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Some more repetitive bene-bashing & a reply

8 August 2013 5 comments

From the letters to the editor page in the Dominion Post, on 8 August – a letter to the editor I took exception to;

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Amanda Purdy - Dominion Post - 8 August 2013

Amanda Purdy – Dominion Post – 8 August 2013

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My reply to Ms Purdy,

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from:     Frank Macskasy
to:     Dominion Post <letters@dompost.co.nz>
date:     Thu, Aug 8, 2013 at 11:42 AM
subject:     letter to the editor

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The Editor
DOMINION POST
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It’s a shame that Ms Purdy mistakenly conflates the worthy issue of workplace safety with that of denigrating the unemployed. (8 Aug)

Since when have those who’ve been made redundant since 2008 become ‘druggies’? This is what she is suggesting with the blanket statement, “smoke dope or work but we can’t expect the taxpayer to fund people who smoke dope”.

Is she suggesting that those laid off from Summit Wool Spinners, Southern Institute of Technology, Geon Group, Ellerslie TAB,  Department of Conservation, Telecom, Park Road Post,  Fonterra, Fisher Funds, Ministry of Justice, NZ Post,  Solid Energy, Delta Utility Services, Canterbury Spinners, WINZ, Holcim Cement, Oringi Freezingworks, Tiwai Smelter, etc, etc – have all suddenly acquired a taste for cannabis?

These people are not dope-heads. They are all Ms Purdy’s fellow New Zealanders – victims of a global financial crisis they had no hand in making, and which is still making it’s effects felt throughout our society and economy.

If Ms Purdy is concerned about workplace safety – as is the CTU – then drug test everyone. No exceptions.

That includes politicians and letter writers like Ms Purdy and myself.

Otherwise she is simply repeating, ad nauseum, National’s desperate  bene-bashing  distractions, to avoid responsibility for rising unemployment.

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-Frank Macskasy
(address & phone number supplied)

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Meanwhile, unemployment has risen from 6.2% to 6.4%, according to the most recent Household Labour Force Survey,

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Economists play down jobless rise

Source: NZ Herald – Economists play down jobless rise

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Another 5,000 drug-users according to people like Ms Purdy?

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Munted links – fixed

Links on my series – Opposition parties work together on “orphan drugs” – from one part to the next –  have been corrected. Apologies for my stuff-ups.

The conclusion the series – part wha – coming soon.

-Frank

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Categories: Various

Opposition parties work together on “orphan drugs” (part toru)

8 August 2013 3 comments
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Continued from: Opposition parties work together on “orphan drugs” (part rua)

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NZORD - seminar - 1 August 2013 - Wellington - pompe disease - manual cover

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NZ, Wellington, 1 August 2013 – A seminar in Wellington was held NZORD, the New Zealand Organisation for Rare Disorders , to discuss the problem of lack of funding for “orphan drugs”. People with rare diseases are missing out of medication – a life-threatening situation.

The seminar’s next guest was introduced; Dr Greg Coyle. Dr Coyle is a social policy analyst and manages the NZ Salvaton Army’s relationships with the Ministry of Social Development,  Housing NZ, Dept of Corrections, Ngai Tahu, Tainui, and Otago University. He is a member of the NZ Institute of Directors, Deputy Chair of Laura Fergusson Trust (Wgtn), and has a Ph.d. and Masters in Public Policy, in the area of fairness;

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[Taken from Greg’s speech notes] “This paper is about fairness and I am grateful to the New Zealand Organisation for Rare Disorders for the opportunity to present these ideas. I wish to talk about about three things. Firstly I will discuss one view of the anatomy of fairness. Secondly, using these ideas, I will examine how fairly PHARMAC has treated sufferers of rare and orphan diseases in relation to it’s wider statutory purpose. Finally I will propose a new funding mechanism for pharmaceuticals for sufferers of rare and orphan diseases which will, I believe, provide cost control and fairness to individuals and the wider community.”

“Fairness is something we each quite easily recognise when we see it, but have great difficulty describing it and agreeing on what it actually is.”

“Gauld described the Social Security Act 1938 as the political and legislative foundation for social welfare in New Zealand. This  social reform was based on a “fair go for all”. The legislation placed New Zealand’s concern for the least well off on a fairness platform.

In 2013, the fall-back position  is now commonly expressed as “well I accept something may be unfair, but who says the world is fair anyway?” as if fairness is now an unreachable and unnecessary attainment. Perfect fairness may well be unattainable, but acceptable levels of fairness in today’s political and social  landscape seems not to be universally accepted.” 

So the moral question here is how much fairness or how much equality is too much to aim for? How much is not enough? How much unfairness and inequality, in terms of state distributions, is our society prepared to tolerate?”

“Fair distributions to citizens are particularly difficult for OECD governments considering the increasing costs of public healthcare, especially pharmaceuticals. Again the question is not why we should ration  medicines, but rather how much rationing are we prepared to tolerate?”

“Hamilton describes this balancing act in terms of ensuring that there is minimal granting of special privileges to favoured individuals, and also ensuring the absence of social abandonment of those who require assistance. More particularly, what we are concerned about here is the process of micro-rationing  of pharmaceuticals to individuals.”

“[John] Rawls’ definition of fairness contends that, in liberal democratic societies, distributions should ensure each person has an equal right to the most extensive liberty compatible  with a similar liberty of others. Where social and economic distributions are to be unequal, they should be arranged so that distributions  are of the greatest benefit for the least advantaged… “

“This fairness principle leads decision-makers to ponder if their decisions would be considered fair by the most advantaged  people in society if, at an instant, they became  the most disadvantaged and required the distribution  for themselves […] This approach is not dissimilar to the maxim “do unto others as you would have them do unto you” which Blackburn contends can be found at the base of almost  every ethical tradition.”

Greg described the functions of PHARMAC, both on the national (meso) level and the individual (micro) level. He said that “sufferers of rare and iorphan diseases commonly fall into this [latter] category presenting in circumstances described as exceptional“.

He said that with regard to the Agency’s  national purchasing strayegies, “PHARMAC does an excellent job of consistently providing subsidy for an adequate range of quality pharmaceuticals” and “estimated that PHARMAC has saved approximately $1.17 billion over 14 years“.

Greg pointed out,

“PHARMAC takes excellent advantage of its market dominance, provided through an exemption from Part 2 of the NZ Commerce Act. The Agency employs aggressive monopsonistic  purchasing practices in negotiating contracts with international pharmaceutical companies.”

“In short PHARMAC is appreciated in New Zealand  as a world leader in meso-level rationing of subsidies on pharmaceuticals.  It provides for a good range of effective medicines to the community. It has done this consistently over 15 years and saved considerable amounts of taxpayer’s money  in doing so.

However, in PHARMAC’s second purpose of providing access to medicines for people whose needs are described as exceptional, the picture could not be more different. My research into the operation of PHARMAC’s ‘Exceptional Circumstances’ policy demonstrated  that PHARMAC does not closely align with high levels  of fairness to individual claimants, particularly sufferers of rare and orphan diseases […] it appears that PHARMAC does not provide subsidy equitably  for people with diseases requiring high cost medicines.”

Greg outlined how Ombudsman David McGee had assessed PHARMAC’s  policy that “supported the position that high and low cost medicines should be examined by the same decision-making criteria, and found that whilst it was lawful, was not reasonable“.

The Ombudsman stated that “… to attempt a specific recognition for rare diseases in the NPPA policy would significantly undermine the Pharmaceutical Schedule“.

Greg summed it up by stating  that “it would seem the two objectives cannot reside amicably in the same house“. He further stated,

“PHARMAC protects the inviolability of the CUA [cost utility analysis] process by not considering the personal circumstances of claimants despite the intention of the legislation to manage the claims of individuals in exceptional circumstances. Similarly, PHARMAC’s assessment of individual  claims takes no interest in the relative condition of claimants…”

He added,

“PHARMAC takes no regard of the needs of the least advantaged before the needs of the most advantaged and does not consider information from claimants about that which they have good reason to value in their lives.”

“PHARMAC also relies heavily  on opinions from it’s committees of  expert health economists. My research shows there was criticism of Quality Adjusted Life Years (QALY’s)  as the only economic assessment tool used in the efficiency study […] I am also aware that NZORD has complained that PHARMAC is choosey about which experts  it consults and has used experts that NZORD considers do not have international credentials to adjudicate on some claims by sufferers of rare and orphan diseases.

My research also demonstrated  the somewhat speculative nature of decision-making in that PHARMAC decision-making committees in the past have not recorded the reasons for decisions nor advised claimants under which criteria their applications have failed.”

Greg’s assessment of PHARMAC’s failings on this point  was explained that “underlying  this PHARMAC practice is a deep anxiety that, if claimants were provided with the reasons why their claims were denied, some would most certainly be challenged.

Greg then asked two questions,

“As a society do we believe that medical practitioners and economists are are qualified to make moral judgements about claimants and what they deserve?

Are medical practitioners and economists the right people to be putting  a price on what claimants have good reason to value in their lives?”

Greg pointed out the reasons why PHARMAC judged claims by individuals suffering rare and orphan diseases, calling threm all “excellent reasons“;

  • If PHARMAC accepted all claims, it would exceed it’s budget and fail it’s statutory duties,
  • PHARMAC had to resist unproven/untested therapies, especially so-called “alternative style health providers who cruelly offer desperate people ‘cures’ which are most often hopeless”,
  • PHARMAC faced pressure from pharmaceutical companies to list their own drugs on the Agency’s Pharmaceutical Schedule. These pressures had to be “contained”.
  • And PHARMAC had to demonstrate that it had a robust national-level “rationing”policy to maintain the confidence of Parliament, DHBs, and the public.

“In summary, PHARMAC celebrates the fact that it applies the same meso-level rationing  tools for micro-level decisions. In assessing the pharmaceutical  needs of sufferers of rare and orphan diseases, the tools are simply not fit for the purpose.”

We Need a Fairer System

Greg acknowledged the unfairness of expecting PHARMAC to manage the Pharmaceutical Schedule with a capped budget as well as having to consider expensive and essentially unaffordable claims for medicines. He said that “this situation had created the animosity and on-going frustration between sufferers of rare and orphan diseases and PHARMAC staff and Board“.

He also said it was “equally unfair of rare and orphan diseases to be denied medicines which will improve their life expectancy [simply] because they are being assessed against an economic metric which applies to a model based on 4 million people“.

Greg said that a fairer system had to be devised. One that ensured that PHARMAC was unencumbered in it’s primary role of nationwide rationing, involving the subsidisation of a wide range of pharmaceuticals for New Zealand. This was a role that PHARMAC did very well.

Greg then offered a solution;

“But we also need a micro-level rationaing system with a different set of rationing criteria more suited to the task of analysing claims of individuals and small groups of sufferers of rare and orphan diseases. The fund would be, let’s call it, the ‘Rare Diseases Funding Agency’ (RDFA). It would have  a Board appointed by the Minister of Health and administered by the Ministry of Health. The Fund should be regularly reviewed and reported to the Minister.

The RDFA will need to carefull consider both relative economic efficiency and locate the best relevant expert advice it can muster. It would make sense for PHARMAC to undertake the CUAs when required on behalf of the new Agency.  The decision making criteria will also need to develop a level of understanding the quotient of fairness and be aligned with community values  in support of micro-rationing…

[…]

… I am in no doubt that the RDFA will from time to time be required to make unpopular decisions. On such occasions the Agency will suffer the same level of criticism and unpopularity as has been visited on PHARMAC. However under such circumstances claimants seeking a review should be able to expect a fair hearing of their circumstances and be advised of the reasons for the decision made.

[…]

The Rare Diseases Fundaing Agency that I have described follows the international  precedents set by Australia, England and soon in Scotland.”

Greg concluded with this salient point,

“I doubt that there will be a day when the Rare Diseases Funding Agency would be able to fund individuals and small groups of people for every treatment available. Under our current funding system, this day will never come. However, the new agency will have fairness and community values among its founding principles. It may not [be] able to provide perfect fairness, but New Zealand would have a system which travels purposefully in that direction and sufferers of rare and orphan diseases would be better off than they are now.”

[Note: a full text of Greg’s presention can be found here: Funding Pharmaceutical treatment for Rare Diseases in New Zealand; we need a fairer way of doing things– Greg’s speech is highly relevant for our wider society as he touches upon issues relating to social equality; individual rights;  and a fairer distribution of resources. My report only briefly touches  on Greg’s main points; his full speech is rich in ideas and information. – Frank Macskasy]

At the conclusion of Greg’s address, which was warmly received by the audience, Wallace invited all speakers to take seats up-front and engage in a question and answer session;

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nzord-seminar-1-august-2013-wellington

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This was followed by guests from the four main political parties represented in Parliament; National, Labour, The Greens, and New Zealand First. (The Maori Party sent an apology along with a policy statement.)

There was to be a surprise policy announcement from one of the parties.

To be concluded at:  Opposition parties work together on “orphan drugs” (part wha)

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Copyright (c)  Notice

All images are freely available to be used, with following provisos,

* Use must be for non-commercial purposes.
* Where purpose of  use is  commercial, a donation to NZ Organisation for Rare Disorders is requested.
* At all times, images must be used only in context, and not to denigrate individuals or groups.
* Acknowledgement of source is requested.

Previous related blogposts

Priorities? (19 Oct 2011)

Terminal disease sufferer appeals to John Key (12 Nov 2012)

Terminal disease sufferer appeals to John Key – Update & more questions (28 Nov 2012)

Health Minister circumvents law to fulfill 2008 election bribe? (18 Dec 2012)

Johnny’s Report Card – National Standards Assessment – Compassion (9 Jan 2013)

“There’s always an issue of money but we can find money for the right projects” – John Key (20 Jan 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part tahi (4 March 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part rua (4 March 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part toru (4 March 2013)

Additional

NZORD

UN Special Rapporteur on Health

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Opposition parties work together on “orphan drugs” (part rua)

8 August 2013 2 comments

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Continued from: Opposition parties work together on “orphan drugs” (part tahi)

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NZORD - seminar - 1 August 2013 - Wellington - pompe disease - manual cover

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NZ, Wellington, 1 August 2013 – A seminar in Wellington was held NZORD, the New Zealand Organisation for Rare Disorders , to discuss the problem of lack of funding for “orphan drugs”. People with rare diseases are missing out of medication – a life-threatening situation.

Following on from Kris Gledhill, host Wallace Chapman – of Prime TV’s ‘Backbenchers‘ fame, introduced the next speaker; Matthew Smith;

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nzord-seminar-1-august-2013-wellington

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Matthew is a barrister at Wellington’s Thorndon Chambers, and practices in the area of civil and commercial litigation. His focus is on public laws and judicial reviews – something of particular relevance to NZORD’s members and supporters.

Matthew presented an overview of the Pharmaceutical Management Agency (PHARMAC) with explanations as to it’s guiding legislation; policies; and obligations.  His primary speech notes can be read here, and are worthwhile  accessing, if only to gain a deeper understanding how the Agency works (the speech notes are brief, only 5 pages, double-spaced typing).

He began with a “starting point” of  public law and the consideration for the judicial oath of office where anyone who becomes a judge of a Court “must do right for all manner of people“. He said this was relevant because that it was part of the decision-making process, and would be relevant in terms of international human rights obligations , domestic human rights obligations, and at an individual level for any funding decisions that PHARMAC makes.

General principles of law were also relevant to all  public-sector decision-making, “and that applies as much to PHARMAC as it does to any other  body“.

Matthew wanted to draw attention to  three main principles;

Firstly, that decisions have to be individual-specific and case-specific; that PHARMAC has to be consistent in decision-making, treating similar patients similarly, as well as recognising that there are points of difference that meant the dis-similar should be treated dis-similarly. Which was relevant, he said, to cost assessments in the context of PHARMAC’s funding decisions.

The third point was the human rights consideration and Matthew referred to Kris’s in-depth analysis of this point. He  confirmed Kris’s comments by stating,

“The relevance of human rights considerations is in least two dimensions in PHARMAC’s decision making. One is in the development of  any general policy  which applies and governs or informs the decision making process. And two, is in the individual level, the application of individual applications by individual applicants for funding, and their relevant human rights and how those rights impact upon the  decision that PHARMAC has to make.”

Matthew said that PHARMAC’s functions are set out in section 48 of the NZ Public Health and Disability Act, which firstly tasks the Agency with maintaining a Pharmaceutical Schedule, and the second to focus on the circumstances in which PHARMAC will make individual exceptions to the Schedule  with additional funding and grants.

PHARMAC’s policy to determine individual applications is governed by  their  Named Patient Pharmaceutical Assessment (NPPA) Policy. There are nine criteria by which they make their decisions. Whilst none of the nine criteria specifically referred to human rights considerations, Matthew pointed out that the ninth criteria referred to “other considerations“.

Matthew wasn’t certain if Pharmac considered human rights factors as part of  “other considerations“, but he said that they should under “human rights obligations“. He said that the general statute under which PHARMAC operated does mandate consideration for human rights factors.

Interestingly, Matthew pointed out that PHARMAC’s,

“…budget is notional, because PHARMAC itself does not pay the subsidies for pharmaceuticals. They are paid by the Ministry of Health, on behalf on the DHBs.”

Matthew repeated that general and broader law required PHARMAC’s decision-making for individual’s making applications,  to consider an  individual’s circumstances, and of the patients who would be beneficiaries of the drugs to be funded. He added that a practical consequence of that criteria was that PHARMAC could not use the price of a medicine as a reason to decline an application.

Matthew also pointed out that in analysing the cost of a particular drug, that cost had to be offset against any other costs otherwise spent by the health system for providing a service that otherwise would not be provided by PHARMAC. Costs, he said, had to be considered in a fairer, broader, more holistic way, taking into account offsetting costs, indirect as well as direct.

In terms of consistency, Matthew said that general consistency of treatment was identified as a principle of law and treating “like with like” flowed from principles of equity and equitable considerations. He added that often it was over-looked that consistency also meant identifying those who were in a different situation  and treating them differently. He used an example of  a population group with disimilarities to the rest of  the population, and that those disimilarities should be taken into account.

Taking differences into consideration maintained consistency. That had to be reflected in processes, as well as in end-decisions.

In answer to a question from the audience, which asked why applications from rare disease patients were still being turned down, Matthew replied, that the Act allowed for cost as one of three considerations.  He accepted that cost was relevant to PHARMAC.  Two other considerations were clinical needs and determinations, and health needs – the latter not defined in the Health Act.

He suggested that too much focus was currently being placed on cost, cost-basis,  and economic analysis, and that we had lost sight of the fact that we are dealing with people and individuals first and foremost. Mathew said,

“…As people born into the Human Family, so to speak, which is the starting point of all human rights obligations… those are being lost sight of, and those aren’t being given sufficient weight in the context of individual decisions,  and circumstances where, as I understand it, PHARMAC has decided that there is no specific earmarking in terms of the last year the $770 odd-million that was allocated for funding. There’s no specific earmarking for exceptional circumstances or rare diseases…”

Without specific “earmarking” of funds, it seems that those with rare disorders were destined to be sidelined by PHARMAC.

But, there was to be a glimmer of hope later.

Wallace then introduced Andrew Moore, associate professor of Philosophy at Otago University. His field and interest was in  ethics as they related to public policy. He has advised four Health ministers, from Labour’s Annette King to National’s Tony Ryall. He was a founding member and chairperson of the National Ethics Advisory Committee.

His advice has contributed to the national health policy, resource allocation, prioritisations, as well as contracting to PHARMAC;

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nzord-seminar-1-august-2013-wellington

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Andrew started with paying tribute to NZORD and it’s director, for an “ongoing resilient committment”  and respect for  the democratic process, to work toward their goals.

Andrew then defined his concept of ethics – which he tied to the seminar issues,

“I have a fairly basic idea about ethics. Ethics, according to me, is just to do with what matters, and how to live in the light of that.”

Andrew added, “that  the topic here is what matters in the allocation of public funds for medicines, devices, and the like“.

He said that what matters in this context is the people who need these treatments and who can benefit from them. Andrew acknowledged PHARMAC’s statutory role was  to deliver best health outcomes for available  funding. The process was driven by the idea of maximising the public health benefit, and because of  budgetary constraints, there was priority for the greatest  health benefit per dollar.

That meant others missing out and not gaining any public funds, or opting for private support such as friends; reliant on corporate largesse;  missing out altogether,

“Or whatever survival means are available.”

Andrew suggested “pushing at the margins” to achieve ends. He suggested pushing for the ideas of “severity of condition” or “severity of circumstances“; or lifetime disadvantage.

He said the the current “maximised benefits” idea was simply not enough to deliver outcomes for those who needed it. He preferred promotiong the idea of “need” and “severity of condition” as a means to focus on.  Andrew suggested keeping things as simple as possible. For some in PHARMAC, ethics was “too complicated”.

He referred to the UK’s citizen  jury process to arrive at good outcomes and ideas.

Any solution had to be “need weighted” benefit, especially for those in dire danger from disorders.

Despite some fearing the possibility of getting into an “ethical view” on this issue, Andrew reminded the audience that even the current system was built on an ethical view, even though it was a somewhat narrow view. It was impossible to avoid ethics in favour of the status quo, said Andrew,

“You can only choose some views over others. There was no hiding place in the status quo”.

Following on from Andrew Moore, Wallace introduced Dr Andrew Veale, a Respiratory and Sleep specialist and Clinical Director for a private Lung Function and Sleep laboratory at the NZ Respiratory and Sleep Institute in Auckland. Dr Veale is also a sleep specialist at Middlemore Hospital, and has diagnosed and treated Acid Maltase deficient (Pompe Disease) patients. He is deeply interested in clinical trials and physiological measurement;

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nzord-seminar-1-august-2013-wellington

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Dr Veale began,

“I’m involved because I fortuitously diagnosed a few patients with Acid Maltase deficiency, or Pompe Disease, and  they’ve allowed me to walk through their lives. In Freda’s case, for twenty years, as they cope with this disorder, which has had no cure. So it’s been an education for me and I hope of some benefit to them. But most of the time we just talk shop. Social things.”

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nzord-seminar-1-august-2013-wellington

Freda (L) and Jenny (R)

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So began Dr Veale’s talk.

With the aid of coloured slides, Dr Veale launched into a full scale medical explanation of the causes of Acid Maltase deficiency, or Pompe Disease. He showed cross-sections of the human cell, and explained the simple deficiency that has wreaked so much harm and tragedy in people’s lives.

He began by stating that Enzyme Replacement Therapy (to treat Acid Maltase deficiency) was different from normal administration of drugs, as the Therapy used a much larger molecule. (Thank god for Fifth and Sixth Form General Science and Biology classes.)  Whilst normal drugs permeated through the whole body, he said, enzyme replacement had to be targetted to enter cells.

Dr Veale’s explanation of the complex processes was simplified for ease of comprehension. In fact, it was probably easier to take in than some of the legal matters that had been presented earlier.

After the science lesson preamble, Dr Veale added another complication into the mix; how to test treatments for rare diseases when the numbers of  patients are so small. As he put it,

“Patients with rare diseases will never have a randomised, double blind,  cross-over, trial while facing East…” (laughter) “These  patients are treated with observational treatments… which are not as good.”

He said there was a problem with randomised double-blind trials in that they disguised a sub-group who might benefit from the wider group.  Dr Veale added that Acid Maltase deficiency  involved trials that  lasted over years and reports could not expected any time soon. So there were inherent difficulties with the model of clinical trials.

Another problem, he said was the variability of tests. Dr Veale said test results depended on the precision of  test instruments. Test results, he said, also depended on how  a test subject was feeling on a given day and what kind of activities they had engaged in. He used Freda as an example saying that she might well fine on a Monday – but knackered on a Friday because she had been doing gardening that  morning. These were all factors that affected outcomes.

Dr Veale presented a slide with four curves to illustrate his point. He said the graphic was a “fantastic” example of the point he was getting across;

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The  sharp, pointy [red coloured] curve, he said offered a test outcome with a very good precision.  It’s got “tight confidence“; “we can trust it“; “it’s the truth“.

The green curve gaves the same result, but was less precise; “the scatter was wider“. “And it might be the truth“.

Dr Veale then used another chart to show how individual data points, from the same patient, would give differing results. One set of data points showed the patient improving – another set of data points other showed the patient deteriorating. But  it was the same patient and from the same set of data. But overall, it showed a more accurate picture of the state of the patient, “this is some real data”, Dr Veale said.

I was reminded of political polling. Individual polls could give a misleading result for political parties – but an overall picture presented a much more accurate result. (See: Polling Chart on The Dim Post blog)

Dr Veale said that with slow-changing diseases, the temptation was to  test infrequently because not much had changed. As a result, there would be misleading test results from data gained from infrequent  testing. Fewer data points would present an incomplete or misleading picture of the disease’s progression. The infrequency of measurement coupled to an imprecise test would yield poor results. The slower a  disease progresses, he said, the more data points were needed to create a more truthful picture. The same applied to an imprecise test – more measuring was required.

For example, Dr Veale sugggested a year’s worth of testing at one-weekly intervals. And then he would want a further year’s worth of follow-up testing of one-weekly measurements to detect any changes in previous data. That, he said, was using the patient as their own ‘control’, as  the best method of showing a subset of beneficiaries.

Dr Veale presented the final slide in his summation,
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Dr Veale made the strong point of having a separate  trial fund for experimental treatments for individuals  patients, with over-sight  by an independent Advisory Board. The purpose was to ensure outcome measures were  important to the individual patient concerned.

He said,

“I think we’ve got to get it right. These are very expensive drugs and it’s all very well to say  ‘well we shouldn’t worry about that’, but there is a [muffled] cost if we don’t do it correctly. I think there is a way forward here. When you make a decision to treat somebody with these sorts of disorders,  you’re not making a decision to spend $100,000 a year, you’re making a decision to spend five million over a life.

And I think there is an obligation on us to show that it’s of use.”

To be continued at:  Opposition parties work together on “orphan drugs” (part toru)

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Copyright (c)  Notice

All images are freely available to be used, with following provisos,

* Use must be for non-commercial purposes.
* Where purpose of  use is  commercial, a donation to NZ Organisation for Rare Disorders is requested.
* At all times, images must be used only in context, and not to denigrate individuals or groups.
* Acknowledgement of source is requested.

Previous related blogposts

Priorities? (19 Oct 2011)

Terminal disease sufferer appeals to John Key (12 Nov 2012)

Terminal disease sufferer appeals to John Key – Update & more questions (28 Nov 2012)

Health Minister circumvents law to fulfill 2008 election bribe? (18 Dec 2012)

Johnny’s Report Card – National Standards Assessment – Compassion (9 Jan 2013)

“There’s always an issue of money but we can find money for the right projects” – John Key (20 Jan 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part tahi (4 March 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part rua (4 March 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part toru (4 March 2013)

Additional

NZORD

UN Special Rapporteur on Health

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= fs =

Welcome to new glorious People’s Republic of New Zealand

8 August 2013 6 comments

We are living in scary times. This is what 1,058,638 voters got when they ticked the box for National;

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Peters says police wanted his private phone records

Source:  Radio NZ –  Peters says police wanted his private phone records

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When the Prime Minister  and his office can unleash the police onto an opposition party Leader, then we are in deep trouble. This is the sort of tactics Robert Mugabe  employed in Zimbabwe against opposition leader, Morgan Tsvangirai (see: Zimbabwe police turn up heat against harassed opposition).

It’s bad enough that the Police wanted access to Peters’ phone records.

But to liaise with the politician’s office – when police investigations should be apolitical and non-partisan – speaks to an unhealthy relationship between the Prime Minister and Police. We’ve already seen Key appoint an old “school chum” as director of the GCSB (Ian Fletcher).  Police raiding media offices.  The Prime Minister’s office gaining access to phone, email, and security-card logs from another member of Parliament and a journalist. And Police seizing info from telcos without a warrant (see: Police seize Cuppagate texts).

If Helen Clark’s office had pulled  stunts like this, every National party  politician and right wing blogger  would be over this like flies on a fresh cow-patty.

More and more, National is disregarding conventions regarding the separation of State power, and over-riding civil rights and privacy.  Key and his party apparatchiks will target anyone; other politicians; journalists; welfare beneficiaries.

Who will be next?

Imagine the extent of their power once the GCSB and TICS Bills are passed through the House. Imagine the abuse of political power once the GCSB will be spying on us all.

We’ll never know.  It will all be legal. And secret.

Borat would feel right at home.

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Opposition parties work together on “orphan drugs” (part tahi)

8 August 2013 4 comments

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NZORD - seminar - 1 August 2013 - Wellington - pompe disease - manual cover

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NZ, Wellington, 1 August 2013 –  At a seminar in Wellington, Labour’s Health spokesperson, Annette King, announced her Party’s new policy to create a new fund for purchasing so-called “orphan drugs” – medicines – for rare diseases.

Labour’s new policy marks a turning point in the critical problem of “orphan drugs” which are not funded by PHARMAC, but which are a matter of life and death for people suffering rare diseases.

The seminar – held by NZORD, the New Zealand Organisation for Rare Disorders – took place at Wellington’s down-town Amora Hotel, and was opened by it’s executive director,  John Forman;

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TV personality, Wallace Chapman, hosted the seminar, introducing each guest speaker and keeping a tight reign during question time (he’d make a great Speaker of the House);

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Representatives from the Green Party, Labour, NZ First, and National attended.

Main speakers included,

  • Dr Christine Forster, GP
  • Dr Alison Davies, Pharmaeconomics
  • Kris Gledhill, lawyer, Director of NZ Centre for Human Rights Law, Policy and Practice
  • Matthew Smith, lawyer
  • Andrew Moore, Associate Professor of Philosophy at the University of Otago
  • Andrew Veale, Respiratory & Sleep Specialist
  • Dr Greg Coyle, social policy practitioner
  • Daniel Webby, patient & patient advocate
  • Dr Andrew Marshall, Paediatrician, Clinuical Leader Child Health in Wellington Hospital
  • John Forman, executive director of NZORD

First speaker, was GP, Dr Christine Forster. Dr Forster has been a GP for thirty years; held appointments as Chairperson of the Abortion Supervisory Committee, plus involved in committees overseeing assisted reproductive procedures. She briefly participated in the Auckland Health and Disability Regional Ethics Committee;

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Dr Forster began by saying that her role was also about general wellbeing; mental health; and advocating for access to services and resources.

She read out the patient’s Code of Practice,

Every consumer has the right to have services provided in a manner consistent with his or her needs.

Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life…

That is our guiding light“, said Dr Forster,”it is a patient-centered focus.”

Dr Forster spoke of PHARMAC’s successes – but added it could do better,

“In general practice we have contact with the decisions that PHARMAC make every day. We are managing the pharmaceutical changes for our patients who have chronic diseases… Managing the change for them is not always as straightforward as I think PHARMAC think. Many are suspicious and wary of change.”

“It’s a worthwhile process because it’s successful in providing routine medications for New Zealanders at a much lower cost than other Western countries. And for most part this process has no harm [or]  minimal harm…”

She pointed out,

“So the success is the savings for the pharmaceutical budget so more drugs can be funded and improved access to newer treatments.The unexpected bonus for us is that it has removed the drug reps from our rooms and offices.. So huge benefits and minimal harm.”

Dr Forster addressed the perceived high cost factor of orphan drugs,

“The approach to funding drugs, high cost pharmaceuticals, and drugs for rare disorders is different. There is harm, because essentially what we’re doing is witholding proven treatments. We’re making drugs unavailable. My question is, really, are we making decisions about pharmaceuticals in isolation to the rest of healthcare?”

Dr Forster pointed out that there are other examples of expensive healthcare where there cost-benefit analysis is not considered prior to treatment – so why are pharmaceuticals held in a different light?

“The argument’s often  about not funding these drugs… often the view is if they do that, the money will come from someone else; that someone else will have to suffer. But this happens all the time, all the time we are treating a small number of people at huge cost… that’s just the normal treatment.”

Dr Forster said she looks at the outcomes of treatment, not just in a clinical approach with drugs. She said that was a very narrow outcome and in general practice she looked for a much broader sense, of a good life,

“A sense of not being abandoned by society”

Dr Forster concluded by saying,

At the end of the end of the day, I think, it comes down to what kind of society do we want to live in.And it’s one about making decisions about people’s health and wellbeing is not on cost alone.”

After questions and answers,  Wallace Chapman also related his own personal circumstances of carrying a rare disorder – Gauche’s Disease –  and the extraordinary steps that his mother took to ensure he received adequate, life-enhancing treatment. He was told by the Dundedin specialist who diagnosed his condition that “there’s nobody else in Otago” who had  the condition.

His mother  “became a star“, said Wallace. His  mother began phoning MPs and ministers, and went to Jenny Shipley, who was then  MP for Ashburton/Rakaia, and demanded that he receive the necessary treatment to save his life.

He expressed his appreciation to then-Wigram MP, and Alliance leader, Jim Anderton, who “championed the cause” to  get Wallace and other Gaucher’s sufferers the necessary drugs to save their lives. Wallace said his dream was that other people like  Freda could also acquire the drugs they needed.

Wallace wondered what might happen if the government took the money away from funding the Waihopai Spybase and spent it on healthcare. He suggested it might be a better world to live in – a comment well received by the audience.

Wallace added that GPs like Dr Forster were the real heroes in our community – especially those that take an interest in such complex, social  issues.

Wallace then introduced Dr Alison Davies to the audience;

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Dr Davies has a diploma in Pharmacy, diploma in Hospital Pharmacy, and Masters in Medical Science (epidemiology). She has practiced as a pharmacist; clinical researcher for 17 years; and worked in pharmaeconomics for a pharmaceutical company. She has taught post-graduate students at Otago University and is a member of Breast Cancer Aotearoa Coalition. She has represented this patient group voluntarily,  gain better access to medicines.

Dr Davies began  with the  criteria used to make decisions in healthcare – particular ‘tools’ such as  “cost effectiveness analysis and cost utility analysis.

Dr Davies compared different systems used in Australia (PBS); the UK (NICE), and PHARMAC in New Zealand; all three take “cost effectiveness” into consideration as a criteria;

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Criteria for decision making

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Dr Davies pointed to  “...a real tension between making decisions about a population’s health and making decisions about an individual’s health.”

We have a choice about which costs to include...”  Dr Davies referred to a Definition of Societal Perspective,

‘Includes everyone affected by the intervention and counts all significant health outcomes and costs that flow from it, regardless of who experiences the outcomes or costs’
 – which means that everyone in society, everybody’s costs and outcomes which are affected by this intervention  are included. Now that’s not how… PHARMAC does it’s analyses. It chooses a perspective of the healthcare system, so only includes the costs that accrue to the healthcare system plus patient contribution to the healthcare, co-payments, that sort of thing. So there’s no inclusion of loss of productivity, personal costs that are outside of health, etc. So there’s no consideration for you getting back to work; the time-costs associated of your caring for a sick or disabled person, your leisure time…”

Dr Davies referred to a person’s  “quality of life”, using the  World Health Organisation definition as  “physical, social and emotional aspects of a patient’s wellbeing that are relevant and important to the individual“.

Dr Davies discussed cost-effective thresholds in the UK and Australia  and asked,

“Does PHARMAC have a cost-effectness threshold?

Pharmac maintain they have no cost-effectiveness threshold for funding of medicines.”

However, she questioned that assertion  and noted a reference to a de facto  threshold in a 2012 NZ Medical Journal.

This impacted on what treatments could or would not be ultimately funded and did not take into account needs such as rare diseases and orphan drugs, she said.

Dr Davies said that breast cancer had 50 types, and the “commoness” of this disease could actually be made up of several rare variants. So we could all have a “rare disease”.

Dr Davies said that “orphan drugs” have a high cost but there are often no alternatives and are often  lifesaving,

“That’s where the rule of rescue” comes in.”

Dr Davies compared sea rescues that often cost over a million dollars and we “don’t blink a eye and we all think that’s a great thing to do“. She called it a human impulse or imperative to save one individual.

The rule of rescue, Dr Davies maintained, could equally be applied to saving lives by funding rare medicines.

We need to have a fair decision-making process“, she said,

“Health economists don’t yet  rule the world, thank god”.

The next speaker was Kris Gledhill, a barrister who worked in London for two decades, working on various human rights cases, mostly for people detained.  He lectures at the Auckland University Law School, which includes teaching human rights law. Since January 2012,  Kris was the inaugual director of the NZ Centre, for Human Rights Law, Policy, and Practice;

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Kris opened by saying that his approach was through a human rights framework, and launched with this empowering statement,

“The reason why  it’s important to talk about rights in this context, I think,  is that,  if it’s a right, the grey men at  the Treasury, in their grey suits, and grey socks and grey underpants,can’t say ‘no’. Because if it’s a right, then it’s something to which you’re entitled  and which is enforceable.”

Kris said that were were a number of Treaties and a UN Human Rights Council, whose role it was promulgate our rights, including the right to health.  He referred to the rights which all New Zealanders have under treaties such as the UN Universal Declaration of Human Rights (1948); the International Covenant on Civil and Political Rights (1966); and the International Covenant on Economic Social and Cultural Rights (1966).

Kris said that both Covenants were signed in 1978 – when conservative Robert Muldoon was Prime Minister of New Zealand. He said Muldoon was no “leftie”.

Kris specifically pointed to the Convention on the Rights of  Persons  with Disabilities (2006),  and said it had “an awful lot  power” because of it’s potential as it had no definition of disabilities. He gave the preamble to the Convention,

“Recognizing that disability is an evolving concept and that disability results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others…”

Kris said that the definition of a disability was wide enough that it could cover those with rare disorder, if it interfered with their ability to participate fully and effectively in society.

He said it was a Convention to be made use of.

Kris also said that once a country like New Zealand signed up to an international Treaty (such as those mentioned above) then there was an expectation that domestic law, policy, and practice,  would be amended to reflect international human rights standards.

He said that where issues such as healthcare were involved, and resourcing was a question, that signatory States were obliged to use “maximum of available  resources” that were available to a particular nation, to give effect to the conventions. “It was not a free choice” – we had an obligation, Kris said.

Kris said that New Zealand’s Bill of Rights Act  and the 1993 Human Rights Act,  gave effect to New Zealand’s international human rights obligations.

Therefore, Kris said, international law was not separate from New Zealand law, but a part of it. He said this was recognised both by Parliament that made laws and the judiciary that interpreted those laws.

He said that of particular relevance was the 1948 Universal Declaration of Human Rights, which stated everyone had a right to a standard of living, adequate to the health and wellbeing for himself and his family,  including medical care and disability. That, he said, was what people believed we were entitled to as far back as 1948. The same Declaration reaffirmed our Right to Life, including extensions to life.

This included medical care in times of emergencies such as pandemics; infant mortality; and disorders that reduce life expectancy. He said this meant a right to live, not just a right to life.

The same Declaration, Kris said,  reaffirmed the right not to be subjected to inhuman or degrading treatment. He said that if the consequences of a  disorder are inhuman or degrading, then you have a right to have something done about it.

Most importantly, we have a right not to be discriminated against on the grounds of status. “Status” he said, included “anything of a disabling feature“. The right not be be discriminated against meant not to be treated differently in the light of your status.

Kris said that New Zealand had an obligation to ensure the highest possible standard of health. He pointed to the International Covenant on Economic Social and Cultural Rights which strated that citizens of  signatory states (ie; New Zealand),

” recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”

and,

“the steps to be taken by the States Parties to the present Covenant  to achieve the the full realisation of this right shall include those necessary  for: … (d) the creation of conditions  which would assure to all medical service  and medical attention in the event of sickness”

He repeated that this was a right, and not a choice by the government. He stressed the point that, that under Article 15, “everyone” had the right “to enjoy the benefits of scientific progress and it’s  applications.”

Therefore the grey men in the Treasury can’t say ‘no’.” The resources-based argument, Kris explained, was designed for developing nations and not rich nations like New Zealand.

Kris said that it’s “grass roots” organisations – and their mothers (which elicited quiet laughter) – that have to make use of these rights. He said we need to raise these international obligations in any legal challenges undertaken.

One such means for a legal challenge was to lay a complaint with the UN Special Rapporteur on Health. The Special Rapporteur, he explained, receives complaints from individuals, or groups in society, who have been affected by a denial of the right to health, or componants of health.

Only one complaint has ever been made from New Zealand to the Special Rapporteur, he said, and this facility could be better used by those who feel discriminated against.

Kris encouraged those present to use the international rights he had outlined because otherwise, “if you don’t use them, you actually don’t have them“.

Wallace then opened the floor and asked for questions.

This blogger asked Kris if the international treaties he had outlined have the same weight as free trade agreements, where member states can take disputes to legal tribunals for judgement?

Kris replied,

“Yes, they’re international obligations;  they’re the same as any international  obligations including the free trade international obligations. And the point is that those free trade obligations, the treaties that we’re signing up to there are all signed up to in the context that there is an existing, long standing human rights framework. So the free trade agreements do not overtake the international human rights framework. They exist in the context of the existing and enforceable human rights framework.”

At that moment, I thought of the other forms of discrimination that National was engaging in – such as punitive new policies against welfare beneficiaries. Could forcing beneficiaries to undertake drug tests or use contraception be a form  of discrimination that could be litigated at an international disputes tribunal such as the UN Special Rapporteur on Health?

To be continued at:  Opposition parties work together on “orphan drugs” (part rua)

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Copyright (c)  Notice

All images are freely available to be used, with following provisos,

* Use must be for non-commercial purposes.
* Where purpose of  use is  commercial, a donation to NZ Organisation for Rare Disorders is requested.
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* Acknowledgement of source is requested.

Previous related blogposts

Priorities? (19 Oct 2011)

Terminal disease sufferer appeals to John Key (12 Nov 2012)

Terminal disease sufferer appeals to John Key – Update & more questions (28 Nov 2012)

Health Minister circumvents law to fulfill 2008 election bribe? (18 Dec 2012)

Johnny’s Report Card – National Standards Assessment – Compassion (9 Jan 2013)

“There’s always an issue of money but we can find money for the right projects” – John Key (20 Jan 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part tahi (4 March 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part rua (4 March 2013)

“One should judge a society by how it looks after the sick and vulnerable” – part toru (4 March 2013)

Additional

NZORD

UN Special Rapporteur on Health

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