetime healthcare expenditure is spent in the last six months of their life, independent of when this occurs. This is obviously not true of everyone, but it is a general truth, and it leads to the inevitable conclusion that no advance in medicine will make health care cheaper; it just postpones the expenditure. The only answer to this is to reduce heavy expenditure and interventionist methods that are often undignified and painful when there is no prospect of appreciable gain in quality adjusted life years (QALYs). This is to some extent antipathetic to the training of doctors, which is very much based on their duty to the individual patient. Much questionable intervention is carried out on patients where there is no realistic prospect of restoring quality of life or even of extending life span for more than a few months. Although there is no easy solution to this dilemma, medicine does need to adjust to the paradigm that active intervention should be undertaken only in anticipation of improving, or at least maintaining, quality of life and not for prolonging life at all costs. In end of life care the cost per QALY can also not be totally ignored, although the criticism that the National Institute for Health and Clinical Excellence consistently attracts when it makes decisions on this basis shows what a sensitive area this is.

Related to this is the right of patients to have their lives terminated if they so wish. In the UK at present this is legal only if done by withholding treatment or nutrition but is a criminal offence if any active assistance is given. There is a strong argument that people have not only a right to life but also a right to death and that it is also an interference with their human rights to deny them access to ending their life painlessly and with dignity if they are minded so to do. There is a particular problem in this area with patients with depression who may wish to end their lives while they are ill but who after treatment are restored to a normal quality of life. Special arrangements would have to be made to ensure that these patients are protected if arrangements for facilitating a right to death were introduced. On the other hand, the overall resistance to doctor assisted suicide has very unhappy consequences and is, in my view, difficult to justify on medical ethical grounds. There are clearly problems that any such system could be abused, and precautions would have to be put in place. The experience in Oregon and in the Netherlands does not suggest that this has been a major problem there. The religious qualms on these grounds are also particularly difficult to understand, since if one believes that this world is a “sea of troubles” from which one escapes to a better life in the next, it is difficult to see why one should make it so difficult to make this transition, once the quality of this life has become a burden.

Implementing changes in these three areas would allow health expenditure to be contained in a way that would make a real difference, unlike tinkering with management structures which is more like rearranging the deckchairs on the Titanic.

Competing interests: PL has consulted for Novartis and GSK on occasions in the past three years on scientific matters concerning the complement system. He and his wife jointly have shares in Roche and Novartis.

1    Black D. Lessons from nostalgia. Clin Med 2002;2:263-5

2    Graham DJ, Ouellet-Hellstrom R, MaCurdy TE, Ali F, Sholley C, Worrall C, et al. Risk of acute myocardial infarction, stroke, heart failure, and death in elderly Medicare patients treated with rosiglitazone or pioglitazone. JAMA 2010;304:411-8.

3    AstraZeneca. AstraZeneca announces agreements in principle in Seroquel product liability litigation. www.astrazeneca.com/media/latest-press-releases/2010-new/SEROQUEL_Prod_Liability?itemId=10914599.

4    Cooksey D. A review of UK health research funding. HM Treasury, 2006. www.hm-treasury.gov.uk/media/4/A/pbr06_cooksey_final_report_636.pdf

5    Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GCS. Time of birth and risk of neonatal death at term: retrospective cohort study. BMJ 2010;341:c3498.

6  Lynn J, Adamson DA. Living well at the end of life: adapting health care to serious chronic illness in old age. RAND Corporation, 2003.