Pressure from ageing populations, stagnant growth and growing medical costs will mean that medical aid schemes will make above-inflation rate hikes, reveals Momentum Health marketing officer Damian McHugh. He made the comments at Momentum Health Solutions’ virtual Healthcare Insights Summit on Tuesday (30 July), where he also noted that the same demands on medical funds are serving to put NHI even further out of reach, estimating a budget of some R1.3 trillion.
If one take’s McHugh’s figures and projects into the coming years, these above-inflation hikes make the target an ever increasing-one, steadily sending the current estimates even further from the realms of affordability. This is a situation which national health schemes of far wealthier countries are now encountering.
This comes as the Council for Medical Schemes advised the 1st of August of inflation plus “reasonable utilisation estimates” resulting in a recommendation to keep under 8.5%. But it given the pressures on medical aid schemes, this is unlikely to be adhered to, as last year already saw increases in excess of this.
Medical aid cost pressures
The CMS acknowledged that above-inflation medical cost increases are inevitable due to “unique industry factors such as technological advancement, the ageing population, and the increasing prevalence of chronic diseases.”
Last year, Discovery Health Medical Scheme (DHMS) announced a weighted average increase of 7.5%, for 2024 – but its comprehensive “premium” segment rose by 13%. Both Momentum and BestMed announced weighted increases of 9.6% for 2024, while Bonitas managed to contain its increases to 6.9% (though its comprehensive cover rose to 9.6%). MediHelp surged to 15.96%, though it justified this increase as its options were the lowest-priced on the market.
Medical aid scheme growth is slow, at best around 0.5% per annum, while there is considerable pressure on subscriber income. Low income brackets only spend around 4% on healthcare, while middle and high income brackets spent 6% and 7%, respectively.
But with claims on the increase, many medical aids are having to tap into reserves and reducing solvency. Many medical aids are running close to 100% claims ratio – obviously a very bad situation for them to find themselves in.
These cost pressures result in a reduction in benefits, with the burden being shifted by reducing day-to-day benefits and members moving to Efficiency Discount Options (EDOs) – in turn, reducing the risk contribution income received by the schemes.
Rate hikes inevitable
In its recommended guidelines for 2025 released in Circular 35 of 2024, the CMS advised that medical aid schemes limit their contribution increases in line with CPIThis was based on the Reserve Bank’s latest inflation forecast which expects headline inflation to average 4.4% and 4.5% in 2025 and 2026, respectively. With last year’s estimated of an additional 3.2% to 3.8%, that works out to about 8.5%. But the CMS noted that medical aid schemes have historically had increases in excess of CPI+4%.
The COVID pandemic bucked the trend, resulting in – though many medical aid schemes saw record profits as procedures were deferred. Price increases were deferred, with increases kept below inflation for 2021 and 2022, with an uptick in 2023.
McHugh pointed out that growth in medical aid schemes has remained largely flat, and the ageing of the insured lives was linked to increasing claims costs as health problems became more complex. He revealed that claims costs per life had risen from about R15 000 in 2017 to R21 000 in 2022. This, spread across the population of South Africa, would require an NHI budget of R1.3 trillion.
Source: CMS Circular 35 of 2024
Breaking down the expenditures, McHugh said that medical schemes spent 37% on hospitals and 28% on specialists, while medicine accounted for 16% and GPs a mere 5%. The CMS also noted that hospitals and specialists had seen greater relative increases than other areas. For the essential coverage of hospitals, medicines, GPs, and dentists, that would amount to R363 billion.
Looking ahead with a little maths
One can take simple compound interest to McHugh’s figures, and even applying the CMS’ best-case “reasonable utilisation estimate” of 3.2%, for say 20 years from will mean that costs rise by 87% in today’s rands. That means the NHI’s ‘basic’ coverage would rise to R682 billion and the full coverage amounting to an incredible R2.4 trillion.
But this nothing special to South Africa. The UK’s NHS costs have similarly grown, at 3.6% per annum in real terms. And that growth has to come out of the GDP: from 3.6% of the GDP in 1949-50 to 8.2% in 2022-23, with a surge to 10.5% in the COVID pandemic.
The UK has now put measures in place to constrain cost growth to 1%, but it remains to be seen whether this will be effective without compromising service delivery. How South Africa can even contemplate an NHI where, 20 years from now, private scheme medical costs run to R39 000 per person in the best case scenario.
While McHugh did not mention the recent High Court blow to the NHI Act that found a key part of it unconstitutional, he described the legal challenge process that would see that part sent back to the National Assembly and the president.
McHugh however struck a note of optimism, noting that the public-private partnerships of the COVID pandemic showed a way forward for NHI and universal healthcare in South Africa. The 2024 elections bring the possibility of the same historic benefits for the population as the 1994 ones.
Cancer patients who participate in clinical trials hoping for better outcomes fare no better than those who do not, when setting aside the new treatment’s effect, according to the results of a study published in the Journal of the American Medical Association. The analysis found that while overall, trials had a positive benefit, this effect diminished after accounting for various factors common to trial participants such as being younger. Evidence of publication bias was also uncovered.
Participation in a clinical trial may confer a survival benefit to cancer patients is known as a trial effect, and results from access to effective new therapies (the treatment effect), but it is also thought that a trial’s closer monitoring provides a distinct benefit as well (the participation effect). The treatment effect only applies if the treatment proves to be effective, while the participation effect should apply regardless of treatment effect. But the evidence for the participation effect has been conflicting. A pair of reviews, one conducted in 2001 and the other in 2004, found no evidence of a participation effect.
The researchers therefore sought to account for biases and confounding in differences between routine care patients and trial patients. A search was performed for studies comparing survival outcomes for the two groups between January 1 2000 and August 31 2022, which turned up 12 791 records. After screening for eligibility and duplicates, this yielded 39 studies (85 comparisons) for analysis. These comparisons involved haematologic (21%), breast (16%), lung (14%), central nervous system (7%), prostate (7%), and pancreatic cancers (5%), as well as melanoma (6%). The remaining 24% consisted of bladder, cervical, colorectal, oesophageal, gastric, head and neck, kidney, ovarian, and solid mix tumours. One-third of the comparisons involved advanced or metastatic cancer.
Initially, the meta-analysis revealed a statistically significant overall survival benefit for trial participants (HR [hazard ratio], 0.76) when all studies were pooled without regard to their design or quality. But in study subsets matching trial participants and routine care patients for eligibility criteria, the survival benefits diminished (HR, 0.85). Finally, the survival benefit disappeared when only high-quality studies were pooled (HR, 0.91). They also disappeared when estimates were adjusted for potential publication bias (HR, 0.94).
Further analysis (using funnel plots and Egger’s regression test) indicated there was a publication bias against studies which lacked a participation effect.
In an accompanying editorial, Wilson et al. note that the participation effect explains that, “Patients in trials are generally younger, fitter, have fewer comorbidities, and come from higher socioeconomic groups; this enrollment bias largely explains the participation effect. The implications of this finding are important for understanding how trials are often viewed in clinical practice. The participation effect is often used to promote the view that “a clinical trial is the best treatment option, ‘but this may be a false narrative.”
Corresponding author Jonathan Kimmelman, PhD concluded: “Our findings provide reassurance that inability to enroll in a cancer trial doesn’t disadvantage a patient, at least in terms of survival. Our findings can help patients (and physicians) focus their consent discussions on the most relevant and evidence-based benefits of trial participation: the prospects of advancing the care of future patients.”
Approximately one in seven patients who discontinued their use of antidepressants experienced discontinuation symptoms, according to a wide-ranging analysis published in The Lancet Psychiatry. In arriving at this figure, the researchers accounted for a high frequency of anticipated discontinuation symptoms.
The emergence of adverse symptoms after antidepressant cessation has been described as far back as 1959, but was mostly neglected until the late 1990s. Today, the existence of antidepressant discontinuation symptoms is widely accepted, with transnational guidelines suggesting safe tapering. They can be highly variable and non-specific, with the most frequently reported symptoms being dizziness, headache, nausea, insomnia, and irritability. It has been reported that symptoms typically occur within a few days and are usually transient, but can last up to several weeks or months.
The incidence and severity of symptoms remained controversial however, with estimates ranging up to a majority (56%) of patients experiencing them, half of them severe. Previous reviews have been criticised for bias, and medical opinions are polarised on the subject.
The researchers reviewed 79 studies involving more than 21 000 participants, and found that about one-third of patients experienced symptoms such as headaches, nausea, insomnia, and irritability after accounting for patient expectations. Even in patients taking placebo, 17% experienced symptoms – suggesting that this is attributable to patient expectations about the adverse effects of stopping the drug.
After taking this into account, roughly one in seven individuals had antidepressant discontinuation symptoms. Neither tapering nor abrupt cessation of the drugs made no difference in the proportion of people who experienced discontinuation symptoms.
In addition, about 1 in 35 people experienced severe discontinuation symptoms. Desvenlafaxine, venlafaxine, imipramine, and escitalopram were associated with higher frequencies of discontinuation symptoms, and imipramine, paroxetine, and either desvenlafaxine or venlafaxine were associated with higher symptom severity. The authors cautioned that there was substantial heterogeneity of results.
While irritable bowel syndrome (IBS) is commonly associated with symptoms outside the intestine, it was not known whether these symptoms differed according to the subtypes of the condition. A new study published in Neurogastroenterology and Motility investigated the prevalence, and found that the IBS-M (mixed bowel habits) subtype had the highest prevalence of most extra-intestinal symptoms symptoms.
The researchers carried out a descriptive cross-sectional study patients with IBS according to Rome IV criteria. They were classified according to subtypes: IBS-D (diarrhoea-predominant), IBS-C (constipation-predominant), and IBS-M (mixed bowel habits). Of the 4862 patients included; there were 608 IBS-D (12.5%), 1978 IBS-C (40.7%), and 2276 IBS-M (46.8%).
Participants completed a patient health questionnaire-9 (PHQ-9) score for depressive symptoms, with IBS-M the highest at 12.7 compared to 11.1 for IBS-D and 10.5 for IBS-C. They also completed an IBS-severity scoring system (IBS-SSS) questionnaire.
Overall, the study found the following results:
IBS-M:
Overweight
High IBS-SSS of 320
Depressive symptoms (80.0%)
Multiple extra-intestinal symptoms
Arthralgia (62.4%)
Chronic cervicalgia (81.0%)
Extremity numbness (64.5%)
Atopic dermatitis (28.2%)
IBS-C:
Lower body mass index
Low BS-SSS of 290
IBS-D:
Overweight (30.9%)
Higher food intolerance perception (9.5%)
History of cholecystectomy (17.8%)
Faecal incontinence (36.2%)
The authors concluded that, “The prevalence of most extra-intestinal symptoms is higher among patients with IBS-M. Further research is needed to better characterize IBS subtypes, which could potentially help refining tailored therapeutic strategies.”
In adults with sepsis or septic shock, β-lactams are recommended by Surviving Sepsis Campaign guidelines, in a prolonged (after an initial bolus) rather than intermittent infusions – but owing to only moderate quality of evidence this is currently a weak recommendation. Now, a new systematic review and meta-analysis comparing the two approaches across multiple clinical trials has found a survival benefit for prolonged infusion The findings appear in JAMA.
To address whether prolonged infusions of β-lactams improve clinically important outcomes in critically ill adults with sepsis or septic shock, the study investigators searched medical databases for relevant randomised controlled trials comparing β-lactam infusion types in critically ill adults with sepsis or septic shock. The primary outcome was 90-day mortality, with secondary outcomes including intensive care unit (ICU) mortality and clinical cure.
In all, they found 18 eligible trials that included 9108 critically ill adults with sepsis or septic shock (median age, 54 years; 5961 men [65%]), 17 trials (9014 participants) contributed data to the primary outcome.
The pooled estimated risk ratio for all-cause 90-day mortality for prolonged infusions of β-lactam antibiotics compared with intermittent infusions was 0.86, with high certainty and a 99.1% posterior probability that prolonged infusions were associated with lower 90-day mortality. There was high certainty that prolonged infusion of β-lactam antibiotics was associated with a reduced risk of ICU mortality (risk ratio, 0.84) and moderate certainty of an increase in clinical cure (risk ratio, 1.16).
The findings were tempered with the authors’ understanding that, “Potential challenges associated with prolonged infusion administration, including drug instability and incompatibility with other intravenous medications, the need for a dedicated intravenous portal, and the potential effect on clinical workload, require some considerations before broad implementation. Future studies should determine the optimal duration of infusion when β-lactam antibiotics are administered as prolonged infusions.”
The authors concluded that, “Among adults in the intensive care unit who had sepsis or septic shock, the use of prolonged β-lactam antibiotic infusions was associated with a reduced risk of 90-day mortality compared with intermittent infusions. The current evidence presents a high degree of certainty for clinicians to consider prolonged infusions as a standard of care in the management of sepsis and septic shock.”
President Cyril Ramaphosa has finished “looking for a pen” to sign the National Health Insurance (NHI) bill into law, and is set to approve the legislation on Wednesday, May 15.
While this “electioneering” move comes as a surprise to many, some experts anticipated this timing. With its signing, the legal battles over it will now begin. An array of medical and professional associations are readying their court papers, armed with numerous expert objections and petitions finding fault with the bill, widely criticised as unaffordable, demoralising and disastrous. But what will it look like in the end? Is it in fact an opportunity to fix public and private healthcare for the better?
To understand the NHI bill’s consequences and possible remedies better, Quicknews asked medico-legal specialist Martin Versfeld of Webber Wentzel & Associates about the legal aspects of the NHI bill, what it means for doctors in private practice, what can be done to ensure it fixes SA healthcare instead of damaging it further, and what its likely outcomes will be.
“The inequality of South Africa’s healthcare situation is not lost on anyone, least of all those in healthcare,” Martin says. “I think every healthcare professional, every hospital group, every healthcare provider recognises a need to assist South Africans more generally and to ensure there is better access to healthcare.”
Examination of the NHI bill has shown that it will simply exacerbate the problem, with possible wider consequences for the country’s economy (If Eskom’s load shedding is anything to go by – Ed). Viable alternatives towards repairing the beleaguered public healthcare system have been suggested, but political pressures have seen the bill signed into law. At this point, it is a certainty that it will face a barrage of litigation.
NHI, the mirage on the horizon
While the NHI is now set to be signed into law, there were efforts to persuade President Ramaphosa to not sign it. Recently, a South African Health Care Practitioners (SAHCP) petition was presented that contains a number of points and precedent to other laws that were rejected due to serious concerns. This petition had gathered 23 000 signatures from healthcare professionals.
Martin believes that it is a very effective petition, and it may have ‘resonated’ except for its timing. “The challenge that we face here is that it is an election year,” he points out. So while this petition and other appeals to the President to reject the legislation might have merit, and may have otherwise succeeded, it is extremely unlikely that Ramaphosa could go against his party’s goals.
“The NHI is a centrepiece, arguably, of the ANC’s election manifesto and they will be very reluctant to signal a climb-down at this point. So I think Cyril, as much as he might personally take a view that, under different circumstances, would be appropriate – I think he’d be under enormous pressure simply to sign the legislation into law.”
The time to act, with the most impact, will be after the elections.
As soon as NHI is signed into law, there will be a tidal wave of litigation, predicts Martin. This will be the next best time to challenge it. There are two avenues; whether the entire legislation is struck down as unconstitutional, or when it comes to the nitty gritty of implementation, when “the plethora of regulations are introduced.”
Even absent the court battles that will be waged, it will take years to fully implement NHI. Martin points out the length of the process, “The NHI is not going to be implemented to the full extent of what the legislation provides from the get go,” he says – it simply can’t be.
“It will be introduced incrementally by way of the introduction of regulations. So what I would expect as a first step would be to introduce the infrastructure required in order to create this collective pooling of funds.
“They will also be regulations which empower Nicholas Crisp and others to employ the essential staffing required to start to implement NHI.
“So it’s envisaged that there will be a very long process.”
‘Decades of litigation’
“Once the legislation takes effect, of course, the doctors and other stakeholders, including the medical schemes, will have an opportunity to carefully review the legislation and take a view as to whether or not they wish to, at this juncture, challenge certain aspects of that legislation on the basis of the – amongst other things – lack of constitutionality thereof.”
Martin stresses that the objections that have been lodged and engagements made to-date are not wasted effort. “It’s very important that the court sees and appreciates all the efforts that the industry has made in order to engage practically and meaningfully with the government. If nothing else, it puts the government on the back foot and the healthcare providers on the front foot.”
“This is not a matter which anyone is going to take lying down,” he says.
Speaking at a media briefing, SAMA’s chairperson, Dr Mvuyisi Mzukwa, said that the NHI bill will impact not only health professionals, but the country as a whole.
“SAMA has, on various platforms, made its position known that, as doctors, we swore an oath of service to those who seek healthcare from us. We do not believe this Bill will achieve what it purports to do,” he said.
The notion of how physicians resist unjust situations is a relatively new one, since the patient takes priority. Unlike worker resistance, which makes use of strikes and disobedience, the resistance of physicians must work within power structure and never compromise patient care. According to a study by Wyatt et al., “physician resistance includes a refusal to comply with professional expectations of limiting their concerns to the bodily care of patients.” Their review found that physicians have often engaged in resistance when their personal and professional interests were threatened, particularly around issues of autonomy.
Keep calm and carry on?
Despite its name, NHI would not actually provide healthcare insurance – instead Section 33 introduces a financing and single-supplier mechanism reminiscent of Eskom’s doomed model.
For most in the healthcare industry, section 33 is the greatest source of uncertainty and concern. It essentially eliminates medical schemes – but those reallocated funds only account for a fraction of the NHI’s true cost. However, this provision only comes into play once NHI is fully implemented – which could take decades, or just never happen, because of its sheer cost. The real threat, Martin says, is the perception and fear around NHI.
Martin has heard of “very negative consequences,” such as on the “decision on the part of students to study medicine; on professionals to stay committed to being in South Africa, leading to significant emigration on the part of healthcare professionals.
“For me, the real concern is less about whether or not NHI will ultimately be implemented in its current form, because I don’t believe it will be simply because we can’t afford it.”
Even if it is implemented, Martin suspects that many doctors will simple opt to operate on a cash basis, and wealthy individuals would be able to pay for specialists, expensive chronic medications and extended hospital stays. Though with the average age of specialists now at around 61, up from 53 in 1996, they may be in short supply in coming years.
There is also the question over what impact the mere threat of NHI will have on those with money and the ability to invest in the economy. Martin is “very anxious about the push factor associated with the perception that we can no longer get the required healthcare services.”
At some point it becomes a question of whether high net worth individuals can afford to pay for private healthcare, like they currently do for solar panels and generators to deal with the loadshedding crisis, and if that becomes a push factor to make them emigrate, taking their wealth, skills and economic contribution with them.
Implementation is still an open question
The devil is in the details, and in this case it is the thousands of specific regulations which will have to be rolled out in order to turn NHI from a law on paper into an actual functioning system.
Martin believes that it is quite likely that the NHI will end up only being partially implemented, if at all. Many of the requirements are quite steep.
All health users will need to have an electronic health record, for example – it will be a colossal undertaking to link South Africa’s 60 million plus, heavily rural, population, not far off of the UK’s 67 million. Just to get such a system running will take years. Still, a nationwide database would be extremely valuable for healthcare.
Even so, the NHI pilot projects failed to deliver on their promise of patient-centric care; the final report on the NHI Phase 1 interventions found that success was driven by factors which included “strong political will, adequate human and financial resources for implementation, good coordination and communication and good monitoring systems in place at the time of implementation.” Factors which worked against the interventions included “inadequate planning, lack of resources, inconsistent communication a lack of coordination where necessary and insufficient mechanisms to monitor progress to ensure course correction.”
(Of the two groups of factors, government initiatives have almost always landed squarely in the latter category – Ed)
In the end, where is the money?
There also is simply no money for the NHI, which is estimated by the Freedom Foundation to cost up to R1 trillion (more, even, than the much decried public wage bill) for full implementation.
Doctors in many provinces are unemployed as their health departments struggle under budget cuts. The Western Cape for example, has a hiring freeze, creating additional workload as positions go unfilled. The strain is being felt by doctors and nurses in hospitals. Already a petition of 1200 HCPs has been sent to the WC government’s offices. Centralised support from the National Department of Health has, in fact, been going backwards, with a number of wage-related issues being dropped squarely on the, already beleaguered, Provincial departments.
The NHI is also without historical precedent, as Martin says “no country that has introduced a form of National Health Insurance has sought to exclude the ability of the private sector to, in parallel, offer an insured medical service.” Ghana trialled a form of national health insurance, only for it to quietly fade away. The system involved capitation, in which a predetermined flat payment is paid to a provider to cover a defined benefit package of services for a patient. In theory, this forces cost containment onto providers.
It is important to note that schemes on the scale of NHI have only been achieved in a mere handful of countries, a list which consists almost entirely of very wealthy countries, with strong tax bases. South Africa’s situation is very different.
“We have a tiny tax base with a massive disease burden,” Martin points out.
Big in Japan
The country that successfully implemented such an initiative the fastest was probably Japan: “it took them 40 years or so,” Martin noted.
Japan, a country noted for the longevity of its people, has a massive tax base and a tiny disease burden, Martin points out. Indeed, for decades it was the world’s second largest economy. Hardly an act that a developing country like South Africa can try and follow in a matter of years, especially when a wealthy country, like the UK, has been struggling to maintain its own NHS.
The economic consequences of attempting it would be a huge tax increase, with high net worth individuals leaving.
Meanwhile, South Africa is a healthcare tourism destination for residents of wealthy countries that have national healthcare, because it has a world-class private health care industry. That source of international income would also fade away, under NHI.
Stick and carrot: building the NHI that South Africa needs
Nevertheless, there is a way forward to Universal Health Care, through successful public-private partnerships.
SAMA’s position also reflects this. “We believe that any form of health reform must be based on a health system that is built on adequate human resources for health, access to essential drugs, medicines and vaccines, suitably utilising evidence-based policies, ethical leadership and governance, as well as being built on digital and technologically integrated systems,” Mzukwa said.
Once the dust from the election settles, then the time will come for healthcare professionals and associations to properly engage with the government on NHI, as it is faced with the reality of implementation.
In that case, Martin says, once government has “considered the cost more carefully and agreed that they need to be more receptive to offers of collaboration with the private healthcare space,” then it can “accept that medical schemes as we know and understand them today can continue to exist and provide a parallel support to those who can afford to pay for medical schemes.”
What can doctors do? Martin advises that they carry on working through their associations. The various healthcare groupings are collaborating to both benefit the government and also to litigate and challenge the legislation and regulations. But these two aims should not be separated into two separate efforts, he says.
“I think there should continue to be an effort to collaborate collectively, to come up with positive solutions for the benefit of all South Africans. I think equally they will obviously have to, in parallel, to the extent necessary, litigate – I believe litigation is entirely inevitable, but they’ll need to collaborate around that.”
A survey conducted in the UK found that people with severe to profound hearing loss who were eligible for cochlear implants were less likely to be referred if they lived in deprived areas and were male.
The study, published in PLOS Medicine, was carried out to determine the rates at which people in the UK with hearing loss were getting correctly referred for implants under the NHS, and where disparities might exist. Referrals were to be made on the basis of meeting pure tone audiometric threshold criteria.
Of 6171 participants in the survey who underwent the pure tone test and already did not have a cochlear implant, only 38% were informed of their eligibility and a mere 9% were actually referred for assessment.
Participants were less likely to be referred if they lived in more economically deprived areas and also within London, were male or were older. In addition to these factors, living in more remote areas, and being Black or Asian also reduced the likelihood of being informed of eligibility.
Lower odds of referrals in economically deprived areas is in line with data from both public and private healthcare sectors in Australia and the U.S.
The researchers also found that the presence of a “cochlear implant champion” increased the likelihood of discussions around cochlear implants but not referrals. That males were less likely to be referred or informed to were interpreted as stemming from men’s differences in health-seeking behaviour compared to women.
Limitations included the observational nature of the study, reliance on accurate documentation of the referring service, and potential underrepresentation of certain demographic groups.
A neurosurgeon alleged during his employment tribunal that a “gang culture” exists within the neurosurgery department of an NHS hospital already beset by claims of a toxic culture and investigations into negligence.
As reported by the BBC, Dr Mansoor Foroughi was dismissed from University Hospitals Sussex in 2022 for misconduct. At a separate employment tribunal, Krish Singh, the former clinical director for general surgery, claimed that rota changes reduced the number of “safe” consultants, putting patients at risk.
Four whistleblowers had also told the BBC of a “Mafia-like” culture, where patients had died unnecessarily and others “maimed”. These new allegations came to light as the BBC and The Times fought a nine-month court battle to have the employment tribunal documents unsealed.
Dr Foroughi alleges that one colleague was signed off to do complex spinal procedures despite lacking training, another performed procedures with a “disproportionate” mortality rate, and yet another took on private work while on call to the NHS – a serious breach of conduct.
University Hospital Sussex encompasses several hospitals, which includes Royal Sussex Country Hospital, which has been the source of many complaints, and a history of poor service delivery, which was put into special measures between 2016 and 2019.
At least 105 cases of alleged medical negligence from failings at the hospital’s neurosurgery and general surgery departments are being investigated by police. According to court documents, there was “serious dysfunctionality in the neurosurgery department” with “stark divisions between colleagues”.
An investigation by the Royal College of Surgeons found that “a culture of fear” existed in the hospital’s surgery department, and that senior staff were “dismissive and disrespectful”. Two staff were allegedly assaulted.
In a statement, the trust said: “The trust will vigorously contest these claims at the Employment Tribunals, which we are keen take place at the earliest opportunity so they can be examined properly and fairly.
“Dismissing anyone, or removing someone from a leadership role, is an absolute last resort and we would always seek to avoid this outcome if possible.
“In both of these cases, due process was followed, and we are confident we did the right things, in the right way, for the benefit of our patients, their care and safety.”
A Swedish study of more than 140 000 individuals with attention-deficit/hyperactivity disorder (ADHD) found that initiation of ADHD medication was significantly associated with a 21% lower mortality two years after diagnosis, according to results published in JAMA. This reduction was especially pronounced for unnatural-cause mortality. Females and males also saw different reductions in types of mortality.
ADHD is the most prevalent neurodevelopmental condition, affecting 5.9% of youths and 2.5% of adults worldwide, according to the 2021 World Federation of ADHD International Consensus Statement. The disorder is associated with a broad range of psychiatric and physical comorbidities, as well as adverse functional outcomes. Furthermore, individuals with ADHD are at twice the risk of premature death, mainly due to unnatural causes.
Randomised controlled trials have demonstrated that ADHD medications, including stimulant and nonstimulant medications, are effective in reducing core ADHD symptoms for children and adults with ADHS. Pharmacoepidemiological studies have also shown reduced risks of negative outcomes, including injuries, traffic collisions, and criminality, which would be expected to decrease the mortality rate. However, there are concerns regarding the cardiovascular safety of ADHD medications, especially following long-term use, which could increase the mortality rate.
To date, three studies have examined the association between ADHD medication and mortality with mixed results. These studies had significant limitations, such as the absence of a control group. To date, there has been no study on the association in adults with ADHD. There are increasing diagnoses of ADHD among adults, who have a higher prevalence of somatic comorbidities, including cardiovascular diseases and other conditions, compared with children and adolescents.
Using the Swedish national registers, the researchers investigated whether initiation of ADHD medication was associated with mortality, using the target trial emulation approach to avoid key biases in pharmacoepidemiological studies.
They assessed for all 6 medications licensed for ADHD treatment in Sweden (methylphenidate, amphetamine, dexamphetamine, lisdexamfetamine, atomoxetine, and guanfacine) during the 2007-2020 period. Analysis of the data showed that, for a two-year follow-up, lower all-cause (hazard ratio [HR], 0.79) and unnatural-cause (HR, 0.75) mortality for the ADHD medication group, but there was no significant association with natural-cause mortality (HR, 0.86). Under unnatural causes, accidental poisoning mortality was halved (HR, 0.47).
Subgroup analysis revealed that for females, the only significant reduction in mortality was for natural causes. The authors noted that this may be due to higher rates of comorbid depression, sleep disorder, atrial fibrillation, and asthma.
When follow-up was extended to five years, associations attenuated save for unnatural-cause mortality (HR, 0.89).
The authors concluded, “ADHD medication may reduce the risk of unnatural-cause mortality by alleviating the core symptoms of ADHD and its psychiatric comorbidities, leading to improved impulse control and decision-making, ultimately reducing the occurrence of fatal events, in particular among those due to accidental poisoning.”
For limitations, the observational nature of the study cannot establish causation, and the authors noted confounding effects such as nonpharmaceutical treatment of ADHD. Potential type I error resulting from multiple comparisons regarding cause-specific mortality and subgroup analyses meant the results are only exploratory. Two more limitations were uncertain adherence to medication and potential misclassification of deaths such as potential cases of suicide being marked as accidental poisoning.
Ischaemic and haemorrhagic stroke. Credit: Scientific Animations CC4.0
Early neurological deterioration (END) within the first 48 hours after acute ischaemic stroke (AIS) onset is relatively common, and is a predictor of poor outcomes. Treatment options are limited and unproven, but but a clinical trial has shown that the anticoagulant argatroban was safe and effective in improving outcomes. The results were published in JAMA Neurology.
Apart from straightforward causes, such as intracerebral haemorrhage and malignant oedema, the mechanism of END remains mostly unclear. Interventions for unexplained END can include plasma volume expansion, induced hypertension, and intensified antithrombotic therapy, but none has been formally proved so far.
The direct thrombin inhibitor argatroban is rapid acting, short acting, and has low bleeding rates, which could help prevent thrombus propagation and provide additional benefit after stroke/TIA. Argatroban has been associated with a reduction in ischaemic stroke damage but the safety and efficacy of argatroban is not well established for AIS treatment, and evidence is lacking for the effect of argatroban in patients with AIS and END.
Researchers conducted a randomised clinical trial that initially included 628 patients, average age 65 and 400 (63.7%) male. Eligible patients were adults with AIS who experienced END, which was defined as an increase of 2 or more points on the National Institutes of Health Stroke Scale within 48 hours from symptom onset.
Patients were randomly assigned to the argatroban group and control group within 48 hours of symptom onset. Both groups received standard therapy based on guidelines, including oral mono or dual antiplatelet therapy. The argatroban group received intravenous argatroban for 7 days (continuous infusion at a dose of 60mg per day for 2 days, followed by 20mg per day for 5 days) in addition to standard therapy.
The results showed that good neurological function at 90 days in those randomised to receive argatroban plus antiplatelet compared with antiplatelet alone was observed in 80.5% vs 73.7%)of participants, a statistically significant difference.
The authors concluded that the trial “shows that the combination of argatroban and antiplatelet therapy resulted in a significantly greater likelihood of good functional outcome at 90 days in patients with END after AIS, with no additional risk of major intracranial or extracranial haemorrhage.”
