Thursday, August 09, 2007

Hygeine discipline everywhere except in the NHS

In the week that Bournemouth council banned the issuing of armbands at its swimming pools, for fear of spreading germs, we are told that 60,000 hospital patients this year will catch the superbug Clostridium difficile. While one part of the public sector is infected with a virulent strain of health and safety disease (let's call it HSD), another - the part that is supposed to look after our health - seems strangely immune.

No one has ever been knowingly infected by blowing up a rubber ring. But the head of the Institute of Sport and Recreation Management was unrepentant, stating: "I don't think it's health and safety gone mad to say that something should be clean and safe." He is surely the perfect candidate to run one of the quarter of hospitals that are not meeting even the basic requirements of the hygiene code.

Even though there is not much hand-washing going on in the NHS, there is plenty of hand-wringing. Cases of "C diff", as it is known in the trade, have risen by 22 per cent in the past year, affecting more than 15,500 people over 65. It is not always lethal: in 2005 it was mentioned on 3,697 English death certificates (MRSA was mentioned on 1,512). But those figures understate the problem, because hospital-acquired infections often go unmentioned as a factor in death. The campaign group MRSA Action UK believes that many deaths that are listed as organ failure will also have involved MRSA. It is generally agreed that the UK's performance in combating these bugs lags behind every other European country except - oh, here's a comfort - Romania. The good news this week was that MRSA rates have started to fall, by 6 per cent in three months. But even this must be seen in the context of a sixfold increase over the past decade.

When superbugs first invaded hospitals in the Netherlands in the early 1990s, the Dutch took a zero-tolerance approach. They used an age-old tactic of infection control: isolating patients in dedicated wards. Their relatively clean hospitals were spruced up even further, and staff who came into contact with infected patients were tested. Mark Enright, an epidemiologist at Imperial College, London, says that NHS managers thought the Dutch had overreacted. But 15 years on, their MRSA rates are 50 times lower than ours.

It is trickier to isolate patients in the NHS because it has far fewer empty beds than almost any other Western health service. That is a direct consequence of the determined reduction in hospital beds from almost 300,000 20 years ago to 175,000 last year. At Stoke Mandeville, where at least 33 and possibly 65 people died from C. difficile in 2004, staff claimed that they could not isolate patients because of budgets and waiting-time targets.

This lack of beds and conflict between targets is critical for ministers to address. But it has been largely obscured by the focus on hand-washing. The problem is that, while hospitals remain dirty, it is hard to see the bigger issue. Ministers must also realise that all these "Wipe Out!", "Saving Lives" and "clean your hands" initiatives, unusually self-explanatory for this acronym-laden bureaucracy, have been staggeringly ineffective.

It is quite clear that a package of measures is needed to combat these infections: it includes isolation of patients, much more careful use of antibiotics in the case of C. difficile, and proper hygiene. The Health Protection Agency this week produced figures showing that some hospital trusts are doing quite well. But they will not permit us humble patients to know the success or failure rates for individual hospitals. The discrepancies must be far too revealing.

The fact is that a clean hospital is a well-managed hospital. Infection control is not impossible. What it really boils down to, in the words of Georgina Duckworth, of the Health Protection Agency, is "running a tight ship". Only a well-managed hospital will get a grip on superbugs. And the fact is that there are still far too many poorly managed hospitals.

The superbugs are not only a problem in themselves - they are also a symptom of what is wrong with the NHS culture. When voters said that they wanted to bring back matron, they did not mean "appoint someone with the title of matron and ask her to build partnerships with team members towards a better future", which is pretty much what happened in 2001. They wanted someone with the authority and willingness to tell others what to do.

The Healthcare Commission report published this week contains some telling quotes from NHS employees. "It's difficult to enforce authority like it was in the past," says one. "Staff have so many rights, unions, human resources," says another. And the report concludes that "overly authoritarian or hierarchical styles of management" can now be perceived as "bullying".

On recent visits to hospitals I have watched as staff turn a blind eye to nurses who do not wash their hands and cleaners who do not clean. Two weeks ago, a postoperative colleague complained about a huge splotch of blood on the wall of the toilet. "Oh," said the nurse, "we hoped you wouldn't notice."

Talk to former members of the nursing profession, such as my great-aunt and my mother-in-law, and they will tell you how they quaked when the infection control man made his daily visit to the ward and ran his finger along the top of every bed curtain. They would not have made excuses about outsourced cleaning contracts. They just got on with saving lives.

Outside the NHS, health and safety is being enforced maniacally. There is no shortage of bossy enforcers to remove your rubber ring. I never thought I'd say it, but we need a bit more of that in the NHS.


Cutting Hospitals Out Of Surgery

When someone has minor outpatient surgery in a hospital, payment includes the cost to cover the procedure, plus an extra few thousand dollars in so-called facility fees. If Rock Rockett has his way, more doctors will ditch the hospital and stitch out of their own offices--in theory capturing a fraction of those facility fees that insurers no longer have to pay.

Happy result: Docs make more dough, insurers save money and, just maybe, the overall cost of health care drops. A 30-year health-insurance industry vet, Rockett is now the head of San Ramon, Calif.-based Validare, a small firm formed in 2001 to help physicians apply for formal accreditation to perform. Today the company also negotiates pricing with insurance companies and even handles doctors' back-office payment services.

If that sounds like a boring business, the opportunities are scintillating. There are now hundreds of different types of procedures--a bunion shaved or a chin tucked--done in an office setting. And the stakes just got higher. Prompted in part by some well-publicized office-surgery deaths, last week the state of New York passed a law mandating that all doctors who perform in-office surgeries have to be accredited within the next two years, or face penalties from the state medical board. (Until now, accreditation had not been required, though doctors who boasted the designation generally commanded higher fees from insurance companies.) Similar legislation is up for debate in Arizona and other states.

All of this could be a boon to Validare, now with just $2 million in revenues. Rockett estimates that there are roughly 2,000 office-surgery facilities in New York, of which Validare services only 100. Meanwhile, the Joint Commission--one of three regulators of office-surgery facilities in the U.S.--estimates that only 5% of the nearly 40,000 physicians' offices where surgeries are performed have the necessary accreditation. "This is a huge shot in the arm for us," says Rockett, 55.

Better yet, the overall pool of customers has been growing. Between 2000 and 2005, the number of freestanding outpatient surgery centers in the U.S. increased 76%, to 5,063, according to a report by Verispan, a health care research outfit. Credit the trend to overcrowded hospitals, better technology (allowing more surgical procedures to be done safely in an office setting) and the doctors' desire to get paid. "Physicians can control their time more if they're doing it in the office," says Michael Kulczycki, executive director for the Ambulatory Accreditation Program at the Joint Commission. "Also patients prefer to have surgeries at a time and place convenient for them."

Dr. Richard Delmonte, a Manhattan podiatrist, is a big believer in office-based surgery. With Validare's help, he recently spent six months worth of nights and weekends adding equipment, overhauling his record-keeping processes and updating his operations manual--all to snag accreditation to perform minor surgeries in his office.

Accreditation isn't cheap. Upfront costs for the certification: $11,000, including $6,000 for Validare's consulting services and $5,000 in fees to the Joint Commission. In addition, Delmonte pays Validare a kingly 15% on the fees he generates in excess of what he would have earned performing surgery in a hospital. All well worth it, says Delmonte, who claims he now pulls in an extra $1,000 or so per procedure and is able to perform more surgeries by avoiding costly hospital delays.

Insurance companies like this strategy too. Health Insurance Plan of New York, the state's largest health maintenance organization, typically forks over $3,000 in hospital facility fees for basic outpatient surgeries, says Eddy Reynoso, the HMO's director of ancillary contracting. "It's a big plus in terms of reducing the cost," says Reynoso, whose company is working with Validare on a trial basis. "The fact that the legislation was approved [also helps] in terms of quality. One of the concerns was that even though the trend was to move procedures from the hospital to an office, we were concerned about the quality of care."

Validare is cultivating relationships with giant insurer UnitedHealth Group and GHI, another New York HMO. Rockett also works with other surgery-pricing consultants, such as Omniplan and Concentra, to get the best deals for his doctor clients. Some big carriers like Aetna still refuse to reimburse for office-based surgeries. And Medicare and Medicaid are so big and standardized that they don't need a middleman like Rockett.

Dr. Scott Tenner, a Brooklyn-based gastroenterologist, signed on with Validare in 2005. A year later, he says, revenues shot up 50%, to $1.5 million, and net income jumped about a third. (He had to add staff and equipment to handle the flow of new patients and to meet more stringent safety standards.) "This has revolutionized my practice," he says. And that New York law has revolutionized Rockett's fee structure. Starting on Aug. 1, Validare will boost its upfront fees 50%, to $9,000 per accreditation. Sounds like this rocket is ready for launch.



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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1 comment:

mark birtles said...

Clostridium Difficile

Clostridium Difficile, is now recognised as the chief cause of hospital acquired Diarrhoea in the US and Europe, and not only in hospitals but also in nursing homes and other facilities for long term care.

Initial recognition of this disease began in the 1970s, with reports of a serious,
sometimes lethal colitis, characterised by the formation of pseudo-membranous
plaques. The cause was identified as Clostridium Difficile in 1978, and it is a
Superbug that is more enduring, than MRSA.

In 2004 in the UK, there were 43,672 cases of Clostridium Difficile, this is an
amazing and frightening two-fold increase from 2001. In 2006 the figure rose to 66,000. The continued lack of reasonable cleanliness in hospitals in the UK and the uncontrolled use of cheap broad spectrum antibiotics (against hospital guidelines) that strip our gut flora, leave us wide open to C-diff infection.

This means that we have had this condition killing patients for over thirty years,
but healthcare professionals have considered it not relevant enough to inform
patient's relatives. Inform them that their loved one died of a Superbug and it
was totally unassociated with the reason they were in the hospital in the first place.

So perhaps since the seventies, just like MRSA, patients have been going into
hospitals to be cured, only to be killed by an erroneous hospital acquired infection.

If you or your loved one go into hospital and develop diarrhoea demand that a stool sample be taken and tested for C-Diff toxin.
If you are C-Diff positive the usual treatment is metronidazole or oral vancomycin.

Mark Birtles