Published in The Lancet, Dr Morelli's (right) work examines a previous study that was used as evidence to suggest that the introduction of patient choice in the NHS reduced deaths from heart attacks.

 The Lancet report, authored (left) by Professor Allyson Pollock of Queen Mary, University of London, points out a series of errors in the study, which the Prime Minister used as justification for the claim that “competition is one way we can make things work better for patients.”
 
The original study examined mortality rates for heart attack patients measured against the number of hospitals within travelling distance of the patient’s GP surgery. It also looked at data on elective surgery for hernia, cataract repair, knee arthroscopy, hip replacement and knee replacement, and claims that introducing greater choice in elective surgery led to lower death rates from heart attacks.
 
Professor Pollock and her colleagues - including Dr Morelli - say the study offers no explanation as to why the availability of choice for such elective procedures should have any effect on whether heart attack patients survive.
 
Their paper, ‘Statistical association is not causation: Claims that patient choice and market competition in the NHS reduce AMI mortality are misleading and false’, was published in the most recent edition of The Lancet.

Dr Morelli says the inaccuracies contained in the original research casts severe doubt over the validity of the legislation. “The link between competition and patient outcomes that the Government claims simply doesn’t exist,” he said. “The outcome is far from linked to geographical dispersion of hospitals.
 
“There are problems contained within the report. One I identified was the measure of competition used. The results were obtained by looking at instances where there were a lot of hospitals in an area.
 
“The better outcomes therefore could be the result of hospitals being closer to heart attack patients, and the availability of specialist treatment. Looking at this, my conclusion would be that competition is used in this sense, as a substitute for urbanisation and collaboration.”
 
Increased choice for patients is a central plank of the Health and Social Care Bill 2011, which currently faces a vote to pass through the House of Lords. Although the legislation relates only to England and Wales, Dr Morelli says there is scope for a study focussing on Scotland, which would show the impact of choice for patients.
 
“My colleagues and I are looking at a possible comparison within Scotland to see how the concentration of hospitals, GPs and patients impacts upon outcomes,” he added.
 
The Lancet report also concluded the following about the original paper:
 

• The researchers do not look at whether the availability of choice has any effect on where patients go for treatment.
• They do not look at whether or how GPs’ patterns of referrals changed when choice became available.
• Recent research indicates the majority of patients who have been offered a choice pick their nearest hospital.
• Heart attack is a medical emergency and patients generally have no choice about where they are treated.
• Outcomes for heart attack patients tend to be better when they are treated in specialist centres in urban areas.
• The authors ignore the possible effects of major changes in primary care prevention and secondary care intervention for heart attacks.
• And that there is no evidence that the data on elective operations is in any way a good measure of choice or competition. 

Professor Pollock said, “The Government’s Health Bill has faced enormous opposition from the public and from health professionals. In trying to win over his critics the Prime Minister has used the study to justify competition within the National Health Service.
 
“Our examination of this research reveals it to be fundamentally flawed, amounting to the conclusion that the paper simply doesn’t prove either cause or effect between patient choice and death rates. This work should not be quoted as scientific evidence to support choice, competition or the new Health and Social Care Bill.”

WRONG TRAFFIC GENERATORS, NO CITY RE-ENGINEERING 

Professor Iain Docherty, reports The Scotsman  said the capital should have followed other tram using cities in initially linking its biggest traffic generators –  main railway station, to such centres as universities and hospitals.

Edinburgh City Council initially planned two lines, the first a loop linking Princes Street, Leith, Granton and Roseburn, and the second between Haymarket and Edinburgh airport.  Funding problems, mean the current route is being built as a single eight-mile stretch between airport and St Andrew Square.

A third line, which would  accorded with Prof Docherty’s thinking in linking Waverley station, Edinburgh University and Edinburgh Royal Infirmary, was shelved after the congestion charge scheme, to  fund its construction, was abandoned in 2005.

Docherty noted that focusing first on the busiest sites for a tram line was a European approach which included Edinburgh's twin city, Nice, France. “Just about every city has joined up the three largest traffic generators. Edinburgh’s current line does not do any of that.”

In giving the Royal Scottish Society of Arts lecture in Edinburgh, Docherty also added that the council had failed to see the bigger picture. “The tram line was not seen as part of a re-engineering of the city centre... but simply as a transport project.

“There was no understanding of how it would underlie the urban fabric of the city. As has been made clear in the past, if you do not understand what a tram scheme is for, it will fail.”

Docherty again drew on Europe's experience saying that French cities allocated about a third of the budget for tram projects was earmarked for improvements to the “urban realm”. He added: “Much more consideration should have been given to routing along [parallel] George Street instead.”

The scheme should also have been accompanied by improvements, such as removing parking from George Street and making more of St Andrew Square a pedestrian zone. “George Street should be a car-free, high-footfall showpiece street.”

Instead the jury was out as to whether the trams would be a success once they started operating, and whether more lines were built, as had happened elsewhere. “Is Edinburgh going to be the first city that hates its trams from the time they start to run, as well as while they are being built?”