Tuesday, July 31, 2007

Surgeon breaks cover over NHS beds crisis

Specialist wards full to breaking point. Patients with serious injuries denied care. A health service paralysed by arguments about funding. Martin Bircher, one of Britain's most senior consultants, speaks out:

One of Britain's leading trauma surgeons has broken cover to expose the scandal of a national shortage of emergency trauma beds which is leading to thousands of serious injury victims suffering in agony. In an unprecedented intervention by a senior practitioner in the NHS, Martin Bircher, a consultant at St George's hospital in London, one of Europe's leading centres in the treatment of major accident victims, has revealed a system paralysed by red tape and disputes over funding, which is putting thousands of patients waiting for treatment in specialist wards at risk. His revelations have prompted calls for a review of funding for A&E services and a shake-up in the management of Britain's leading trauma centres.

Mr Bircher says the problem is worsened by the bureaucracy of the internal market. He has become so frustrated that he has broken free of NHS strictures against speaking to the press and agreed to talk to The Independent on Sunday about the suffering patients are put through.

Every one of Britain's specialist trauma beds is full, which means some patients can wait up to three weeks after their accident before badly broken bones can be repaired. The delay, says Mr Bircher, can jeopardise recovery. With nothing but praise for frontline staff, he says patients who have been critically injured in road or other accidents have to wait an average of 12 days - often in agonising pain - before they can receive the vital specialist treatment. This is because only a limited number of hospitals have the expertise to repair smashed bones, and those hospitals have a shortage of intensive care beds. With the average cost of keeping a trauma patient at around 500 pounds a day and up to 2,000 a day in intensive care, this is also a false economy.

Reacting to the revelations Andrew Lansley, the shadow Health Secretary, said: "It is vital that clinicians are able to prioritise patients according to clinical criteria. It's only if we dispense with central targets and the bureaucratic burdens of the Department of Health that we can give GPs and local hospitals the opportunity to make services more efficient." John Pugh, the Lib Dem health spokesman, added: "This shows how counterproductive the target culture is. Patients are being shunted in and out of A&E to satisfy the expectations of Whitehall. Medical staff should feel free to act in the best interests of patients."

Squabbles over funding

Mr Bircher, who risks censure from the NHS for speaking out, said primary care trust and bed managers are involved in making the final decision as to whether a patient can be moved. If they have to move them there is often a conflict or reluctance because the new area does not want an extra cost. So after initial admission to a general hospital's emergency wards, where lives are saved, patients can find themselves waiting up to three weeks before their real recovery process can begin.

Mr Bircher, 52, cited one patient who had a motorcycle accident earlier this month and was referred to him to decide if she needed surgery to repair her badly broken pelvis. However, he did not receive the request for a week because an initial referral to another hospital was "intercepted by the primary care trust" and rerouted to a hospital that did not have a surgeon with the expertise to make the decision.

He called for emergency medicine to be funded centrally. "These are basic core services that have to be provided," he said. "We shouldn't be sending each other little bills. Trauma and other emergency services like cardiac and stroke services should be top sliced. The money should come from central government funds." Mr Bircher added that doctors and nurses on the frontline in hospitals should not be criticised. He said they do their best but are hampered by layers of managers whose major concern is the budget rather than patient care.

Delays in treatment

He said: "The delays are caused at various levels. If doctors, nurses, physiotherapists, the treating teams, were left to communicate between themselves without bureaucracy, things would happen much more quickly. In the good old days somebody would ring me up about a patient, I'd say send them across, make one call to sister on the ward and it would happen. "Now I'm loath to accept a patient unless I'm sure their injury requires surgery. If I'm unsure I ask them to send X-rays. Even in this technological age this can take two or three days. It's not unusual for them to be delayed or get lost.

"It may be decided that the patient needs an operation and we decide to bring them in. There can still be a delay because bed managers are reluctant to accept a patient for three or four days before the operation is due because of the extra costs. So the patients often come in just hours before the operation. It is not unusual for a patient to arrive in the early hours of the morning, a very short time before their surgery.

"You suddenly find the patient may develop a problem and you can't operate. So you've accepted a patient for a slot and then you can't operate. A much better system would be to have a free flow of patients to the trauma centre where we can get to know them preoperatively. But because trusts all have separate budgets, though we're all playing for the same team, there seems to be a reluctance to accept patients at an appropriate time before the operation. "You can argue whether a patient needs a hip replacement at hospital x or y," he added. "As long as it's done in a reasonable time by a good team it doesn't matter. You can't have these petty squabbles. There just isn't time with trauma."

Patients in pain

His argument is illustrated by Lucy Lynn-Evans, a 21-year-old student from London who was severely injured in a road accident last month. She was riding her scooter to Brighton when she was run over by a 10-tonne lorry which came to rest on her hip. She is alive only because a laptop in her backpack took the full force when the lorry ran over her spine. Her life was saved a second time by the staff at Redhill hospital, where she was initially taken with a smashed pelvis, smashed knee and leg broken in two places. They gave her a blood transfusion - she had lost five pints - and wrapped her hip, described by doctors as a "bag of crisps", in a sheet which was then pulled tight to keep the fragmented bones together.

This is the correct procedure. But Redhill hospital did not have the expertise to repair Ms Lynn-Evans's bones. That would require specialist surgeons and equipment that can be found only in certain hospitals around the country. All they could do in Redhill was put her on morphine and wait for a bed - which at one point she was told could take up to three weeks.

Her pain was so intense, however, that the morphine "only took the edge off it". "I was in a lot of pain, especially when they log-rolled me to change the sheet," Ms Lynn-Evans said from her hospital bed at St George's on Thursday. "It took four people to turn me. The nights were horrible. The mornings were really painful. The three weeks of waiting is an extra three weeks of pain. You just feel like you're going mad. You feel black and despairing. You want with all your heart for someone to make it better. I asked Dad to leave me outside the hospital because then it would be more likely I'd get a bed, rather than waiting by the phone. I felt despair, lying there feeling empty and feeling that I had to tackle this day by day for weeks."

Lack of beds

Ms Lynn-Evans's problem was that she was stable and not going to die; when a bed became available it would go to another more pressing case. At one point a bed became available at the John Radcliffe hospital in Oxford, but before she could be moved John Radcliffe's fund manager had to agree. The fund manager did not arrive at work until 9.30am. By the time Ms Lynn-Evans's case came to the top of the administrator's pile and permission was granted, the bed had gone. Fortunately for Ms Lynn-Evans her mother, Julie, is a psychotherapist who works in child mental health. She is also a broadcaster with a string of top NHS officials in her contacts book. She was able to make a fuss where it counts, and her daughter was moved to St George's hospital in London after only five days.

"Because of the problems with the beds I didn't know where to go to after the accident," Julie Lynn-Evans said. "Lucy was taken to Redhill on the Friday and they saved her life. I cannot thank the doctors enough. But they knew they didn't have the expertise to fix her so I was told not to go to Redhill because they were going to move her. Then at 4am I was told to go to Redhill after all. I'd spent the whole time living through a mother's worst nightmare and yet unable to go to my child. The same night as Lucy, a woman came in from a car crash. She was 63 and had a clot in her lung. Lucy was considered stable, so the woman got her bed. All the time Lucy's having no treatment. As a mother you'd do anything to help your child when you see them in so much pain. But I know that in securing a bed for Lucy, someone else had to wait longer."

Fortunately Lucy is going to make a full recovery, which she and her family put down to the excellent care they have received from surgeons, nurses and doctors at both St George's and Redhill hospitals. The delays, however, caused by bureaucracy and a shortage of beds, could have led to a very different outcome. "The delays not only cause distress to families and patient, but other serious medical issues - thrombosis, bed sores, chest infections and urine and wound infections," said Mr Bircher. "The longer the bone fragments are left displaced, the more the clot begins to form new bone, thus the harder it is to replace the fragment to the correct position.

Patients suffer

"The first step to dealing with the problem is an acceptance and realisation that the system isn't working with trauma and other emergency services in medicine. Sending each other forms and bills is not a good way of doing it. I'm acutely aware that resources are an issue. But basic emergency services should be of the highest quality. If we consider ourselves a leading nation we should have a first-class emergency healthcare system. We do not, and the situation is worsening. "It's pot luck where you go. There's not a defined system. We have to fight every day to get patients in. We have to break through the bureaucracy and develop a new system. There is a lack of intensive care beds in London and around the country which further magnifies the problem.

"Direct funding from the centre, perhaps cutting out the trusts, is perhaps a good idea. One must involve clinicians at the sharp end in the decision-making. Like the Bank of England the politicians should let it go. Doctors, honestly, know best."

Dermot O'Riordan, a member of the council of the Royal College of Surgeons, agreed that a number of services - not just trauma - needed commissioning at a higher level and in some cases co-ordinating nationally, although not necessarily centrally funding. Mr O'Riordan, the RCS council member responsible for the Delivery of Surgical Services Committee, said: "Commissioning of very specialist services, whether elective or emergency, needs to be done at a higher level than a primary care trust. Some need to be co-ordinated by the strategic health authority and some even at national level."

A spokesman for the Department of Health said: "We recognise that a very small number of patients may wait to receive appropriate care. This is because they need very specialised treatment, and critically ill patients waiting for treatment is the exception rather than the rule. "Capacity in intensive care units has improved dramatically in recent years. We now have almost 1,000 more ICU beds than in 2000 and we are looking at ways to increase capacity further."


More overseas doctor concerns in Australia

The inquest into the death of a 16-year-old girl who died in a Sydney hospital after being hit by a golf ball may have to be reopened following allegations about the competence and assessment of two overseas-trained doctors involved in her care. The allegations -- aired on ABC TV's Stateline program in NSW last night -- claimed neither of the overseas doctors treating Vanessa Anderson had been "subject to any appointments or selection process".

Anderson died in 2005 while being treated for a fractured skull caused by the golf ball. The inquest at Westmead Coroners Court, which held its final hearing two weeks ago, heard there were "a number of deficiencies" in her care, including one doctor's failure to give anti-convulsive drugs as ordered by a consultant. Another doctor, anaesthetics registrar Sanaa Ismail, increased the dosage of painkilling drugs to a level the consultant in charge told the inquest was "too high".

It has now emerged that the inquest may be reopened after a senior hospital anaesthetist, Stephen Barratt, wrote to Deputy State Coroner Carl Milovanich about the allegations. In a statement to Stateline, NSW Health director-general Debora Picone said the "accuracy and relevance of a number of the assertions" made by Dr Barratt were "disputed". "The tragic death of Vanessa deserves proper investigation by the state Coroner and I do not think it appropriate to pre-empt the coronial process," Professor Picone said.

In his letter, Dr Barratt said Dr Ismail -- whom he was supervising -- had previously been judged by him to be "not safe" to treat patients after two previous incidents just months earlier. Dr Barratt also revealed he was "unhappy" with how the inquest had unfolded and added "you need the truth". Azizi Bakar, the doctor who had failed to provide the anti-convulsive drugs ordered by a consultant, was the other doctor whom Dr Barratt suggested had not been properly screened prior to employment.

Dr Ismail faced questions during the inquest over her decision to double the dose of a painkilling opiate drug, oxycodone, to treat Anderson's headache, despite the fact that she only spoke to the patient for a pre-operative check. Dr Ismail said she did not realise Anderson was already receiving Panadeine Forte, a painkiller with a high level of codeine, another opiate drug.

Dr Barratt's letter alleged that Dr Ismail's salary was being paid by the Saudi Government, an arrangement that he said was "not unusual in the public hospital system -- that is, there are many others like her". "In fact, a few months before the Vanessa Anderson incident a bureaucrat from the Department of Health came pleading with us to take more of these 'trainees'," Dr Barratt wrote.

Professor Picone said "learning exchange" arrangements was a "feature of any modern health system". Out of a total 11,000 doctors in NSW public hospitals, about 100 at any one time would be paid for by an overseas government or other agency, she said.

Alison Reid, medical director of the NSW Medical Board, refused to discuss the case specifically but said that generally applications to register doctors first had to come from a prospective employer, supported by letters from the relevant medical college. Qualifications were independently verified and certificates of good standing sought from previous regulatory bodies.



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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