Threat to patient care as third of British public hospitals in red

No money is ever enough where you have hungry bureaucrats to feed

Despite rapidly increasing budgets, more than a third of hospitals and a quarter of all NHS trusts failed to break even last year. The Healthcare Commission, publishing its annual star ratings, said that the overall deficit was œ500 million, a small fraction of the NHS budget of 69.7 billion pounds.

But, with the NHS facing a tougher future, with no big increases in funding after 2008 and a new and riskier financial regime, the failure hints at future problems and should be taken seriously, Anna Walker, the chief executive of the commission, said. "Financial management is really important. Patient care will suffer if it is not put right," she added. "Quality of care is inextricably linked to good financial management. Temporary instability must not lead to a permanent problem. If it does, patients will lose out because the standards of care will suffer."

The 2004-05 star ratings - the last that will appear in this form - also show that tighter targets in accident and emergency departments have caught hospitals out. For the first nine months of the year, all trusts met the target that 90 per cent of patients should wait less than four hours. But, when the bar was raised to 98 per cent for the last three months of the year, 62 out of 159 trusts with A&E departments failed to meet the higher standard.

The star ratings will be replaced by a new system that, to the casual eye, may not look very different. The "annual health check" promised by the commission will provide, it says, a more comprehensive picture of performance, but it will end, just like the star ratings, with a four-point scale, ranging from excellent to weak. For excellent, read three stars; for weak, no stars.

The star ratings' final hurrah paints a picture of gradual improvement across the NHS, despite the financial problems. Sir Ian Kennedy, the chairman of the commission, said: "There is no doubt that star ratings have been an important step on the road to effective measurement of the performance of the NHS. "They have played a part in the improvement of care, not least in a significant reductions in waiting times. But the system has not provided a comprehensive picture. We need a richer picture, reflecting the needs of patients."

Gill Morgan, chief executive of the NHS Confederation, which represents hospital managers, relished the demise of star ratings. She said: "The scrapping of star ratings is a good day for patients who may believe that their local hospital has lost a star because its services have deteriorated over the past year. "In fact, trusts have been measured against targets that have become progressively tougher and so some NHS trusts may earn fewer stars this year despite providing a better standard of care. We believe that, in some instances, star ratings have become a perverse system that scares patients and the public unnecessarily and demoralises hard-working NHS staff. That's why we are delighted that star ratings are being abolished and replaced with a new, fairer system of assessment."

This year's figures show improvements in death rates for diseases such as heart disease and cancer and a more rapid service in hospitals, with waiting times for elective operations halved from 18 to 9 months.

While 13 more Primary Care Trusts achieved a three-star rating, only 19 per cent in all earned the top status - compared with 42 per cent of ambulance trusts. But Ms Walker said that they also had concerns about the performance of trusts in the South East, an affluent part of the country with fewer health problems than more deprived areas in the North. "There are some hospitals that are not performing so well," she said. "Whether this is really a pattern or is random we don't yet know." But Andrew Lansley, the Shadow Health Secretary, said that the star ratings did not reflect the reality of clinical standards in the NHS. "Many clinical priorities aren't recorded and some targets, like A&E and GP bookings, create more problems than they solve," he said. "However, the star ratings do reflect the reality of financial performance. NHS finances are close to meltdown. One quarter of NHS trusts failed to break even last year and more are facing deficits this year

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About Those Uninsured Americans...

Over the past several years there has been much discussion in both public policy circles and the media about the plight of those Americans who lack health insurance. "Over 43 million U.S. residents, nearly one in six Americans under the age of 65, lack health coverage," says the website of the nonprofit Institute of Medicine of the National Academies. This or some similar statistic is often used as evidence that there exists a large subset of the country's population that has little or no access to healthcare and that the crisis will only grow worse if some action -- typically government-funded and/or government-mandated healthcare coverage -- is not taken immediately. The facts are somewhat different.

One problem with the 43-45 million uninsured Americans figure is the fact that the statistic is dynamic, not static. "[T]he uninsured population is fluid, with many people gaining and losing coverage," reported the Congressional Budget Office on May 12, 2003, in a brief on Americans who lack health insurance coverage. "Between half and two-thirds of the people who experienced a period of time without insurance in 1998, for example, had coverage for other portions of the year." Thus, the 40-odd million uninsured people in December of a given year are mostly a different group of people from the 40-odd million uninsured from the previous January.

Another problem with the statistic is that it tells us how many uninsured Americans there are, but not who they are. This is an important distinction. A 70 year old with multiple medical problems who lacks health insurance is obviously in a much direr situation than a healthy 20 year old who lacks health insurance. Michael F. Cannon, director of health policy studies at the Cato Institute, looked into the aforementioned report from the Congressional Budget Office to find out just who the uninsured are. He discovered that "the persistently uninsured are mostly young (39 percent are under age 25, and another 22 percent are under age 35) or healthy (86 percent report their health to be 'good,' 'very good,' or 'excellent')."

In discussions about the uninsured, there appears to be a tendency -- in some cases unintentional, in others almost certainly deliberate -- to regard "health insurance" and "access to healthcare" as synonymous. Not having health insurance obviously curtails one's ability to obtain certain medications, office visits, and procedures for fractions of their actual cost since the cost is not defrayed by the premiums contributed by thousands of other policy-holders. But it is inaccurate and misleading to equate health insurance with access to nominal or even emergency medical services.

At my own practice, we frequently see uninsured or "private pay" patients. Some of these patients are working people whose employer does not offer health insurance coverage. A fair number of these patients are small business owners. If asked, most of these people would say that they cannot afford health insurance, but this is simply another way of saying that it makes no financial sense for them to pay an insurance company hundreds of dollars per month in premiums so that the charge for a $55.00 office visit can be reduced to a $25.00 co-pay. While the private pay approach to healthcare carries the obvious risk of great personal financial hardship due to medical expenses in the event of developing a serious medical condition or sustaining a major injury, the unlikelihood of this happening must be weighed against the absolute certainty of having to repeatedly pay out insurance premiums to cover likelier and less costly medical services whose monthly or annual totals will most probably exceed the cost of paying out of pocket for the same services.

A lack of healthcare insurance does not preclude access to emergency medical services; indeed, such access is guaranteed by the Emergency Medical Treatment and Labor Act of 1986 at any hospital taking part in Medicare. While even a brief trip to the emergency room can be tremendously expensive for the private paying patient, relatively few such trips are made.

Reuters health and science correspondent Maggie Fox filed a story in October 2004 citing a study that debunks the idea that the poor and uninsured fill America's emergency departments. "Contrary to popular perception, individuals who do not have a usual source of care are actually less likely to have visited an emergency department than those who have such care," said Dr. Ellen Weber, a professor in the division of emergency medicine at the University of California San Francisco, who led the study which was published in the journal Annals of Emergency Medicine. According to the study, 85 percent of patients who visit the country's emergency departments have medical insurance and 79 percent have incomes above the poverty level. Said Dr. Weber, "The mistaken belief that emergency departments are overcrowded by a small, disenfranchised portion of the U.S. population can lead to misguided policy decisions."

None of this should be construed to mean that there is no problem with the delivery of healthcare in America. There are undeniable flaws in our healthcare system that prevent a significant subset of patients from getting the healthcare they require. But such flaws cannot be properly addressed if the problems are defined by statistics that are inflated or considered out of context. Just as an inaccurate set of vital signs or laboratory tests can result in a patient being given an incorrect diagnosis and improper treatment, false assumptions about the extent and character of the problem of uninsured Americans can likewise lead us to spurious remedies.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

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