Memorandum by the Medical Technology Group
(MT 44)
INTRODUCTION
The Medical Technology Group (MTG) appreciates
the opportunity to submit evidence to the Health Select Committee,
addressing the critical issue of patient access to medical technology
in the United Kingdom. Representing 25 health care organisations,
the MTG is a coalition of patient groups, clinicians and industry
representatives committed to increasing patient access to medical
technologies within the NHS (see Appendix A). As such the MTG
welcomes the announcement of the Committee's inquiry.
The MTG has long been concerned that the UK
lags behind other industrialised nations in its use of critical,
life-saving and enhancing medical technologies. The reasons behind
the barriers to patient access of medical technology are numerous
and the MTG's submission attempts to outline the nature of these
barriers plus make recommendations for reform.
MTG VIEWS ON
THE INQUIRY'S
TERMS OF
REFERENCE
1. The effectiveness and cost benefit of
new technologies
1.1 Medical device technologies span a very
broad range of therapeutic, palliative and preventive modalities,
serving patients in innumerable ways. From tissue based implants
for reconstructive surgery to neurostimulators for severe movement
disorders, to computer-driven drug delivery systems, medical technology
plays a role in every facet of health care.
1.2 The uses of medical technology bring
enormous benefits to patients, from critical and acute care to
rehabilitation, patients depend on medical technologies to continue
every day activities and to give new hope for productive, healthier
lives. In addition to clinical and other patient benefits, medical
technologies also bring significant economic benefits to the NHS
and to our society.
1.3 But traditional tools for measuring
the benefits of medical technologies often have failed to reach
beyond the clinical setting. This broad range of life enhancing
products can bring economic and human returns in terms of enhanced
quality of life and renewed patient and health care provider productivity.
1.4 Models for assessing the benefit of
technology should consider wider benefits to society as a whole.
A patient who's quality of life is improved by more effective
treatment methods, reduced hospitalisation and fewer return visits
to hospital is likely to have a quicker return to pre illness
activity. That might be a return to work and income generation,
to a vital caring role within the family or just to live independently.
All reduce the burden on other community services and/or State
support.
1.5 The MTG believes that adequate patient
access to medical technology will enable the Government to achieve
many targets including those set out in the National Service Frameworks
(NSFs) and other Department of Health guidelines.
Improved quality of life for patients
1.6 In addition to providing cost benefits
and effective clinical solutions, medical technology has an enormous
role to play in raising the quality of life of patients who suffer
from a wide range of chronic and acute medical conditions. This
manifests itself in a number of different ways:
— Increased life expectancy.
— Reducing further complications
for patients.
— Improved standards of living.
— Improved productivity, both
for patients and their caregivers.
1.7 In contrast to this, there are significant
costs if adequate provision of medical technology is not made.
For example, the continued dominance of coronary heart disease
patients in UK hospitals is a problem that can be addressed through
new technologies for prevention and treatment.
1.8 A questionnaire by SADS UK to families
with a member suffering from a cardiac condition that had been
addressed by an implantable cardio-defibrillator (ICD), showed
that there was not only increased quality of life, but peace of
mind for parents and carers:
"The positive response from those living
with an ICD or as a parent of a child with an ICD was quite staggering
compared to the more negative response of those purely taking
anti-arrhythmic medication".[15]
Personal statements from this survey included:
— "I feel it's a life saver."
— "It gives me freedom from
the anxiety of suffering cardiac arrest."
— "It's like having a portable
hospital inside me."
— "I can live as normal a
life as possible without the worry of dropping dead at any moment."
— "It's a life-saver after
losing my other child to the same condition."
1.9 There is evidence that suggests once
a condition is detected, and the necessary treatment is given,
patients can experience improvements in psychological well-being.
In a study of 38 patients (6-18 years) with recurrent arrhythmias
who underwent radio frequency catheter ablation of ectopic myocardial
foci, psychological functioning was assessed and the patients
resembled a normal population without elevations in anxiety or
depression. After they had had the ablation, the patients showed
reductions in the "fear of their heart problem" and
increases in "the things that they enjoy". The findings
showed that the patients who underwent a curative ablation had
better functioning and that children appear to have the opportunity
for an improved quality of life after ablation[16].
Increased Safety
1.10 Improved safety and reduced complications
often result from the adoption of new medical technologies. This
lessens the anxiety for patients and their families, that results
from uncertainty and repeated hospital visits. For example, innovations
in phacoemulsification for cataract removal mean that fewer complications
will occur, meaning less post-operative visits and increased patient
throughput.
1.11 Case Study 1 (below)—Reduction
of injuries using safer needle devices, demonstrates clearly that
all the stakeholders have worked together to massively reduce
the risk from sharps to both healthcare worker and patients (see
case study 1 and Figure 1, below). Reducing these complications
has led to service improvements:
Case Study 1—Reduction of injuries
using safer needle devices
— It is estimated that over 100,000
sharps injuriesi occur in the NHS every year, and these could
cost NHS trusts as much as £500,000 per yearii.
— But sharps modified with safety devices
are now readily available to the NHS (see Fig 1).
— The Department of Health's "Blue
Book" on preventing sharps injuries is expected soon, and
will require NHS trusts to take measures to improve data collection,
identify training needs and identify where safety technology could
be introduced to reduce risksi.
— MTG supports the Government in this
drive and notes that additional funding may be required, in the
first instance, for safer technologies to be introduced.
i www.saferneedlesnow.net
ii National Audit Office, "A Safer
Place to Work: Improving the Health and Safety Risk to Staff in
NHS Trusts", p 30, 2004.
Figure 1
REDUCTION OF INJURIES USING "SAFETY"
CATHETERS AND WINGED STEEL "SAFETY" NEEDLES[17]
Economic benefits
1.12 The use of medical technology plays a large
role in helping transform the NHS and increasing patient productivity—a
vital element in an economy facing the prospect of an ageing society.
According to Government figures, the number of people aged over
65 has doubled in the last 70 years and the number of people over
90 will double in the next 25 years[18].
New technology can increase the throughput of patients, address
problems of bed blocking, reduce patient waiting times and improve
overall patient access to the NHS (see Case Study 2, overleaf).
— Hospital productivity
1.13 The use of medical technologies can bring
long-term economic gains by shifting the site of care to less
intensive settings, for instance from inpatient hospital to day-surgeries
or home care. By reducing hospitalisation, waiting times are often
reduced and hospital capacity is freed. For example, women suffering
from menorrhagia (heavy menstrual bleeding) can be treated by
free fluid thermal endometrial ablation in a day case setting
and consequently avoid the need to undergo surgical hysterectomy,
which has an average hospital stay of over five days and many
weeks recuperation period.
— Improved patient productivity
1.14 Increased investment in medical technology
leads to an increase in societal productivity. In today's ageing
society, this is vital if people are to lead active lives unencumbered
by the health and mobility problems associated with old age. For
instance, technologies like hip and knee implants are improving
the quality of health care and reducing costs by enabling people
to return more quickly to active, productive lifestyles. These
effects therefore have the potential to assist the UK economy
in its drive to maintain a competitive edge—and by reducing
dependency on social security and disability benefits.
1.15 Use of technology to improve public health
has widespread consequences for the economy. For example, in the
US, the societal value of a 1% reduction in heart disease has
been found to be worth some $500 billion—twice the size
of the public Medicare insurance annual budget[19].
According to David Canning, a health economist whose work is cited
in the 2002 Wanless Report, a similar per-ratio figure for the
UK is not inconceivable. A new study investigating Patent Foramen
Ovale closure for migraine could begin to address the £750
million and 18 million work days lost to the UK economy each year
due to migraines[20].
Case study 2—Thyroidectomy by
Harmonic Scalpel
— In the UK currently around 9,000
thyroidectomies are performed annuallyi; the procedure takes between
one and three hours to perform. The current technique involves
careful dissection and tying of the vessels with sutures, which
results in blood loss.
— Alternatively, thyroidectomy can
be performed using the harmonic scalpel. This reduces blood loss,
clinical risk and procedure time by 30 minutesii.
— Based on sample resource costs from
11 NHS hospitals, it is estimated that the net saving would be
around £740,000 across the UK after taking into account additional
capital and consumable costs. This should also free up NHS capacity
to treat more than 3,000 additional patients waiting for major
surgery. iii.
— Adoption rates for this technology
are limited by annual capital budget constraints at the hospital
level and poor financial flexibility on capital finance options.
i Hospital Episode Statistic 2003-04 and industry
estimates of private activity.
ii P Voutilainen et al. "Ultrasonically
Activated Shears in thyroidectomies", Helsinki University,
Finland.
iii Estimate by Johnson and Johnson, based on
average resource costs of the 11 Trusts taken from reference cost
databases.
2. The Speed of and Barriers to, the Introduction
of New Technologies
2.1 Although the UK is a world leader in
inventing and developing technologies, [21]this
is in stark contrast to its continued failure to exploit this
strength in innovation, and utilise the vast investment in research
and development. The UK lags far behind other countries in its
spending on medical technology, as illustrated in Figure 2:
Figure 2
EXPENDITURE ON MEDICAL TECHNOLOGIES BY SELECTED
COUNTRIES, AS A PROPORTION OF TOTAL HEALTHCARE EXPENDITURE AND
GROSS dOMESTIC PRODUCT[22]
| Country | % of healthcare spent on medical technologies
| % of GDP spent on medical technologies
|
| France | 6.5 | 0.62
|
| Germany | 8.6 | 0.92
|
| Italy | 5.8 | 0.5
|
| Slovenia | 7.1 | 0.57
|
| Spain | 6.1 | 0.46
|
| UK | 4.8 |
0.36 |
| European average | 6.4 |
0.55 |
| USA | 5.1 | 0.71
|
2.2 Because of these low rates of utilisation, patients
in the UK fail to reap the benefits of technologies available
to other nations, through shorter recovery times, reduced hospitalisations,
and increased quality of life and productivity. Illustrated overleaf
is just one example of the UK's technology access gap: modern
cancer screening techniques that are used more widely in other
countries.
Figure 3
2.3 Not surprisingly, the same countries listed above
with higher screening rates also enjoy higher survival rates for
these two types of cancers. [23]Nationwide,
the NHS would stand to benefit from increased utilisation rates
for many technologies, as capacity and waiting times would improve,
as more patients could be treated more effectively with fewer
hospital beds, and nurse and physician time.
2.4 Where the Government has attempted to improve particular
areas of healthcare, through focussing on recommended solutions
in the National Service Frameworks accompanied by significant
and sustained investment, technology uptake has been higher and
Government targets reached. For example, the National Service
Framework on Coronary Heart Disease set a goal of 750 interventions
per million population each, for coronary artery bypass grafting
and coronary angioplasty; these targets were exceeded in 2003.
[24]
2.5 However, where this investment and focus has been
less concentrated, so uptake has been less rapid. For example,
a low-cost patient monitoring device that assists GPs in the early
diagnosis of atrial fibrillation (AF) for stroke prevention and
other life-threatening heart rhythm disturbances has been taken
up by less than 1% of all GPs since its introduction over four
years ago, even though estimates by the current users suggest
that over 150 patients' lives have been saved since then. [25]
Barriers to Introduction of New Technologies
2.6 The MTG has identified three potential barriers that
we believe will threaten patient access to new technologies. These
are outlined below.
(i) Inadequate Tariffs Under Payment by Results.
2.7 The MTG applauds the enormous efforts of the Department
of Health (DOH) to design and implement a system of "Payment
by Results" to facilitate choice and patient centred care.
While Payment By Results promises to bring new efficiency and
improved performance over time, the current transition to Heathcare
Resource Groups (HRGs) for English hospitals as the central method
of achieving payment by results risks the use of tariffs that
do not reflect the true costs of patient care for a number of
critical technologies.
2.8 HRG tariffs are calculated based on prior two year
data submitted by hospitals. Inaccuracy for certain tariffs may
reflect routine errors on the part of hospitals in submitting
costing data, as many hospitals are challenged in adapting to
this complex system. For newer technologies, inadequate tariffs
simply reflect the absence of an appropriate code available to
collect data two years' previously—so related costs become
"lost" in the hospital costing data.
2.9 To address potential shortfalls, the DOH established
a "pass-through" payment that allows for primary care
trusts (PCTs) to pay for the additional costs of new technologies
in a supplemental fashion, for a period of up to two years. The
DOH also recently expanded the pass through definition to include
certain low volume, existing therapies that may face underpayment.
2.10 The MTG fully supports these measures but remains
concerned that PCTs actually have the staff and financial resources
to establish pass-throughs for critical technologies. MTG also
is concerned that a diverse, local approach to providing pass-through
payment will present new challenges once the two-year period has
expired for a technology and a tariff amount must be calculated.
Finally, MTG wishes to bring attention to a number of existing
technologies that likely do not fit the pass through criteria,
but are nonetheless facing extremely low payment under the 2005
tariffs (please see Appendix B).
Figure 4
CARDIAC PACEMAKERS CONSTITUTE A HIGH VOLUME, EXISTING TECHNOLOGY
FACING TARIFF UNDERPAYMENT IN 2005[26]
MTG has written a policy paper on the HRG issues, with recommendations
for Government action; this paper is attached as Appendix C.
(ii) Audit Mechanisms in Support of NICE Determinations
2.11 MTG has long supported a fair and transparent product
review process by the National Institute for Clinical Excellence
(NICE) and has worked to support the adoption and enforcement
of NICE recommendations. However, the adoption of technologies
covered by NICE recommendations has failed to improve substantially
and patients continue to face barriers to access.
2.12 One hindrance to improving adoption of NICE recommendations
is the current absence of reliable national measures for technology
utilisation, that could be used to gauge progress towards NICE
targets for uptake. A recent study by York University published
in the British Medical Journal[27]
shows that following guidance from NICE, there was no apparent
increase in the uptake of several critical device technologies:
hearing aids, hip prostheses, implantable cardioverter defibrillators,
laparoscopic hernia repair and laparoscopic colorectal cancer
surgery. The study also found that NICE guidance has been "less
influential in surgical procedures and use of medical devices"
than for pharmaceuticals.
2.13 MTG calls on the Government to ensure that NHS bodies—such
as the Healthcare Commission—understand the difficulties
of auditing devices and recognise the need to do so. The Group
is also working to ensure that the Healthcare Commission and its
counterparts in the devolved nations have in place appropriate
systems to monitor uptake of all NICE-approved technologies. Through
monitoring uptake, NHS bodies will be able to commission effectively
and plan the provision of healthcare to achieve targets and respond
to the needs of local communities. Monitoring uptake will also
help NICE to assess its own effectiveness as a reviewing body
and its relevance to frontline care providers.
2.14 Ensuring compliance with NICE guidance can be achieved
by relating the commissioning arrangements within PCTs to the
NICE recommendations. Recent Government activity to this end is
a positive sign. For example, the Department of Health's Standards
for Better Health[28]
include the need for healthcare organisations to "ensure
they conform to NICE technology appraisals and, where it is available,
take into account nationally agreed guidance when planning and
delivering treatment and care."
2.15 However, there is certainly more work to do. With
inadequate assessment tools, the economic benefits of NICE-approved
technologies are often not taken into account, and Trusts could
be forced to choose between following NICE recommendations or
going over budget. There is also evidence of "seasonal prescribing",
whereby patients are denied access to certain technologies at
times of the year or month when budgets are likely to over-run.
In the future, budget constraints will be increasingly problematic
for technologies facing HRG tariffs that are too low to cover
the basic costs of care. Thus, further mechanisms must be put
in place to reinforce guidance and ensure and encourage its implementation.
(iii) Procurement mechanisms and their impact on quality of
patient care
2.16 The MTG is worried that the methods of purchasing
medical technology products are shifting away from the interests
of the patients and physicians who depend on them. Procurement
systems must ensure the availability of the best treatment options
for the full diversity of clinical needs of our population, while
still supporting innovation. In 2004, the Commercial Directorate
embarked on an ambitious scheme to consolidate suppliers, create
rapid financial savings, and apply generic, price-focused purchasing
tactics to a broad range of items such as office supplies, food
products, office furniture and, in equal measure, to medical technologies.
2.17 This is implemented by PASA whose primary focus
has been the use of reverse auctions and internet-based purchasing
that disproportionately favour price as a purchasing criterion.
PASA has maintained that quality will be addressed through its
purchasing process, but the MTG is very concerned that this is
simply unachievable under the purchasing methods in use. Unlike
office furniture, which is purchased by a diversity of consumers
in the UK, health care products are purchased almost exclusively
by the NHS—and will easily vanish from the marketplace under
adverse purchasing conditions that do not recognise clinical value.
2.18 The MTG remains concerned that the approach of PASA
is inappropriate for most medical products and threatens to severely
limit the treatment options available to clinicians and patients
in the UK. In short, we believe that whilst the NHS is seeking
to promote innovation and the use of the latest therapies which
are wanted by patients and needed by doctors this approach by
the Commercial Directorate is creating barriers to access.
2.19 To illustrate the patient impact of this current
PASA activity, a recent PASA procurement action excludes a silver
alloy and hydrogel urinary catheter that has been identified by
the Health Protection Agency's Rapid Review Panel as having potential
value in preventing pervasive MRSA bacterial infections—a
leading concern in English hospitals. MRSA infections are resistant
to antibiotics and have been linked to numerous excess patient
deaths. Some hospitals have been obliged to close because of persistent
MRSA patient infections. Silver alloy and hydrogel-coated catheters
have been demonstrated with extensive clinical evidence to reduce
infections, yet they will be unavailable to English patients because
of a PASA process that is focused disproportionately on price.
2.20 While the Rapid Review Panel finding serves as a
positive model of Government action to address an urgent healthcare
need—PASA's actions for this product example shows that
it is out of step with the views of other important public bodies
such as NICE and the Rapid Review Panels. MTG proposes that nationally-agreed
guidance, guidelines and recommendations from public bodies, such
as NICE and Rapid Review Panels, should be given more authority,
and that a clear division of responsibility is made, so that where
action is recommended by such bodies, it is supported and implemented
by other bodies.
3. Key outputs of the Healthcare Industries Task Force
(HITF) Report
3.1 The MTG is hugely encouraged by the key outputs of
the Healthcare Industry Task Force (HITF) and is anxious to see
its policies implemented quickly and comprehensively. A coordinated
approach by Government Departments was taken on the researching
and drafting of HITF and a similar coordinated approach by the
Departments for Health, Trade and Industry and HM Treasury is
needed for the successful implementation of its agreed policies.
Amongst the key outputs of HITF, there are a number of particular
interest to MTG, as they will have direct impact on patient access
to technology.
3.2 Device Evaluation: The MTG supports measures that
ensure patient safety, but within a framework that speeds patient
access to important new therapies. A barrier to uptake of new
technologies is the duplication of evaluations prior to procurement,
causing needless delays in patient access and wasted NHS resources.
A principle of "once-only" evaluation should be adopted,
and an expanded Device Evaluation Service should be the vehicle
for accelerating new technology adoption. To achieve this, the
DES will require governance to ensure impartiality and independence
from short-term cost-saving initiatives that might be drivers
of PASA behaviour.
3.3 Procurement: The MTG strongly supports HITF recommendations
for a regional procurement focus and joint commissioning between
PCTs and SHAs. MTG recommends that mechanisms be established for
discussions between policy-makers, industry and commissioners
about how to adopt new technologies, across PCT and SHA borders
where necessary. HITF also rightly recognises the pivotal role
of clinicians in progressive and effective procurement. The early
and active involvement of clinicians with procurement representatives
should be built in to the commissioning structure to allow for
informed, value-driven commissioning and procurement decisions.
3.4 Communication with patients and the public: The MTG
strongly supports the recommendation to improve public understanding
of medical devices, their benefits and risks and the nature of
the regulatory system. We applaud the proposal that MHRA should
lead a project to achieve this, as part of their efforts to increase
communication with the public. We believe that this patient education
effort fits squarely within the Government's support of patient
choice. MTG would recommend a single source repository of patient
information (NHS website or NHS Direct) that contains links to
approved sources of information for patients and carers. MTG also
recommends the establishment of multiple media channels for the
dissemination of this information as Internet penetration has
been shown to influence only parts of the patient population,
whilst being largely ineffective with hard-to-reach patient populations.
3.5 Training and education: Using technology almost always
requires taking on new skills; therefore where training is under-provided,
incorrect usage can lead to unsafe practices. Therefore, the MTG
welcomes the recommendation on training in the use of devices,
and notes that substantial training already undertaken by manufacturers
is a valuable part of the use of medical technology products.
It is also important to ensure that clinicians are kept updated
with developments in diagnosis and recognition of symptoms.
4. The utilisation of Telemedicine (including Telecare)
and its future potential for improving services
4.1 Telemedicine and other remote care innovations are
technology applications that can truly recast the paradigm of
health care in the UK. Cutting edge technologies in this area
include remote transmitting pacemakers that allow for continuous
observation of patient heart functions, to remote monitoring tools
that survey patient heart rate and blood glucose levels, and other
key indicators from the patient's home. Technologies such as these
not only displace the need for in-person care, they provide insight
to clinicians that in some instances is far more robust that what
can be assessed in a clinical setting.
4.2 Remote technologies, including the broad range of
telemedicine applications also provide essential economic benefits
by reducing the need for hospital observation and testing, shortening
waiting times and leveraging more fully hospital based diagnostic
assets.
4.3 The challenges facing telemedicine are potentially
greater than those faced by conventional therapies, since the
provision of diagnostic and monitoring services and their reimbursement
has traditionally been linked to in-person clinical visits. In
telemedicine, the site of investment is often disconnected from
the site where cost savings occur. Additionally, and because investment
and cost benefit are rarely linked and the benefits are accrued
in other parts of the system, new, comprehensive ways of measuring
total cost effectiveness are needed to truly appraise the value
of these important new technologies.
4.4 The inequities across different regions in adoption
of related technologies is also a challenge, and many of these
technologies require capital investments that are beyond the reach
of smaller institutions and physician practices. In addition,
there is currently a lack of infrastructure to deal with information
that is collected, a problem that may be addressable through the
new national framework for IT. MTG recommends investigation into
the potential for joint commissioning of telemedicine and across
PCTs.
5. Summary of recommendations to the Committee
MTG recommends to the Committee the following points for
action by the Government:
— Put patient care and access to effective
treatment as the guiding factor in all commissioning and purchasing
arrangements for Medical Technology.
— Ensure that tariffs under Payment by Results
reflect the true cost of patient care for new technologies, and
do not prevent the introduction of technologies through inaccurate
data.
— Equip Primary Care Trusts with the resources
to establish pass-through payments, and to ensure there are payment
mechanisms for all new technologies.
— Introduce further mechanisms to reinforce
guidance from NICE and other public bodies and ensure and encourage
its implementation.
— Review the procurement methods utilised by
PASA and the NHS Commercial Directorate, with the objective of
identifying if and how they limit the introduction of new technologies.
— Implement the key outputs of HITF quickly
and comprehensively.
— Investigate the potential for joint commissioning
of telemedicine across PCTs and identify mechanisms to link incentives
to provision of patient care.
— Nationally-agreed guidance, guidelines and
recommendations from public bodies, such as NICE and Rapid Review
Panels, should be given more authority, and a clear division of
responsibility made, so that where action is recommended by such
bodies, it is supported and implemented by other bodies.
15
Anne Jolly, SADS UK Chair, speech to the Parliamentary launch
of the "Making the Case for Economic Technology",
June 2004. Back
16
DeMaso et al, "Psychological Functioning in Children
and Adolescents Undergoing Radiofrequency Catheter Ablation",
Psychosomatics 41: 134-139, 2000; research by Cardiac Risk
in the Young. Back
17
Chen et al, "Prevention of needlestick injuries in
healthcare workers: 27 month experience with a resheathable `safety'
winged steel needle"; Mendelson et al, "Evaluation
of a safety IV catheter"; both Mount Sinai Med Center, New
York, NY, 2000. Back
18
Department of Health, National Service Framework on Older
People's Care, 2001. Back
19
University of Chicago research by economists Robert Topel and
Kevin Murphy. Back
20
Migraine Intervention with STARflex technology trial, 2004; see
www.migraine-mist.org Back
21
Technology in Orthopaedics, Professor John Kenwright, Research
Director, Wishbone Trust; Science in Parliament, Vol 60, No 1,
Spring 2003. Back
22
Eucomed Medical Technology Brief 2004. Back
23
Source: Health Affairs, 23:3, May/June 2004, p 92, Exhibit 1. Back
24
BCIS audit return, adult interventional procedures, 2003. Back
25
British Journal of Cardiology: (2001: Vol 8-6). "Changes
in referral patterns to cardiac out-patient clinics with AECG
monitoring in general practice". Back
26
Reflects Tariff payment estimates for applicable HRGs, with adjustments
for specialised services. Cost of care estimate reflects an average
industry-collected data from typical hospital purchasers of pacemakers. Back
27
Sheldon et al, "What's the evidence that NICE
guidance has been implemented, BMJ 329:999, October 2004. Back
28
Department of Health, "Standards for Better Health"
July 2004.@PARA@@PARA@ @PARA@ Back
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