Monday, May 01, 2006


With some history and what it shows

The prime minister was blunt. "No gain without pain" was his Easter message to the National Health Service to celebrate his third attempt to reorganise it. Two days later I felt the pain. It was a stabbing sensation from a burst cyst and it occurred in two equally alarming places. One was the right groin and the other was mid-Wales. The latter is currently the NHS's Bermuda triangle, where doctors, ambulances and entire hospitals simply disappear from the radar each time I visit.

Not long ago this part of Wales had a 24-hour GP service in the village and two hospitals, one offering surgery, within 10 miles. Now the 24-hour service is a Cardiff call centre with a response from a locum doctor 25 miles away in Dolgellau. The latter explained that under NHS rules I had to visit her in person before she could refer me for an operation a further 40 miles away, either in Bangor or in Aberystwyth. If I were you, she said, I would drive yourself to an A&E somewhere, take a good book and hope for the best. I suddenly saw what Blair meant by his new "patient-driven, choice-based" NHS. You drive, we choose.

To the public the present NHS "crisis" must be baffling. Not a day passes without a bad news story in the press. Deficits are soaring, hospitals going into virtual administration, drug treatments being decided by the High Court and 6,000 staff about to be sacked. Even in fashionable Kensington and Chelsea the health trust has recently found itself with 6 mi;;ion pounds in invoices not accounted for and the auditor not noticing. The same auditor, Price Waterhouse Coopers, is then called in to audit the loss, doubtless adding its own invoice to the pile.

Yet I can dimly see method in Blair's pain and gain. There is at last an NHS "narrative". Waiting lists are down and gleaming hospitals are rising at least in the big cities. The much-quoted 800 million pound deficit is no big deal in a service costing 72 billion. It is only getting publicity because, at last, the government is refusing to rob Peter to pay Paul. The pus of inefficiency is finally starting to ooze from the NHS patient.

The British health service had by the mid-1980s become an unsustainable racket. Doctors were running hospitals according to mind-bending restrictive practices. Theatre productivity was pitiful. Nurses and paramedics were treated by doctors as serfs. A&E patients were handed from one clinician to another in a ludicrous make-work scheme. Drug companies, computer firms, management consultants, negligence lawyers and staff unions were walking away with the till each night.

By 1987 the Tories had doubled spending and the money had vanished. Margaret Thatcher lost her temper. Wailing to Panorama about the "bottomless pit" of NHS costs, she set in train what became the 1990 NHS Act and two decades of reform. Any Briton who smugly insults public administration in France or Italy or Paraguay or Papua New Guinea should study Britain's NHS, c1990-2006. Thatcher's reform began as essentially sound. She introduced fundholding doctors and trust hospitals, forcing GPs to be more resource-minded and trying to release hospitals from the grip of a reactionary medical profession. A bureaucratised NHS would be supplanted by a market-led local one.

The 1990 Act was scuppered first by the Treasury and then by the Labour party. The Treasury refused to allow hospital trusts financial autonomy, even denying them freedom to negotiate their own wages. They lost control of their costs and simply dumped the bill on the exchequer. Yet as a recent report for auditors KPMG by Rupert Darwall - a director of the Reform think tank - has shown, Thatcher's fundholding yielded a more dramatic fall in waiting times than did Labour's extravagance.

When Blair came to office in 1997 he wrecked this structure out of sheer political vengeance. His health secretary, Frank Dobson, dismantled fundholding and the internal market and reduced the NHS to administrative chaos. There followed three structural reorganisations, roughly in 1998, 2002 and 2004 (though connoisseurs have counted seven). There are now 572 hospital and primary care trusts. Community health councils give way to patient forums. Some 40 quangos float round Whitehall as flotsam left over by some overnight headline-grabbing initiative. Last week, desperate for a good news story, Patricia Hewitt came up with "dignity nurses".

Within two years of being created, some 30 "strategic health authorities" are to be cut to 10 and 303 primary care trusts to be cut to 100. Millions of pounds have gone on these reorganisations, which are completely unrelated to health care. Some 15 billion (some say 30 billion) is being allocated to a nationwide "choose and book" computer for which nobody unconnected with the project sees any need. It would have been of no use to me last weekend, in contrast with a tiny fraction of that sum spent on a modicum of local healthcare.

After a further doubling of health spending Blair has returned to where Thatcher was in 1987, with fundholding, trust hospitals and internal markets. This time he appears to mean it, but he will need to keep his nerve. The "missing billions" that caused such anguish to trust budgets this year resulted from Brown's disastrous insistence that Whitehall, which means the Treasury, negotiates NHS pay. The resulting 2004 pre-election award to doctors sent GP pay to 100,000 pounds (and reportedly to 250,000 pounds for some). It came as a bolt from the blue to hospital treasurers. So has the new national tariff for hospital operations. Neither took any account of local costs and wrecked all long-term planning. Four top children's hospitals, including Great Ormond Street, have indicated that the tariff may bankrupt them.

Hospitals are the financially threatened species of the new Blair/Thatcherism. By allowing hospitals to borrow at will - rather than borrow from him - Brown has allowed them to build up a 6 billion liability at private rates of interest with twice as much in the pipeline. A big hospital such as Queen Elizabeth's Woolwich predicts an annual debt charge of 100 million pounds, money it certainly does not have. British hospitals will soon be fighting for their lives.

The government appears to have accepted that an NHS hospital is no longer regarded by staff or patients as a philanthropic charity but as a factory supplying an expensive service, lucrative for some. Blair says he expects 40% of operations to be performed privately. But if hospitals are to revert to their 19th-century status their independence must be real.

Hospitals must be free to collaborate, plan their specialisms, liaise with "cottage" outposts and not have the Treasury and the NHS central costs imposed on them, whether expensive staff or expensive drugs. Otherwise they will end up like Railtrack, healthcare's infrastructure authority with ministers meddling in every bedpan.

Blair is clearly relying on his new breed of highly paid and entrepreneurial GPs to hold and disburse NHS cash. It is a version of Thatcher's original (but diluted) Enthoven plan whereby "money follows the patient". Gone will be the local general hospital offering a table d'hote service within easy range of patients, which is why northwest Scotland and mid-Wales are being denuded of beloved institutions.

On the other hand local GPs, their pockets and "commissioning" budgets bursting with money, may band together with local authorities to run new health centres, perhaps even hospitals. Already Wychavon council in Worcestershire is doing just that. If there is any superfluous tier in all this it is the once-vaunted primary care trusts. They should be put out of their misery.

GPs should go back to the arrangement before the war, under the wing of elected local health committees. They were cheap and they worked. There will be "postcode lottery" rows. But democratic accountability will be clear, as in Scandinavia, Germany and other countries where healthcare contrives to be better than ours yet is not "nationalised". In Denmark just 5% of patients need treatment that cannot be supplied within the remit of their elected county health authority.

It is possible, just possible, that this is the "gain" of which Blair was talking. Of the pain there is no doubt.


South Australian public hospitals hit by 'thousands' of mishaps

And health officials are spinning like a top

The number of adverse events being reported in South Australian public hospitals has soared as officials move to make the system safer. A concerted effort to make the system more open, including a 24-hour "dob-in" line for health workers to report incidents or near-misses, saw reported incidents jump from about 8000 two years ago to more than 22,000 last financial year. An "adverse event" in the health system is any incident that accidentally causes harm or has the potential to cause harm to patients or to staff, and may range from minor events, such as slippery surfaces, to major surgical errors.

The rise in reports is expected to continue, with more than 16,000 reported in the financial year to March. However, officials say the high number is due to staff being encouraged to report all incidents rather than reflecting a rise in problems. They say patient safety is being improved as a result. Incidents being reported - and investigated for future prevention - range from minor problems to major medical disasters. A 2003/04 report, the latest published in-depth data, showed these included 66 incidents causing serious harm to patients, and five "sentinel", or most serious, events. They were:

TWO suicides in hospitals.

ONE intravascular gas embolism.

ONE reaction from a transfusion of incompatible blood.

ONE maternal death or serious morbidity associated with childbirth.

Officials estimate more than 10 per cent of the 360,000 people admitted to SA public hospitals will suffer an adverse event.

To reduce this, the Health Department three years ago introduced a new approach aimed at making the health care system safer. A key point was encouraging staff to report events including near-misses so they could be investigated to ensure such events did not occur again anywhere in the public health system. A 24-hour, seven-day hotline was established where incidents could be reported, then followed up with an investigation rather than simply being recorded.

From a slow start, health workers have embraced the idea and last month reported 1200 incidents on the hotline. SA Chief Medical Officer Professor Chris Baggoley said this week the rise in reports was due to the new culture of openness rather than a rise in problems. "This is about getting people to call in to prevent problems," he said. "Fully three-quarters of the total reports relate to what we call close calls, and that is something to encourage. "No one came to harm, but could have unless someone was on the ball. "Even though people are alert and preventing problems, people still get on the phone and report it, which is really good; it is a culture coming in. "There have been significant improvements in safety in a variety of areas but there are still improvements to be made."

As part of the major overhaul of the public system, a new SA Hospitals Safety and Quality Council will be launched on July 1. Prof Baggoley said private hospitals, GPs and community health services would be invited to join as part of the concerted effort to improve patient safety across the state. The move to upgrade safety has seen the Health Department launch initiatives, including a 10 Tips for Safer Health Care brochure urging hospital patients to take a more active role in their health care. Another is a new protocol upgrading checks to ensure the correct person receives the correct operation or medication. A BloodSafe Nurses program has reduced blood transfusions given outside national guidelines from 18 per cent to less than 2 per cent. More than 1000 senior staff have been trained in root cause analysis methods to find why problems occurred and correct the system rather than simply finding someone to blame.

By June 30, all metropolitan hospitals will have a uniform medication chart which will be extended statewide by June 30 next year to cut the chance of mistakes as staff move between hospitals. "We want patients to be partners in this because they can reduce their own risk," Prof Baggoley said. "In the past, there was a tendency to say once in hospital, 'I'm in you're care' but we want people to ask questions, to help make sure they are getting the right medication and so on."



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?

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